NUES 1234 EXAM QUESTIONS WITH CORRECT ANSWERS A+
A patient who is taking a potassium-wasting diuretic for treatment of hypertension complains of generalized
weakness. It is most appropriate for the nurse to take which action?
a. Assess for facial muscle spasms.
b. Ask the patient about loose stools.
c. Suggest that the patient avoid orange juice with meals.
d. Ask the health care provider to order a basic metabolic panel.
ANS: D
Generalized weakness is a manifestation of hypokalemia. After the health care provider orders the metabolic
panel, the nurse should check the potassium level. Facial muscle spasms might occur with hypocalcemia.
Orange juice is high in potassium and would be advisable to drink if the patient was hypokalemic. Loose stools
are associated with hyperkalemia.
A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important
for the nurse to monitor for while the patient is receiving this infusion?
a. Lung sounds
b. Urinary output
c. Peripheral pulses
d. Peripheral edema
ANS: A
Hypertonic solutions cause water retention, so the patient should be monitored for symptoms of fluid excess.
Crackles in the lungs may indicate the onset of pulmonary edema and are a serious manifestation of fluid
excess. Bounding peripheral pulses, peripheral edema, or changes in urine output are also important to monitor
when administering hypertonic solutions, but they do not indicate acute respiratory or cardiac decompensation.
A patient is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data will
require the most rapid response by the nurse?
a. The patients radial pulse is 105 beats/minute.
b. There is sediment and blood in the patients urine.
c. The blood pressure increases from 120/80 to 142/94.
d. There are crackles audible throughout both lung fields.
ANS: D
Crackles throughout both lungs suggest that the patient may be experiencing pulmonary edema, a life-
threatening adverse effect of hypertonic solutions. The increased pulse rate and blood pressure and the
appearance of the urine also should be reported, but they are not as dangerous as the presence of fluid in the
alveoli.
After receiving change-of-shift report, which patient should the nurse assess first?
Patient with serum potassium level of 5.0 mEq/L who is complaining
a. of abdominal cramping
Patient with serum sodium level of 145 mEq/L who has a dry mouth
b. and is asking for a glass of water
Patient with serum magnesium level of 1.1 mEq/L who has tremors
c. and hyperactive deep tendon reflexes
Patient with serum phosphorus level of 4.5 mg/dL who has multiple
d. soft tissue calcium-phosphate precipitates
,NUES 1234 EXAM QUESTIONS WITH CORRECT ANSWERS A+
ANS: C
The low magnesium level and neuromuscular irritability suggest that the patient may be at risk for seizures. The
other patients have mild electrolyte disturbances and/or symptoms that require action, but they are not at risk for
life-threatening complications.
A patient who had a transverse colectomy for diverticulosis 18 hours ago has nasogastric suction and is
complaining of anxiety and incisional pain. The patients respiratory rate is 32 breaths/minute and the
arterial blood gases (ABGs) indicate respiratory alkalosis. Which action should the nurse take first?
a. Discontinue the nasogastric suction.
b. Give the patient the PRN IV morphine sulfate 4 mg.
c. Notify the health care provider about the ABG results.
d. Teach the patient how to take slow, deep breaths when
anxious. ANS: B
The patients respiratory alkalosis is caused by the increased respiratory rate associated with pain and anxiety.
The nurses first action should be to medicate the patient for pain. Although the nasogastric suction may
contribute to the alkalosis, it is not appropriate to discontinue the tube when the patient needs gastric suction.
The health care provider may be notified about the ABGs but is likely to instruct the nurse to medicate for pain.
The patient will not be able to take slow, deep breaths when experiencing pain.
A patient is admitted for hypovolemia associated with multiple draining wounds. Which assessment would be
the most accurate way for the nurse to evaluate fluid balance?
a. Skin turgor
b. Daily weight
c. Presence of edema
d. Hourly urine output
ANS: B
Daily weight is the most easily obtained and accurate means of assessing volume status. Skin turgor varies
considerably with age. Considerable excess fluid volume may be present before fluid moves into the interstitial
space and causes edema. Although very important, hourly urine outputs do not take account of fluid intake or
of fluid loss through insensible loss, sweating, or loss from the gastrointestinal tract or wounds.
During assessment of the patient with fibromyalgia, the nurse would expect the patient to report which of the
following (select all that apply)?
a. Sleep disturbances
b. Multiple tender points
c. Cardiac palpitations and dizziness
d. Multijoint pain with inflammation and swelling
e. Widespread bilateral, burning musculoskeletal
pain ANS: A, B, E
These symptoms are commonly described by patients with fibromyalgia. Cardiac involvement and joint
inflammation are not typical of fibromyalgia.
