NURS 316 EXAM 1 QUESTIONS WITH COMPLETE
SOLUTIONS
Course
NURS 316
1. A nurse is assessing a patient with pneumonia. Which of the following
findings would be most indicative of a serious complication?
A. Fever and chills
B. Productive cough with green sputum
C. Tachypnea and use of accessory muscles
D. Dullness to percussion over lung fields
Answer: C. Tachypnea and use of accessory muscles
Rationale: Tachypnea and the use of accessory muscles indicate respiratory distress,
suggesting a serious complication such as respiratory failure or severe hypoxia in a
patient with pneumonia. While fever, chills, and productive cough are common, they
do not indicate the severity of the condition as much as the respiratory distress.
2. A nurse is caring for a patient diagnosed with diabetes mellitus type 2
who is receiving metformin. Which of the following lab values should
the nurse monitor?
A. Blood glucose levels
B. Serum potassium levels
C. Liver function tests
D. Serum creatinine levels
Answer: D. Serum creatinine levels
Rationale: Metformin is contraindicated in patients with renal impairment as it can
lead to lactic acidosis. Therefore, monitoring serum creatinine levels is crucial to
ensure the patient’s kidneys are functioning adequately.
3. A patient with chronic heart failure is prescribed a low-sodium diet.
Which of the following foods would be most appropriate for the nurse
to suggest?
A. Canned soup
B. Fresh fruits
C. Processed cheese
D. Pickled vegetables
Answer: B. Fresh fruits
Rationale: Fresh fruits are naturally low in sodium and should be encouraged in a
low-sodium diet. Canned soup, processed cheese, and pickled vegetables typically
contain high amounts of sodium, which should be avoided in patients with heart
failure.
4. A nurse is teaching a patient about self-management of hypertension.
Which statement by the patient indicates a correct understanding of the
teaching?
A. "I can stop taking my medication if my blood pressure is normal."
, B. "I will monitor my blood pressure daily at the same time."
C. "I can consume as much salt as I want as long as I take my medication."
D. "I should only exercise if my blood pressure is high."
Answer: B. "I will monitor my blood pressure daily at the same time."
Rationale: Consistent monitoring of blood pressure at the same time each day helps
track the effectiveness of treatment and identify any significant changes. Medications
should not be stopped without consulting a healthcare provider, and sodium intake
should be limited regardless of medication adherence.
5. A nurse is assessing a patient who has just undergone surgery for a
total hip replacement. Which of the following findings would indicate a
possible complication?
A. Pain at the surgical site
B. Slight fever
C. Diminished pulses in the affected leg
D. Swelling around the incision site
Answer: C. Diminished pulses in the affected leg
Rationale: Diminished pulses in the affected leg can indicate impaired circulation or
a potential vascular complication, such as deep vein thrombosis (DVT) or arterial
occlusion. Pain, slight fever, and swelling may be expected post-surgery but require
monitoring for changes.
6. A nurse is caring for a patient with a gastrointestinal bleed. Which
laboratory value should the nurse expect to be abnormal?
A. Decreased hemoglobin and hematocrit
B. Increased serum calcium
C. Increased white blood cell count
D. Decreased platelet count
Answer: A. Decreased hemoglobin and hematocrit
Rationale: A gastrointestinal bleed typically leads to a decrease in hemoglobin and
hematocrit due to blood loss. The white blood cell count may be increased due to
stress or infection, but it is not a direct indicator of bleeding.
7. A nurse is providing education to a patient with asthma about the use
of a peak flow meter. Which statement indicates the patient
understands the instructions?
A. "I will use it when I feel short of breath."
B. "I will blow into it as hard as I can."
C. "I will take my reading before I use my inhaler."
D. "I should aim for the lowest reading possible."
Answer: B. "I will blow into it as hard as I can."
Rationale: The patient should blow into the peak flow meter forcefully to obtain an
accurate reading of their peak expiratory flow rate. Readings should ideally be taken
when the patient is not experiencing symptoms to monitor baseline lung function.
, 8. A patient with a history of substance abuse is being discharged with a
prescription for naloxone (Narcan). The nurse explains that this
medication is used to:
A. Treat opioid withdrawal symptoms
B. Reverse the effects of an opioid overdose
C. Manage chronic pain
D. Prevent respiratory depression in opioid users
Answer: B. Reverse the effects of an opioid overdose
Rationale: Naloxone (Narcan) is an opioid antagonist used to reverse the effects of an
opioid overdose, particularly respiratory depression. It is not used to manage chronic
pain or treat withdrawal symptoms.
9. A nurse is reviewing medication orders for a patient with heart
failure. Which medication is most important for the nurse to administer
on time?
A. Furosemide (Lasix)
B. Lisinopril (Prinivil)
C. Digoxin (Lanoxin)
D. Metoprolol (Lopressor)
Answer: A. Furosemide (Lasix)
Rationale: Furosemide, a loop diuretic, is critical in managing fluid overload in heart
failure patients. Timely administration helps prevent complications related to fluid
retention. While the other medications are important, diuretics often have immediate
effects on fluid status.
