NU180 | NU180 Nursing and Healthcare II | NCLEX
Style Midterm v2 | Questions with Correct Answers
and Expert Explanation for Each Question | Galen
1. A nurse is assessing a client for early signs of hypoxia. Which of the following
findings should the nurse identify as an early indicator?
A. Cyanosis of the lips
B. Bradycardia
C. Restlessness
D. Bradypnea
Correct Answer: C
Expert Explanation: Restlessness and apprehension are the earliest signs of
hypoxia because the central nervous system is highly sensitive to oxygen
deprivation. Cyanosis and bradycardia are considered late signs indicating
significant physiological decompensation. The nurse should always monitor for
changes in mental status to identify declining oxygenation before more severe
symptoms occur.
2. Which task is most appropriate for the registered nurse (RN) to delegate to an
unlicensed assistive personnel (UAP)?
A. Assisting a stable patient with a bed bath
,B. Assessing a patient’s pain level
C. Evaluating the effectiveness of a nebulizer treatment
D. Educating a patient on a new medication
Correct Answer: A
Expert Explanation: The UAP’s scope of practice includes basic tasks such as
hygiene, feeding, and mobility for stable patients. Assessment, evaluation, and
education are core responsibilities of the RN that require clinical judgment.
Delegating inappropriate tasks can lead to patient harm and legal repercussions for
the nurse.
3. A nurse observes a partial-thickness skin loss involving the epidermis and dermis,
presenting as a shallow open ulcer. Which stage is this pressure injury?
A. Stage IV
B. Stage I
C. Stage III
D. Stage II
Correct Answer: D
Expert Explanation: Stage II pressure injuries are characterized by partial-
thickness loss of skin with a visible pink or red wound bed. Stage I involves intact
,skin with non-blanchable redness, while Stage III involves full-thickness tissue loss.
Proper classification of pressure injuries is vital for implementing correct wound
care protocols.
4. The nurse is preparing a client for a surgical procedure. Who is ultimately
responsible for obtaining the informed consent?
A. The charge nurse
B. The circulating nurse
C. The surgeon
D. The anesthesia provider
Correct Answer: C
Expert Explanation: The surgeon or primary provider performing the procedure is
legally responsible for explaining the risks, benefits, and alternatives to obtain
informed consent. The nurse’s role is to witness the signature and ensure the client
understands what they are signing. If the client has questions about the procedure
itself, the nurse must notify the provider to come back and clarify.
5. When performing hand hygiene with an alcohol-based hand rub, the nurse should
continue rubbing until:
A. The solution is dry on the hands
B. The hands are visibly clean
, C. Exactly 15 seconds have passed
D. The patient says it is okay
Correct Answer: A
Expert Explanation: Alcohol-based hand rubs must be rubbed over all surfaces of
the hands until they are completely dry to ensure maximum efficacy. This process
typically takes about 20 to 30 seconds depending on the volume used. If the hands
are visibly soiled, soap and water must be used instead of alcohol-based products.
6. A nurse is caring for a client with a potassium level of 2.8 mEq/L. Which cardiac
finding is most likely to be observed?
A. Shortened QT interval
B. Peaked T waves
C. Inverted T waves
D. Widened QRS complex
Correct Answer: C
Expert Explanation: Hypokalemia, defined as a potassium level below 3.5 mEq/L,
can cause EKG changes such as U waves, ST-segment depression, and inverted T
waves. Peaked T waves are conversely associated with hyperkalemia, which is a
Style Midterm v2 | Questions with Correct Answers
and Expert Explanation for Each Question | Galen
1. A nurse is assessing a client for early signs of hypoxia. Which of the following
findings should the nurse identify as an early indicator?
A. Cyanosis of the lips
B. Bradycardia
C. Restlessness
D. Bradypnea
Correct Answer: C
Expert Explanation: Restlessness and apprehension are the earliest signs of
hypoxia because the central nervous system is highly sensitive to oxygen
deprivation. Cyanosis and bradycardia are considered late signs indicating
significant physiological decompensation. The nurse should always monitor for
changes in mental status to identify declining oxygenation before more severe
symptoms occur.
2. Which task is most appropriate for the registered nurse (RN) to delegate to an
unlicensed assistive personnel (UAP)?
A. Assisting a stable patient with a bed bath
,B. Assessing a patient’s pain level
C. Evaluating the effectiveness of a nebulizer treatment
D. Educating a patient on a new medication
Correct Answer: A
Expert Explanation: The UAP’s scope of practice includes basic tasks such as
hygiene, feeding, and mobility for stable patients. Assessment, evaluation, and
education are core responsibilities of the RN that require clinical judgment.
Delegating inappropriate tasks can lead to patient harm and legal repercussions for
the nurse.
3. A nurse observes a partial-thickness skin loss involving the epidermis and dermis,
presenting as a shallow open ulcer. Which stage is this pressure injury?
A. Stage IV
B. Stage I
C. Stage III
D. Stage II
Correct Answer: D
Expert Explanation: Stage II pressure injuries are characterized by partial-
thickness loss of skin with a visible pink or red wound bed. Stage I involves intact
,skin with non-blanchable redness, while Stage III involves full-thickness tissue loss.
Proper classification of pressure injuries is vital for implementing correct wound
care protocols.
4. The nurse is preparing a client for a surgical procedure. Who is ultimately
responsible for obtaining the informed consent?
A. The charge nurse
B. The circulating nurse
C. The surgeon
D. The anesthesia provider
Correct Answer: C
Expert Explanation: The surgeon or primary provider performing the procedure is
legally responsible for explaining the risks, benefits, and alternatives to obtain
informed consent. The nurse’s role is to witness the signature and ensure the client
understands what they are signing. If the client has questions about the procedure
itself, the nurse must notify the provider to come back and clarify.
5. When performing hand hygiene with an alcohol-based hand rub, the nurse should
continue rubbing until:
A. The solution is dry on the hands
B. The hands are visibly clean
, C. Exactly 15 seconds have passed
D. The patient says it is okay
Correct Answer: A
Expert Explanation: Alcohol-based hand rubs must be rubbed over all surfaces of
the hands until they are completely dry to ensure maximum efficacy. This process
typically takes about 20 to 30 seconds depending on the volume used. If the hands
are visibly soiled, soap and water must be used instead of alcohol-based products.
6. A nurse is caring for a client with a potassium level of 2.8 mEq/L. Which cardiac
finding is most likely to be observed?
A. Shortened QT interval
B. Peaked T waves
C. Inverted T waves
D. Widened QRS complex
Correct Answer: C
Expert Explanation: Hypokalemia, defined as a potassium level below 3.5 mEq/L,
can cause EKG changes such as U waves, ST-segment depression, and inverted T
waves. Peaked T waves are conversely associated with hyperkalemia, which is a