A 27-year-old patient who has been treated for status epilepticus in the emergency department will be
transferred to the medical nursing unit. Which equipment should the nurse have available in the
patients assigned room (select all that apply)?
a. Side-rail pads
,NUES 1234 EXAM QUESTIONS WITH CORRECT ANSWERS A+
b. Tongue blade
c. Oxygen mask
d. Suction tubing
e. Urinary catheter
f. Nasogastric tube
ANS: A, C, D
The patient is at risk for further seizures, and oxygen and suctioning may be needed after any seizures to clear
the airway and maximize oxygenation. The beds side rails should be padded to minimize the risk for patient
injury during a seizure. Use of tongue blades during a seizure is contraindicated. Insertion of a nasogastric (NG)
tube is not indicated because the airway problem is not caused by vomiting or abdominal distention. A urinary
catheter is not required unless there is urinary retention.
Which nursing actions can the nurse working in a womens health clinic delegate to unlicensed
assistive personnel (UAP) (select all that apply)?
a. Call a patient with the results of an endometrial biopsy.
b. Assist the health care provider with performing a Pap test.
c. Draw blood for CA-125 levels for a patient with ovarian cancer.
d. Screen a patient for use of medications that may cause amenorrhea.
Teach the parent of a 10-year-old about the human papilloma virus (HPV) vaccine
e. (Gardasil).
ANS: B, C
Assisting with a Pap test and drawing blood (if trained) are skills that require minimal critical thinking and
judgment and can be safely delegated to UAP. Patient teaching, calling a patient who may have questions
about results of diagnostic testing, and risk-factor screening all require more education and critical thinking and
should be done by the registered nurse (RN).
The nurse is preparing to teach a 43-year-old man who is newly diagnosed with type 2 diabetes about home
management of the disease. Which action should the nurse take first?
a. Ask the patients family to participate in the diabetes education program.
b. Assess the patients perception of what it means to have diabetes mellitus.
c. Demonstrate how to check glucose using capillary blood glucose monitoring.
d. Discuss the need for the patient to actively participate in diabetes management.
ANS: B
Before planning teaching, the nurse should assess the patients interest in and ability to self-manage the diabetes.
After assessing the patient, the other nursing actions may be appropriate, but planning needs to be
individualized to each patient.
Which finding by the nurse when assessing a patient with Hashimotos thyroiditis and a goiter will
require the most immediate action?
a. New-onset changes in the patients voice
b. Apical pulse rate at rest 112 beats/minute
c. Elevation in the patients T3 and T4 levels
d. Bruit audible bilaterally over the thyroid gland
ANS: A
, NUES 1234 EXAM QUESTIONS WITH CORRECT ANSWERS A+
Changes in the patients voice indicate that the goiter is compressing the laryngeal nerve and may lead to airway
compression. The other findings will also be reported but are expected with Hashimotos thyroiditis and do not
require immediate action.
Which prescribed medication should the nurse administer first to a 60-year-old patient admitted to
the emergency department in thyroid storm?
a. Propranolol (Inderal)
b. Propylthiouracil (PTU)
c. Methimazole (Tapazole)
d. Iodine (Lugols solution)
ANS: A
b-Adrenergic blockers work rapidly to decrease the cardiovascular manifestations of thyroid storm. The other
medications take days to weeks to have an impact on thyroid function.
Which assessment finding for a 33-year-old female patient admitted with Graves disease
requires the most rapid intervention by the nurse?
a. Bilateral exophthalmos
b. Heart rate 136 beats/minute
c. Temperature 103.8 F (40.4 C)
d. Blood pressure 166/100 mm Hg
ANS: C
The patients temperature indicates that the patient may have thyrotoxic crisis and that interventions to lower the
temperature are needed immediately. The other findings also require intervention but do not indicate
potentially life-threatening complications.
A 37-year-old patient is being admitted with a diagnosis of Cushing syndrome. Which findings will the
nurse expect during the assessment?
a. Chronically low blood pressure
b. Bronzed appearance of the skin
c. Purplish streaks on the abdomen
d. Decreased axillary and pubic hair
ANS: C
Purplish-red striae on the abdomen are a common clinical manifestation of Cushing syndrome. Hypotension and
bronzed-appearing skin are manifestations of Addisons disease. Decreased axillary and pubic hair occur with
androgen deficiency.
hich nursing assessment of a 69-year-old patient is most important to make during initiation of thyroid
replacement with levothyroxine (Synthroid)?
a. Fluid balance
b. Apical pulse rate
c. Nutritional intake
d. Orientation and alertness
ANS: B
In older patients, initiation of levothyroxine therapy can increase myocardial oxygen demand and cause angina
or dysrhythmias. The medication also is expected to improve mental status and fluid balance and will increase
A patient who is taking a potassium-wasting diuretic for treatment of hypertension complains of generalized
weakness. It is most appropriate for the nurse to take which action?
a. Assess for facial muscle spasms.
b. Ask the patient about loose stools.
c. Suggest that the patient avoid orange juice with meals.
d. Ask the health care provider to order a basic metabolic panel.
