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NUR 280 ACTUAL EXAM 2024/2025 VERFIED QUESTIONS AND ANSWERS WITH RATIONALE GRADED A+(SOLVED)
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NUR 280 ACTUAL EXAM 2024/2025 VERFIED QUESTIONS AND ANSWERS WITH RATIONALE GRADED A+(SOLVED)
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NUR 280 ACTUAL EXAM 2024/2025NUR 280 ACTUAL EXAM 2024/2025 VERFIED
QUESTIONS AND ANSWERS WITH RATIONALE
GRADED A+(SOLVED)
The nurse is reviewing medical prescriptions for newly admitted clients. It would be a priority for the
nurse to follow up with the physician if a client with
(a) a potassium level of 4.5mEq/L has Kayexalate (sodium polystyrene)
prescribed
(b) a Dilantin (phenytoin) level of 8 mcg/ml is placed on seizure precautions
(c) sensitivity to Aspirin (acetylsalicylic acid) is prescribed Tylenol (acetaminophen)
(d) sensitivity to Penicillin is prescribed Zithromax (azithromycin)
1. A. The normal potassium level is 3.5 - 5.0 mEq/L. Giving Kayexalate in this situation may cause the
client to lose potassium, causing hypokalemia, therefore the drug is not indicated; the therapeutic level
for Dilantin is 10 - 20 mcg/ml, a level of 8 is sub therapeutic thereby increasing the risk of seizure
activity. Acetaminophen can be safely prescribed to clients with ASA sensitivity. Azithromycin
(Zithromax) can be safely prescribed for clients with sensitivity to Penicillin.
The nurse should intervene if the nurse notes a staff member
(a) obtaining a clients consent prior to their operative procedure after receiving
Ativan (lorazepam)
(b) placing a client on the affected side following surgical repair of a retinal
detachment
(c) handling a wet cast with the palms of the hands
(d) using a broad base of support while transferring a client
2. A. Informed consent, explanation and decision making must occur before sedation is given;
therapeutic interventions for retinal detachment include bedrest with the area of detachment in a
,NUR 280 ACTUAL EXAM 2024/2025
dependent position to promote healing; the cast should be handled with the palms of the hands while
wet to prevent denting; a broad base of support is used during transfers to prevent muscle injury.
The community health nurse is caring for the following clients. It would be a
priority for the nurse to initiate a multidisciplinary conference for the client who
is
(a) 12 years old with Autism who is starting a new school and recently had a
URI (upper respiratory tract infection)
(b) 16 years old, has type 1 Diabetes Mellitus, is unemployed and had a recent
Hemoglobin A1c of 13%
(c) 52 years old, with Myasthenia Gravis, recently prescribed Mestinon (pyridostigmine) and employed
as a mail carrier
(d) 70 years old, has schizophrenia, lives alone and reports hearing
non threatening voices.
3. B. An adolescent with uncontrolled Diabetes Mellitus would require the greatest number of
disciplines (multidisciplinary) to manage their care i.e. Medicine, Nursing, Social Work, Nutritionist; the
other choices do not require as many providers of care to meet their needs.
The nurse from the postpartum unit has been temporarily assigned to the
medical surgical unit. It would be most appropriate to assign this nurse to the
client who
(a) has returned from right total hip replacement surgery four hours ago
(b) is being observed for increased intracranial pressure
(c) had surgery two hours ago to remove the appendix
(d) is two weeks post partum being maintained on a mechanical ventilator for respiratory failure
,NUR 280 ACTUAL EXAM 2024/2025
4. C. The management of a client following abdominal surgery is standard. The postpartum nurse
routinely cares for mothers following caesarean section; therefore it is appropriate to assign this client;
The other choices are not appropriate to assign to this nurse.
The nurse in a well baby clinic has assessed several children today. It would
be a priority for the nurse to suggest follow up for the child who is
(a) 2 months old with a positive babinski reflex
(b) 5 months old and does not hold their own bottle
(c) 10 months old who cries around strangers
(d) 18 months old who needs support while ambulating
5. D. A child experiencing normal growth and development should be ambulating independently by 12
months; the Babinski reflex disappears after 2 years of age; an infant typically holds their own bottle by
6 months; stranger anxiety usually develops at approximately 7 months
The nurse is caring for a mechanically ventilated client who was declared brain
dead. An Advance Directive is not documented on the medical record. It
would be most appropriate to obtain consent for organ donation from the
(a) client's primary care provider
(b) client's nurse manager
(c) closest living family member
(d) hospital's ethics committee
6. C. Consent for organ donation is given by a client's next of kin in the absence of an Advance Directive
The nurse has received report on four clients. The nurse should first
, NUR 280 ACTUAL EXAM 2024/2025
assess the client who has:
(a) Chronic Obstructive Pulmonary Disease (COPD) with a pulse oximetry reading of 90%
(b) Parkinson's Disease and is demanding to leave the hospital against medical advice (AMA)
(c) been admitted with suspected Guillian Barre Syndrome and has begun plasmapheresis therapy
(d) Congestive Heart Failure (CHF) whose pitting edema has increased to 2(+)
7. C. The client admitted with Guillain-Barre' Syndrome should be assessed first because of the
possibility of rapid progression of this illness and neuromuscular respiratory failure; clients with COPD
are likely to have pulse oximetry readings of 90% related to chronic hypoxia; this client along with the
other two choices are important, but not the priority.
It would be appropriate to assign which of these tasks to the CNA?
(a) Feeding a client who is experiencing dysphagia
(b) One-on-one client observation for safety
(c) Removal of an indwelling catheter
(d) Performing a simple dressing change
B. The Certified Nursing Assistant may be assigned to a client that requires one- to-one observation for
safety; the other choices require skilled nursing intervention by a LPN (Licensed Practical Nurse) or RN
(Registered Nurse).
The nurse should intervene if a staff member is observed:
(a) discussing a client's diagnosis with visiting family members
(b) collaborating with another nurse to review a prescription for blood transfusion
(c) interrupting other staff members discussing a client in the cafeteria
(d) reviewing a clients lab values with the nutritionist
9. A. To maintain confidentiality the nurse should not discuss the client's diagnosis with family members;
it is advisable that two nurses review the prescription for blood transfusion to identify the client, blood
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