Nu 310 Exam 1 Actual Exam Newest With Complete Questions And Correct Detailed Answers|
Brand New Version!
Question 1
Which of the following clinical findings would be the primary reason to delay a patient’s
discharge from the hospital following surgery?
A) Reported pain level of 4/10 during ambulation
B) Inability to void since the completion of surgery
C) A stable hemoglobin level of 8 g/dL
D) A resting heart rate of 100 beats per minute
E) Patient request to stay for one more meal
Correct Answer: B) Inability to void since surgery
Rationale: Postoperative urinary retention is a common complication that must be resolved
before discharge. It can lead to bladder distention and kidney injury. While pain, low
hemoglobin, and a high-normal heart rate are important, they can often be managed or
monitored outpatient if stable, but the inability to void is an acute functional failure.
Question 2
A patient presents with a temperature of 101°F, HR 100, and RR 30. The patient is using
accessory muscles to breathe and crackles are heard at the bases. What is the priority nursing
action?
A) Obtain a sputum sample and blood cultures
B) Administer oxygen to maintain O2 saturation >95%
C) Infuse one liter of normal saline
D) Start the first dose of IV antibiotics
E) Perform a focused secondary head-to-toe assessment
Correct Answer: B) Give him oxygen so his O2 sat is >95%
Rationale: According to the ABC (Airway, Breathing, Circulation) priority framework, the
patient's respiratory distress and tachypnea take precedence. Ensuring adequate
oxygenation is the immediate priority before performing diagnostic tests like cultures or
administering medications.
Question 3
A nurse identifies a potassium level of 6.0 mEq/L in a patient's lab results. Which of the
following is an expected clinical finding?
A) Heart palpitations
B) Severe muscle spasms
C) Dark amber-colored urine
D) Extreme drowsiness
E) Hyperactive bowel sounds
Correct Answer: A) Heart palpitations
Rationale: Hyperkalemia (potassium > 5.0) significantly affects cardiac conduction.
, 2
Elevated potassium can lead to life-threatening dysrhythmias and cardiac arrest.
Palpitations are a common early subjective sign of these cardiac changes.
Question 4
A patient being discharged after chemotherapy for Acute Myeloid Leukemia (AML) should be
instructed to report which finding immediately?
A) Mild nausea and one episode of vomiting
B) Muscle twitching and cramping
C) Generalized fatigue after activities
D) Brief vertigo when changing positions
E) Loss of appetite for one day
Correct Answer: B) Muscle twitching and cramping (indicates hyperkalemia, pt may go into
renal failure)
Rationale: In AML patients, chemotherapy can cause Tumor Lysis Syndrome (TLS), leading
to rapid cell death. This releases intracellular potassium and phosphorus into the blood.
Muscle twitching and cramping are signs of hyperkalemia/hypocalcemia, which can lead to
acute renal failure and cardiac arrest.
Question 5
What is often the first symptom of pneumonia in an 80-year-old male patient?
A) High temperature and rigors (chills)
B) Altered mental status or confusion
C) Productive cough with green sputum
D) Severe shortness of breath
E) Sharp chest pain during inspiration
Correct Answer: B) Altered mental status
Rationale: Geriatric patients often present with "atypical" symptoms of infection. Instead
of a high fever or cough, the first sign of pneumonia or UTI in the elderly is frequently a
sudden change in mental status, confusion, or lethargy.
Question 6
A patient has a serum calcium level of 16 mg/dL. Which of the following is a potential
complication the nurse should monitor for?
A) Increased risk of falls due to muscle weakness
B) Acute kidney injury
C) Bacterial pneumonia
D) Excessive heart palpitations
E) Spontaneous bone fractures
Correct Answer: B) Acute kidney injury
Rationale: Severe hypercalcemia (calcium > 10.5) can cause nephrocalcinosis and
, 3
vasoconstriction of the renal arteries, leading to acute kidney injury (AKI). It also leads to
polyuria and dehydration, further compromising renal function.