ANS: D
Generalized weakness is a manifestation of hypokalemia. After the health care provider orders the metabolic
panel, the nurse should check the potassium level. Facial muscle spasms might occur with hypocalcemia.
Orange juice is high in potassium and would be advisable to drink if the patient was hypokalemic. Loose stools
are associated with hyperkalemia.
A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important
for the nurse to monitor for while the patient is receiving this infusion?
a. Lung sounds
b. Urinary output
c. Peripheral pulses
d. Peripheral edema
ANS: A
Hypertonic solutions cause water retention, so the patient should be monitored for symptoms of fluid excess.
Crackles in the lungs may indicate the onset of pulmonary edema and are a serious manifestation of fluid
excess. Bounding peripheral pulses, peripheral edema, or changes in urine output are also important to monitor
when administering hypertonic solutions, but they do not indicate acute respiratory or cardiac decompensation.
A patient is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data will
require the most rapid response by the nurse?
a. The patients radial pulse is 105 beats/minute.
b. There is sediment and blood in the patients urine.
c. The blood pressure increases from 120/80 to 142/94.
d. There are crackles audible throughout both lung fields.
ANS: D
Crackles throughout both lungs suggest that the patient may be experiencing pulmonary edema, a life-
threatening adverse effect of hypertonic solutions. The increased pulse rate and blood pressure and the
appearance of the urine also should be reported, but they are not as dangerous as the presence of fluid in the
alveoli.
After receiving change-of-shift report, which patient should the nurse assess first?
Patient with serum potassium level of 5.0 mEq/L who is complaining
a. of abdominal cramping
Patient with serum sodium level of 145 mEq/L who has a dry mouth
b. and is asking for a glass of water
Patient with serum magnesium level of 1.1 mEq/L who has tremors
c. and hyperactive deep tendon reflexes
Patient with serum phosphorus level of 4.5 mg/dL who has multiple
d. soft tissue calcium-phosphate precipitates
,NUES 1234 EXAM QUESTIONS WITH CORRECT ANSWERS A+
ANS: C
The low magnesium level and neuromuscular irritability suggest that the patient may be at risk for seizures. The
other patients have mild electrolyte disturbances and/or symptoms that require action, but they are not at risk for
life-threatening complications.
A patient who had a transverse colectomy for diverticulosis 18 hours ago has nasogastric suction and is
complaining of anxiety and incisional pain. The patients respiratory rate is 32 breaths/minute and the
arterial blood gases (ABGs) indicate respiratory alkalosis. Which action should the nurse take first?
a. Discontinue the nasogastric suction.
b. Give the patient the PRN IV morphine sulfate 4 mg.
c. Notify the health care provider about the ABG results.
d. Teach the patient how to take slow, deep breaths when
anxious. ANS: B
The patients respiratory alkalosis is caused by the increased respiratory rate associated with pain and anxiety.
The nurses first action should be to medicate the patient for pain. Although the nasogastric suction may
contribute to the alkalosis, it is not appropriate to discontinue the tube when the patient needs gastric suction.
The health care provider may be notified about the ABGs but is likely to instruct the nurse to medicate for pain.
The patient will not be able to take slow, deep breaths when experiencing pain.
A patient is admitted for hypovolemia associated with multiple draining wounds. Which assessment would be
the most accurate way for the nurse to evaluate fluid balance?
a. Skin turgor
b. Daily weight
c. Presence of edema
d. Hourly urine output
ANS: B
Daily weight is the most easily obtained and accurate means of assessing volume status. Skin turgor varies
considerably with age. Considerable excess fluid volume may be present before fluid moves into the interstitial
space and causes edema. Although very important, hourly urine outputs do not take account of fluid intake or
of fluid loss through insensible loss, sweating, or loss from the gastrointestinal tract or wounds.
During assessment of the patient with fibromyalgia, the nurse would expect the patient to report which of the
following (select all that apply)?
a. Sleep disturbances
b. Multiple tender points
c. Cardiac palpitations and dizziness
d. Multijoint pain with inflammation and swelling
e. Widespread bilateral, burning musculoskeletal
pain ANS: A, B, E
These symptoms are commonly described by patients with fibromyalgia. Cardiac involvement and joint
inflammation are not typical of fibromyalgia.