10. A nurse is caring for a patient with a diagnosis of pancreatitis.
Which of the following dietary recommendations should the nurse
provide?
A. High-fat diet to promote calorie intake
B. Low-protein diet to reduce strain on the pancreas
C. Clear liquids during the acute phase
D. Full-fat dairy products to increase nutrition
Answer: C. Clear liquids during the acute phase
Rationale: During the acute phase of pancreatitis, a clear liquid diet is often
recommended to minimize pancreatic stimulation. As the patient stabilizes, the diet
can gradually progress to low-fat foods. High-fat and full-fat dairy products can
exacerbate pancreatitis.
11. A nurse is caring for a patient who has just received a blood transfusion.
Which of the following findings would indicate a potential transfusion
reaction?
A. Mild fever and chills
B. Hives and itching
C. Dyspnea and chest tightness
, D. Increased heart rate
Answer: C. Dyspnea and chest tightness
Rationale: Dyspnea and chest tightness are indicative of a potentially serious transfusion
reaction, such as an anaphylactic or hemolytic reaction. While mild fever, hives, and
increased heart rate can occur, dyspnea and chest tightness are more critical and require
immediate intervention.
12. A nurse is assessing a patient with chronic obstructive pulmonary disease
(COPD) who is experiencing shortness of breath. Which position would be
most beneficial for this patient?
A. Supine
B. Fowlers
C. Prone
D. Lithotomy
Answer: B. Fowlers
Rationale: The Fowler's position (sitting upright) is beneficial for patients with COPD as it
promotes lung expansion and eases shortness of breath. It allows for better ventilation and
can help improve oxygenation.
13. A nurse is providing discharge teaching to a patient who has undergone a
total abdominal hysterectomy. Which of the following statements by the
patient indicates a need for further teaching?
A. "I will avoid heavy lifting for six weeks."
B. "I should expect some vaginal bleeding for a few days."
C. "I can resume sexual activity as soon as I feel ready."
D. "I should use a heating pad on my abdomen if I feel discomfort."
Answer: D. "I should use a heating pad on my abdomen if I feel discomfort."
Rationale: After a total abdominal hysterectomy, using a heating pad on the abdomen is
generally discouraged due to the risk of increasing swelling and bleeding. Patients should be
advised on proper pain management and when to contact their healthcare provider.
SOLUTIONS
Course
NURS 316
1. A nurse is assessing a patient with pneumonia. Which of the following
findings would be most indicative of a serious complication?
A. Fever and chills
B. Productive cough with green sputum
C. Tachypnea and use of accessory muscles
D. Dullness to percussion over lung fields
Answer: C. Tachypnea and use of accessory muscles
Rationale: Tachypnea and the use of accessory muscles indicate respiratory distress,
suggesting a serious complication such as respiratory failure or severe hypoxia in a
patient with pneumonia. While fever, chills, and productive cough are common, they
do not indicate the severity of the condition as much as the respiratory distress.
2. A nurse is caring for a patient diagnosed with diabetes mellitus type 2
who is receiving metformin. Which of the following lab values should
the nurse monitor?
A. Blood glucose levels
B. Serum potassium levels
C. Liver function tests
D. Serum creatinine levels
Answer: D. Serum creatinine levels
Rationale: Metformin is contraindicated in patients with renal impairment as it can
lead to lactic acidosis. Therefore, monitoring serum creatinine levels is crucial to
ensure the patient’s kidneys are functioning adequately.
3. A patient with chronic heart failure is prescribed a low-sodium diet.
Which of the following foods would be most appropriate for the nurse
to suggest?
A. Canned soup
B. Fresh fruits
C. Processed cheese
D. Pickled vegetables
Answer: B. Fresh fruits
Rationale: Fresh fruits are naturally low in sodium and should be encouraged in a
low-sodium diet. Canned soup, processed cheese, and pickled vegetables typically
contain high amounts of sodium, which should be avoided in patients with heart
failure.
4. A nurse is teaching a patient about self-management of hypertension.
Which statement by the patient indicates a correct understanding of the
teaching?
A. "I can stop taking my medication if my blood pressure is normal."
, B. "I will monitor my blood pressure daily at the same time."
C. "I can consume as much salt as I want as long as I take my medication."
D. "I should only exercise if my blood pressure is high."
Answer: B. "I will monitor my blood pressure daily at the same time."
Rationale: Consistent monitoring of blood pressure at the same time each day helps
track the effectiveness of treatment and identify any significant changes. Medications
should not be stopped without consulting a healthcare provider, and sodium intake
should be limited regardless of medication adherence.
5. A nurse is assessing a patient who has just undergone surgery for a
total hip replacement. Which of the following findings would indicate a
possible complication?