Question 7
Under which of the following circumstances is it incorrect or dangerous to clamp a chest tube?
A) When changing out the drainage system
B) When assessing the system for potential air leaks
C) When the patient is ambulating with physical therapy
D) When turning the patient and briefly placing the system above their body
E) When the doctor has ordered a trial to see if the patient can tolerate removal
Correct Answer: C) When having the patient ambulate with PT
Rationale: Chest tubes should never be clamped during ambulation or transport as this can
lead to the rapid development of a tension pneumothorax. Clamping is only done briefly
for specific reasons like changing the drainage unit or identifying an air leak.
Question 8
A patient develops Syndrome of Inappropriate Antidiuretic Hormone (SIADH) after
chemotherapy. What is the most significant risk to this patient?
A) Muscle cramps and twitching
B) Seizure-like activity
C) Cardiac palpitations
D) Anorexia and pallor
E) Severe hypertension
Correct Answer: B) Seizure like activity
Rationale: SIADH causes excessive water retention, leading to dilutional hyponatremia.
When sodium levels drop rapidly or become very low (<120), the brain cells swell, posing a
high risk for seizures, coma, and death.
Question 9
A post-op patient has an SpO2 of 95%, increased work of breathing, and crackles in the lung
bases. Which nursing intervention is most appropriate?
A) Apply a nasal cannula at 2L/min
B) Administer a 500mL bolus of Normal Saline
C) Assist the patient with an incentive spirometer
D) Request a prescription for broad-spectrum antibiotics
E) Place the patient in a Trendelenburg position
Correct Answer: C) Have him use incentive spirometer
Rationale: Crackles and increased work of breathing post-surgery are classic signs of
atelectasis (collapsed alveoli). Using an incentive spirometer (IS) encourages deep breathing
and alveolar expansion, which is the primary treatment and prevention for this condition.
, 4
Question 10
Which of the following patients should the nurse evaluate first after receiving the morning
report?
A) A patient on post-op day one reporting pain as 7/10
B) A patient with a confirmed DVT who is now complaining of shortness of breath
C) A patient with a chest tube showing intermittent bubbling in the water seal
D) A patient with pneumonia who has positive blood cultures
E) A diabetic patient with a morning blood glucose of 160 mg/dL
Correct Answer: B) A patient with a DVT who is complaining of shortness of breath
Rationale: Shortness of breath in a patient with a Deep Vein Thrombosis (DVT) is a
hallmark sign of a Pulmonary Embolism (PE), which is a life-threatening emergency. This
patient is the highest priority due to unstable respiratory/circulatory status.
Question 11
A patient with uncontrolled asthma remains short of breath after receiving an albuterol nebulizer
treatment. What is the nurse's next expected action?
A) Prepare the patient for STAT Pulmonary Function Tests (PFTs)
B) Administer IV Corticosteroids as prescribed
C) Place the patient on continuous high-flow oxygen
D) Administer the first dose of IV antibiotics
E) Encourage the patient to use an incentive spirometer
Correct Answer: B) Give IV Steroids
Rationale: If a bronchodilator (Albuterol) fails to resolve an asthma exacerbation, the next
step is to address the underlying inflammation. IV steroids (like methylprednisolone) are
used to reduce airway swelling in acute episodes.
Question 12
A patient arrives after a severe motor vehicle accident with HR 150, BP 90/50, and RR 18. What
should the nurse do first?
A) Draw blood for a basic metabolic panel and electrolytes
B) Administer a STAT dose of potassium
C) Administer IV opioids for pain management
D) Document the vital signs in the electronic health record
E) Start two large-bore IVs and begin rapid fluid resuscitation
Correct Answer: A) Take blood for electrolytes
Rationale: In trauma, especially with crushing injuries or massive blood loss, electrolyte
imbalances (like hyperkalemia) can occur rapidly. Establishing baseline labs is essential.
(Note: While fluid resuscitation is also a priority, the question asks among these options—
taking blood is a critical early step during IV insertion).
