NU180 | NU180 Nursing and Healthcare II | NCLEX
Style Final Exam v2 | Questions with Correct
Answers and Expert Explanation for Each Question
| Galen
1. A nurse is caring for a client with a serum potassium level of 2.8 mEq/L. Which
clinical manifestation should the nurse monitor for most closely?
A. Muscle twitching and hyperreflexia
B. Diarrhea and abdominal cramping
C. Irregular heart rate and flattened T-waves
D. Numbness and tingling in the extremities
Correct Answer: C
Expert Explanation: Hypokalemia significantly affects cardiac electrical
conduction, leading to dysrhythmias and characteristic EKG changes like flattened
T-waves. Potassium is a vital intracellular cation necessary for maintaining the
resting membrane potential of cardiac muscle. The nurse must prioritize cardiac
monitoring to prevent life-threatening complications.
2. Which action should the nurse prioritize when a client presents with a suspected
anaphylactic reaction after receiving an antibiotic?
A. Administer intramuscular epinephrine
,B. Assess the client’s blood pressure
C. Apply high-flow oxygen via non-rebreather mask
D. Contact the physician for orders
Correct Answer: A
Expert Explanation: Epinephrine is the first-line treatment for anaphylaxis to
reverse systemic vasodilation and bronchoconstriction. Delays in administering
epinephrine are associated with increased mortality in allergic emergencies. While
assessment and oxygen are important, they should not delay the life-saving
administration of the drug.
3. A nurse is teaching a client about a new prescription for Alendronate. Which
instruction is essential for preventing esophageal irritation?
A. Remain upright for at least 30 minutes after taking the drug
B. Take the medication with a full glass of milk
C. Take the medication immediately before going to bed
D. Crush the tablet if it is too difficult to swallow
Correct Answer: A
Expert Explanation: Alendronate, a bisphosphonate, can cause severe esophageal
erosion if it remains in contact with the esophageal mucosa. Clients must stay
,upright and take it with a full glass of water on an empty stomach to facilitate transit
to the stomach. This instruction is the most critical safety teaching point for this
medication class.
4. A nurse assesses a post-operative client and notes a sudden onset of chest pain and
shortness of breath. What is the nurse’s priority action?
A. Obtain a 12-lead EKG
B. Auscultate lung sounds for crackles
C. Elevate the head of the bed and apply oxygen
D. Administer prescribed pain medication
Correct Answer: C
Expert Explanation: Sudden chest pain and dyspnea in a post-op client suggest a
pulmonary embolism, which is a medical emergency. Elevating the head of the bed
helps maximize lung expansion and ease the work of breathing. Providing oxygen
immediately addresses potential hypoxia while further diagnostic tests are
organized.
5. The nurse is caring for a client with Type 1 Diabetes who is found unconscious with
a blood glucose of 42 mg/dL. What should be the nurse’s immediate intervention?
A. Administer 15 grams of simple carbohydrates orally
B. Administer 50% Dextrose (D50) intravenously
, C. Give a subcutaneous injection of regular insulin
D. Monitor the client for another 15 minutes
Correct Answer: B
Expert Explanation: When a client is unconscious and unable to swallow safely,
oral carbohydrates are contraindicated due to the risk of aspiration. Intravenous
D50 is the fastest and safest way to raise blood glucose levels in an emergency
inpatient setting. The nurse must act quickly to prevent permanent neurological
damage from severe hypoglycemia.
6. A client is diagnosed with Clostridioides difficile (C. diff). Which infection control
measure is most appropriate?
A. Use an alcohol-based hand rub after leaving the room
B. Wear a gown and gloves for all client contact
C. Place the client in a room with negative pressure
D. Wear an N95 respirator when providing care
Correct Answer: B
Expert Explanation: C. diff requires contact precautions, which include the use of
gowns and gloves to prevent the spread of spores. Alcohol-based rubs are
ineffective against C. diff spores; therefore, handwashing with soap and water is
Style Final Exam v2 | Questions with Correct
Answers and Expert Explanation for Each Question
| Galen
1. A nurse is caring for a client with a serum potassium level of 2.8 mEq/L. Which
clinical manifestation should the nurse monitor for most closely?
