NU180 | NU180 Nursing and Healthcare II | NCLEX
Style Final Exam v3 | Questions with Correct
Answers and Expert Explanation for Each Question
| Galen
1. A patient with heart failure is receiving furosemide. Which laboratory value should
the nurse monitor most closely?
A. Serum sodium
B. Serum calcium
C. Serum potassium
D. Serum creatinine
Correct Answer: C
Expert Explanation: Furosemide is a loop diuretic that causes the excretion of
potassium through the kidneys. Hypokalemia is a significant side effect that can lead
to cardiac dysrhythmias. The nurse must monitor potassium levels to ensure they
stay within the normal range of 3.5 to 5.0 mEq/L.
2. Which assessment finding is the most sensitive indicator of altered neurological
status?
A. Pupillary reaction
B. Vital signs
,C. Motor response
D. Level of consciousness
Correct Answer: D
Expert Explanation: The level of consciousness is the most sensitive and earliest
indicator of neurological change. Changes in orientation, alertness, or
responsiveness often precede other clinical signs. Pupillary changes and motor
responses usually occur later as neurological deterioration progresses.
3. A nurse is caring for a patient who is 24 hours postoperative following a total hip
arthroplasty. Which action should the nurse prioritize?
A. Maintaining the abduction pillow between the legs
B. Assessing for signs of a deep vein thrombosis
C. Ensuring the patient remains in a supine position
D. Encouraging the use of an incentive spirometer
Correct Answer: A
Expert Explanation: Maintaining hip alignment is crucial to prevent dislocation of
the new prosthesis. An abduction pillow keeps the legs apart and prevents
adduction, which is a common cause of dislocation. While respiratory care and DVT
prevention are important, joint stability is a specific priority for this procedure.
,4. A patient with Type 1 Diabetes Mellitus is found unresponsive and clammy. What is
the priority nursing action?
A. Administer glucagon intramuscularly
B. Check the patient’s blood glucose level
C. Administer 15g of simple carbohydrates orally
D. Notify the healthcare provider immediately
Correct Answer: A
Expert Explanation: An unresponsive patient cannot safely take oral carbohydrates
due to the risk of aspiration. Glucagon is the emergency treatment of choice for
severe hypoglycemia in an unconscious patient. Checking blood glucose is
important, but immediate treatment for suspected hypoglycemia takes precedence
when the patient is unresponsive.
5. A nurse is teaching a patient about a low-sodium diet. Which food choice indicates
that the patient understands the teaching?
A. Fresh grilled chicken breast
B. Canned vegetable soup
C. Deli turkey sandwich
D. Cottage cheese
, Correct Answer: A
Expert Explanation: Fresh meats such as grilled chicken are naturally low in
sodium compared to processed foods. Canned soups, deli meats, and many cheeses
are high in hidden sodium used for preservation. Education should focus on
choosing fresh, whole foods to manage hypertension or heart failure.
6. A patient is prescribed warfarin for atrial fibrillation. Which laboratory value is used
to monitor the effectiveness of this medication?
A. Activated partial thromboplastin time (aPTT)
B. Platelet count
C. International Normalized Ratio (INR)
D. Hemoglobin and Hematocrit
Correct Answer: C
Expert Explanation: The INR is the standard laboratory test used to monitor the
therapeutic level of warfarin therapy. The target INR for most patients is between
2.0 and 3.0 to prevent clots without excessive bleeding. The aPTT is used primarily
to monitor heparin therapy, not warfarin.
7. The nurse is preparing to administer a medication to a patient. Which action is the
most reliable method to identify the patient?
A. Asking the patient to state their full name
Style Final Exam v3 | Questions with Correct
Answers and Expert Explanation for Each Question
| Galen
1. A patient with heart failure is receiving furosemide. Which laboratory value should
the nurse monitor most closely?
A. Serum sodium
B. Serum calcium
C. Serum potassium
D. Serum creatinine
Correct Answer: C
Expert Explanation: Furosemide is a loop diuretic that causes the excretion of
potassium through the kidneys. Hypokalemia is a significant side effect that can lead
to cardiac dysrhythmias. The nurse must monitor potassium levels to ensure they
stay within the normal range of 3.5 to 5.0 mEq/L.
2. Which assessment finding is the most sensitive indicator of altered neurological
status?
A. Pupillary reaction
B. Vital signs
,C. Motor response
D. Level of consciousness
Correct Answer: D
Expert Explanation: The level of consciousness is the most sensitive and earliest
indicator of neurological change. Changes in orientation, alertness, or
responsiveness often precede other clinical signs. Pupillary changes and motor
responses usually occur later as neurological deterioration progresses.
3. A nurse is caring for a patient who is 24 hours postoperative following a total hip
arthroplasty. Which action should the nurse prioritize?
A. Maintaining the abduction pillow between the legs
B. Assessing for signs of a deep vein thrombosis
C. Ensuring the patient remains in a supine position
D. Encouraging the use of an incentive spirometer
Correct Answer: A
Expert Explanation: Maintaining hip alignment is crucial to prevent dislocation of
the new prosthesis. An abduction pillow keeps the legs apart and prevents
adduction, which is a common cause of dislocation. While respiratory care and DVT
prevention are important, joint stability is a specific priority for this procedure.
,4. A patient with Type 1 Diabetes Mellitus is found unresponsive and clammy. What is
the priority nursing action?
A. Administer glucagon intramuscularly
B. Check the patient’s blood glucose level
C. Administer 15g of simple carbohydrates orally
D. Notify the healthcare provider immediately
Correct Answer: A
Expert Explanation: An unresponsive patient cannot safely take oral carbohydrates
due to the risk of aspiration. Glucagon is the emergency treatment of choice for
severe hypoglycemia in an unconscious patient. Checking blood glucose is
important, but immediate treatment for suspected hypoglycemia takes precedence
when the patient is unresponsive.
5. A nurse is teaching a patient about a low-sodium diet. Which food choice indicates
that the patient understands the teaching?
A. Fresh grilled chicken breast
B. Canned vegetable soup
C. Deli turkey sandwich
D. Cottage cheese
, Correct Answer: A
Expert Explanation: Fresh meats such as grilled chicken are naturally low in
sodium compared to processed foods. Canned soups, deli meats, and many cheeses
are high in hidden sodium used for preservation. Education should focus on
choosing fresh, whole foods to manage hypertension or heart failure.
6. A patient is prescribed warfarin for atrial fibrillation. Which laboratory value is used
to monitor the effectiveness of this medication?
A. Activated partial thromboplastin time (aPTT)
B. Platelet count
C. International Normalized Ratio (INR)
D. Hemoglobin and Hematocrit
Correct Answer: C
Expert Explanation: The INR is the standard laboratory test used to monitor the
therapeutic level of warfarin therapy. The target INR for most patients is between
2.0 and 3.0 to prevent clots without excessive bleeding. The aPTT is used primarily
to monitor heparin therapy, not warfarin.
7. The nurse is preparing to administer a medication to a patient. Which action is the
most reliable method to identify the patient?
A. Asking the patient to state their full name