Brand New Version!
Question 1
Which of the following clinical findings would be the primary reason to delay a patient’s
discharge from the hospital following surgery?
A) Reported pain level of 4/10 during ambulation
B) Inability to void since the completion of surgery
C) A stable hemoglobin level of 8 g/dL
D) A resting heart rate of 100 beats per minute
E) Patient request to stay for one more meal
Correct Answer: B) Inability to void since surgery
Rationale: Postoperative urinary retention is a common complication that must be resolved
before discharge. It can lead to bladder distention and kidney injury. While pain, low
hemoglobin, and a high-normal heart rate are important, they can often be managed or
monitored outpatient if stable, but the inability to void is an acute functional failure.
Question 2
A patient presents with a temperature of 101°F, HR 100, and RR 30. The patient is using
accessory muscles to breathe and crackles are heard at the bases. What is the priority nursing
action?
A) Obtain a sputum sample and blood cultures
B) Administer oxygen to maintain O2 saturation >95%
C) Infuse one liter of normal saline
D) Start the first dose of IV antibiotics
E) Perform a focused secondary head-to-toe assessment
Correct Answer: B) Give him oxygen so his O2 sat is >95%
Rationale: According to the ABC (Airway, Breathing, Circulation) priority framework, the
patient's respiratory distress and tachypnea take precedence. Ensuring adequate
oxygenation is the immediate priority before performing diagnostic tests like cultures or
administering medications.
Question 3
A nurse identifies a potassium level of 6.0 mEq/L in a patient's lab results. Which of the
following is an expected clinical finding?
A) Heart palpitations
B) Severe muscle spasms
C) Dark amber-colored urine
D) Extreme drowsiness
E) Hyperactive bowel sounds
Correct Answer: A) Heart palpitations
Rationale: Hyperkalemia (potassium > 5.0) significantly affects cardiac conduction.
, 2
Elevated potassium can lead to life-threatening dysrhythmias and cardiac arrest.
Palpitations are a common early subjective sign of these cardiac changes.
Question 4
A patient being discharged after chemotherapy for Acute Myeloid Leukemia (AML) should be
instructed to report which finding immediately?
A) Mild nausea and one episode of vomiting
B) Muscle twitching and cramping
C) Generalized fatigue after activities
D) Brief vertigo when changing positions
E) Loss of appetite for one day
Correct Answer: B) Muscle twitching and cramping (indicates hyperkalemia, pt may go into
renal failure)
Rationale: In AML patients, chemotherapy can cause Tumor Lysis Syndrome (TLS), leading
to rapid cell death. This releases intracellular potassium and phosphorus into the blood.
Muscle twitching and cramping are signs of hyperkalemia/hypocalcemia, which can lead to
acute renal failure and cardiac arrest.
Question 5
What is often the first symptom of pneumonia in an 80-year-old male patient?
A) High temperature and rigors (chills)
B) Altered mental status or confusion
C) Productive cough with green sputum
D) Severe shortness of breath
E) Sharp chest pain during inspiration
Correct Answer: B) Altered mental status
Rationale: Geriatric patients often present with "atypical" symptoms of infection. Instead
of a high fever or cough, the first sign of pneumonia or UTI in the elderly is frequently a
sudden change in mental status, confusion, or lethargy.
Question 6
A patient has a serum calcium level of 16 mg/dL. Which of the following is a potential
complication the nurse should monitor for?
A) Increased risk of falls due to muscle weakness
B) Acute kidney injury
C) Bacterial pneumonia
D) Excessive heart palpitations
E) Spontaneous bone fractures
Correct Answer: B) Acute kidney injury
Rationale: Severe hypercalcemia (calcium > 10.5) can cause nephrocalcinosis and
, 3
vasoconstriction of the renal arteries, leading to acute kidney injury (AKI). It also leads to
polyuria and dehydration, further compromising renal function.