A. Muscle twitching and hyperreflexia
B. Diarrhea and abdominal cramping
C. Irregular heart rate and flattened T-waves
D. Numbness and tingling in the extremities
Correct Answer: C
Expert Explanation: Hypokalemia significantly affects cardiac electrical
conduction, leading to dysrhythmias and characteristic EKG changes like flattened
T-waves. Potassium is a vital intracellular cation necessary for maintaining the
resting membrane potential of cardiac muscle. The nurse must prioritize cardiac
monitoring to prevent life-threatening complications.
2. Which action should the nurse prioritize when a client presents with a suspected
anaphylactic reaction after receiving an antibiotic?
A. Administer intramuscular epinephrine
,B. Assess the client’s blood pressure
C. Apply high-flow oxygen via non-rebreather mask
D. Contact the physician for orders
Correct Answer: A
Expert Explanation: Epinephrine is the first-line treatment for anaphylaxis to
reverse systemic vasodilation and bronchoconstriction. Delays in administering
epinephrine are associated with increased mortality in allergic emergencies. While
assessment and oxygen are important, they should not delay the life-saving
administration of the drug.
3. A nurse is teaching a client about a new prescription for Alendronate. Which
instruction is essential for preventing esophageal irritation?
A. Remain upright for at least 30 minutes after taking the drug
B. Take the medication with a full glass of milk
C. Take the medication immediately before going to bed
D. Crush the tablet if it is too difficult to swallow
Correct Answer: A
Expert Explanation: Alendronate, a bisphosphonate, can cause severe esophageal
erosion if it remains in contact with the esophageal mucosa. Clients must stay
,upright and take it with a full glass of water on an empty stomach to facilitate transit
to the stomach. This instruction is the most critical safety teaching point for this
medication class.
4. A nurse assesses a post-operative client and notes a sudden onset of chest pain and
shortness of breath. What is the nurse’s priority action?
A. Obtain a 12-lead EKG
B. Auscultate lung sounds for crackles
C. Elevate the head of the bed and apply oxygen
D. Administer prescribed pain medication
Correct Answer: C
Expert Explanation: Sudden chest pain and dyspnea in a post-op client suggest a
pulmonary embolism, which is a medical emergency. Elevating the head of the bed
helps maximize lung expansion and ease the work of breathing. Providing oxygen
immediately addresses potential hypoxia while further diagnostic tests are
organized.
5. The nurse is caring for a client with Type 1 Diabetes who is found unconscious with
a blood glucose of 42 mg/dL. What should be the nurse’s immediate intervention?
A. Administer 15 grams of simple carbohydrates orally
B. Administer 50% Dextrose (D50) intravenously
, C. Give a subcutaneous injection of regular insulin
D. Monitor the client for another 15 minutes
Correct Answer: B
Expert Explanation: When a client is unconscious and unable to swallow safely,
oral carbohydrates are contraindicated due to the risk of aspiration. Intravenous
D50 is the fastest and safest way to raise blood glucose levels in an emergency
inpatient setting. The nurse must act quickly to prevent permanent neurological
damage from severe hypoglycemia.
6. A client is diagnosed with Clostridioides difficile (C. diff). Which infection control
measure is most appropriate?
A. Use an alcohol-based hand rub after leaving the room
B. Wear a gown and gloves for all client contact
C. Place the client in a room with negative pressure
D. Wear an N95 respirator when providing care
Correct Answer: B
Expert Explanation: C. diff requires contact precautions, which include the use of
gowns and gloves to prevent the spread of spores. Alcohol-based rubs are
ineffective against C. diff spores; therefore, handwashing with soap and water is