A. Pain at the surgical site
B. Slight fever
C. Diminished pulses in the affected leg
D. Swelling around the incision site
Answer: C. Diminished pulses in the affected leg
Rationale: Diminished pulses in the affected leg can indicate impaired circulation or
a potential vascular complication, such as deep vein thrombosis (DVT) or arterial
occlusion. Pain, slight fever, and swelling may be expected post-surgery but require
monitoring for changes.
6. A nurse is caring for a patient with a gastrointestinal bleed. Which
laboratory value should the nurse expect to be abnormal?
A. Decreased hemoglobin and hematocrit
B. Increased serum calcium
C. Increased white blood cell count
D. Decreased platelet count
Answer: A. Decreased hemoglobin and hematocrit
Rationale: A gastrointestinal bleed typically leads to a decrease in hemoglobin and
hematocrit due to blood loss. The white blood cell count may be increased due to
stress or infection, but it is not a direct indicator of bleeding.
7. A nurse is providing education to a patient with asthma about the use
of a peak flow meter. Which statement indicates the patient
understands the instructions?
A. "I will use it when I feel short of breath."
B. "I will blow into it as hard as I can."
C. "I will take my reading before I use my inhaler."
D. "I should aim for the lowest reading possible."
Answer: B. "I will blow into it as hard as I can."
Rationale: The patient should blow into the peak flow meter forcefully to obtain an
accurate reading of their peak expiratory flow rate. Readings should ideally be taken
when the patient is not experiencing symptoms to monitor baseline lung function.
, 8. A patient with a history of substance abuse is being discharged with a
prescription for naloxone (Narcan). The nurse explains that this
medication is used to:
A. Treat opioid withdrawal symptoms
B. Reverse the effects of an opioid overdose
C. Manage chronic pain
D. Prevent respiratory depression in opioid users
Answer: B. Reverse the effects of an opioid overdose
Rationale: Naloxone (Narcan) is an opioid antagonist used to reverse the effects of an
opioid overdose, particularly respiratory depression. It is not used to manage chronic
pain or treat withdrawal symptoms.
9. A nurse is reviewing medication orders for a patient with heart
failure. Which medication is most important for the nurse to administer
on time?
A. Furosemide (Lasix)
B. Lisinopril (Prinivil)
C. Digoxin (Lanoxin)
D. Metoprolol (Lopressor)
Answer: A. Furosemide (Lasix)
Rationale: Furosemide, a loop diuretic, is critical in managing fluid overload in heart
failure patients. Timely administration helps prevent complications related to fluid
retention. While the other medications are important, diuretics often have immediate
effects on fluid status.
10. A nurse is caring for a patient with a diagnosis of pancreatitis.
Which of the following dietary recommendations should the nurse
provide?
A. High-fat diet to promote calorie intake
B. Low-protein diet to reduce strain on the pancreas
C. Clear liquids during the acute phase
D. Full-fat dairy products to increase nutrition
Answer: C. Clear liquids during the acute phase
Rationale: During the acute phase of pancreatitis, a clear liquid diet is often
recommended to minimize pancreatic stimulation. As the patient stabilizes, the diet
can gradually progress to low-fat foods. High-fat and full-fat dairy products can
exacerbate pancreatitis.
11. A nurse is caring for a patient who has just received a blood transfusion.
Which of the following findings would indicate a potential transfusion
reaction?
A. Mild fever and chills
B. Hives and itching
C. Dyspnea and chest tightness
, D. Increased heart rate
Answer: C. Dyspnea and chest tightness
Rationale: Dyspnea and chest tightness are indicative of a potentially serious transfusion
reaction, such as an anaphylactic or hemolytic reaction. While mild fever, hives, and
increased heart rate can occur, dyspnea and chest tightness are more critical and require
immediate intervention.
12. A nurse is assessing a patient with chronic obstructive pulmonary disease
(COPD) who is experiencing shortness of breath. Which position would be
most beneficial for this patient?
A. Supine
B. Fowlers
C. Prone
D. Lithotomy
Answer: B. Fowlers
Rationale: The Fowler's position (sitting upright) is beneficial for patients with COPD as it
promotes lung expansion and eases shortness of breath. It allows for better ventilation and
can help improve oxygenation.
13. A nurse is providing discharge teaching to a patient who has undergone a
total abdominal hysterectomy. Which of the following statements by the
patient indicates a need for further teaching?
A. "I will avoid heavy lifting for six weeks."
B. "I should expect some vaginal bleeding for a few days."
C. "I can resume sexual activity as soon as I feel ready."
D. "I should use a heating pad on my abdomen if I feel discomfort."
Answer: D. "I should use a heating pad on my abdomen if I feel discomfort."
Rationale: After a total abdominal hysterectomy, using a heating pad on the abdomen is
generally discouraged due to the risk of increasing swelling and bleeding. Patients should be
advised on proper pain management and when to contact their healthcare provider.