Question 7
Under which of the following circumstances is it incorrect or dangerous to clamp a chest tube?
A) When changing out the drainage system
B) When assessing the system for potential air leaks
C) When the patient is ambulating with physical therapy
D) When turning the patient and briefly placing the system above their body
E) When the doctor has ordered a trial to see if the patient can tolerate removal
Correct Answer: C) When having the patient ambulate with PT
Rationale: Chest tubes should never be clamped during ambulation or transport as this can
lead to the rapid development of a tension pneumothorax. Clamping is only done briefly
for specific reasons like changing the drainage unit or identifying an air leak.
Question 8
A patient develops Syndrome of Inappropriate Antidiuretic Hormone (SIADH) after
chemotherapy. What is the most significant risk to this patient?
A) Muscle cramps and twitching
B) Seizure-like activity
C) Cardiac palpitations
D) Anorexia and pallor
E) Severe hypertension
Correct Answer: B) Seizure like activity
Rationale: SIADH causes excessive water retention, leading to dilutional hyponatremia.
When sodium levels drop rapidly or become very low (<120), the brain cells swell, posing a
high risk for seizures, coma, and death.
Question 9
A post-op patient has an SpO2 of 95%, increased work of breathing, and crackles in the lung
bases. Which nursing intervention is most appropriate?
A) Apply a nasal cannula at 2L/min
B) Administer a 500mL bolus of Normal Saline
C) Assist the patient with an incentive spirometer
D) Request a prescription for broad-spectrum antibiotics
E) Place the patient in a Trendelenburg position
Correct Answer: C) Have him use incentive spirometer
Rationale: Crackles and increased work of breathing post-surgery are classic signs of
atelectasis (collapsed alveoli). Using an incentive spirometer (IS) encourages deep breathing
and alveolar expansion, which is the primary treatment and prevention for this condition.
, 4
Question 10
Which of the following patients should the nurse evaluate first after receiving the morning
report?
A) A patient on post-op day one reporting pain as 7/10
B) A patient with a confirmed DVT who is now complaining of shortness of breath
C) A patient with a chest tube showing intermittent bubbling in the water seal
D) A patient with pneumonia who has positive blood cultures
E) A diabetic patient with a morning blood glucose of 160 mg/dL
Correct Answer: B) A patient with a DVT who is complaining of shortness of breath
Rationale: Shortness of breath in a patient with a Deep Vein Thrombosis (DVT) is a
hallmark sign of a Pulmonary Embolism (PE), which is a life-threatening emergency. This
patient is the highest priority due to unstable respiratory/circulatory status.
Question 11
A patient with uncontrolled asthma remains short of breath after receiving an albuterol nebulizer
treatment. What is the nurse's next expected action?
A) Prepare the patient for STAT Pulmonary Function Tests (PFTs)
B) Administer IV Corticosteroids as prescribed
C) Place the patient on continuous high-flow oxygen
D) Administer the first dose of IV antibiotics
E) Encourage the patient to use an incentive spirometer
Correct Answer: B) Give IV Steroids
Rationale: If a bronchodilator (Albuterol) fails to resolve an asthma exacerbation, the next
step is to address the underlying inflammation. IV steroids (like methylprednisolone) are
used to reduce airway swelling in acute episodes.
Question 12
A patient arrives after a severe motor vehicle accident with HR 150, BP 90/50, and RR 18. What
should the nurse do first?
A) Draw blood for a basic metabolic panel and electrolytes
B) Administer a STAT dose of potassium
C) Administer IV opioids for pain management
D) Document the vital signs in the electronic health record
E) Start two large-bore IVs and begin rapid fluid resuscitation
Correct Answer: A) Take blood for electrolytes
Rationale: In trauma, especially with crushing injuries or massive blood loss, electrolyte
imbalances (like hyperkalemia) can occur rapidly. Establishing baseline labs is essential.
(Note: While fluid resuscitation is also a priority, the question asks among these options—
taking blood is a critical early step during IV insertion).