A 27-year-old patient who has been treated for status epilepticus in the emergency department will be
transferred to the medical nursing unit. Which equipment should the nurse have available in the
patients assigned room (select all that apply)?
a. Side-rail pads
,NUES 1234 EXAM QUESTIONS WITH CORRECT ANSWERS A+
b. Tongue blade
c. Oxygen mask
d. Suction tubing
e. Urinary catheter
f. Nasogastric tube
ANS: A, C, D
The patient is at risk for further seizures, and oxygen and suctioning may be needed after any seizures to clear
the airway and maximize oxygenation. The beds side rails should be padded to minimize the risk for patient
injury during a seizure. Use of tongue blades during a seizure is contraindicated. Insertion of a nasogastric (NG)
tube is not indicated because the airway problem is not caused by vomiting or abdominal distention. A urinary
catheter is not required unless there is urinary retention.
Which nursing actions can the nurse working in a womens health clinic delegate to unlicensed
assistive personnel (UAP) (select all that apply)?
a. Call a patient with the results of an endometrial biopsy.
b. Assist the health care provider with performing a Pap test.
c. Draw blood for CA-125 levels for a patient with ovarian cancer.
d. Screen a patient for use of medications that may cause amenorrhea.
Teach the parent of a 10-year-old about the human papilloma virus (HPV) vaccine
e. (Gardasil).
ANS: B, C
Assisting with a Pap test and drawing blood (if trained) are skills that require minimal critical thinking and
judgment and can be safely delegated to UAP. Patient teaching, calling a patient who may have questions
about results of diagnostic testing, and risk-factor screening all require more education and critical thinking and
should be done by the registered nurse (RN).
The nurse is preparing to teach a 43-year-old man who is newly diagnosed with type 2 diabetes about home
management of the disease. Which action should the nurse take first?
a. Ask the patients family to participate in the diabetes education program.
b. Assess the patients perception of what it means to have diabetes mellitus.
c. Demonstrate how to check glucose using capillary blood glucose monitoring.
d. Discuss the need for the patient to actively participate in diabetes management.
ANS: B
Before planning teaching, the nurse should assess the patients interest in and ability to self-manage the diabetes.
After assessing the patient, the other nursing actions may be appropriate, but planning needs to be
individualized to each patient.
Which finding by the nurse when assessing a patient with Hashimotos thyroiditis and a goiter will
require the most immediate action?
a. New-onset changes in the patients voice
b. Apical pulse rate at rest 112 beats/minute
c. Elevation in the patients T3 and T4 levels
d. Bruit audible bilaterally over the thyroid gland
ANS: A
, NUES 1234 EXAM QUESTIONS WITH CORRECT ANSWERS A+
Changes in the patients voice indicate that the goiter is compressing the laryngeal nerve and may lead to airway
compression. The other findings will also be reported but are expected with Hashimotos thyroiditis and do not
require immediate action.
Which prescribed medication should the nurse administer first to a 60-year-old patient admitted to
the emergency department in thyroid storm?
a. Propranolol (Inderal)
b. Propylthiouracil (PTU)
c. Methimazole (Tapazole)
d. Iodine (Lugols solution)
ANS: A
b-Adrenergic blockers work rapidly to decrease the cardiovascular manifestations of thyroid storm. The other
medications take days to weeks to have an impact on thyroid function.
Which assessment finding for a 33-year-old female patient admitted with Graves disease
requires the most rapid intervention by the nurse?
a. Bilateral exophthalmos
b. Heart rate 136 beats/minute
c. Temperature 103.8 F (40.4 C)
d. Blood pressure 166/100 mm Hg
ANS: C
The patients temperature indicates that the patient may have thyrotoxic crisis and that interventions to lower the
temperature are needed immediately. The other findings also require intervention but do not indicate
potentially life-threatening complications.
A 37-year-old patient is being admitted with a diagnosis of Cushing syndrome. Which findings will the
nurse expect during the assessment?
a. Chronically low blood pressure
b. Bronzed appearance of the skin
c. Purplish streaks on the abdomen
d. Decreased axillary and pubic hair
ANS: C
Purplish-red striae on the abdomen are a common clinical manifestation of Cushing syndrome. Hypotension and
bronzed-appearing skin are manifestations of Addisons disease. Decreased axillary and pubic hair occur with
androgen deficiency.
hich nursing assessment of a 69-year-old patient is most important to make during initiation of thyroid
replacement with levothyroxine (Synthroid)?
a. Fluid balance
b. Apical pulse rate
c. Nutritional intake
d. Orientation and alertness
ANS: B
In older patients, initiation of levothyroxine therapy can increase myocardial oxygen demand and cause angina
or dysrhythmias. The medication also is expected to improve mental status and fluid balance and will increase
