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NUR 213 NUR213 - FINAL EXAM _Q&A/NUR 213 - FINAL EXAM
1 _Q& QUESTIONS AND CORRECT ANSWERS (VERIFIED
ANSWERS) PLUS RATIONALES 2025 Excelsior College
- What is the primary function of the respiratory system? a) Digestion b) Gas exchange c) Hormone production d) Waste elimination The respiratory system's main role is to facilitate gas exchange, bringing oxygen into the body and removing carbon dioxide.
- Which electrolyte imbalance is most commonly associated with prolonged vomiting? a) Hyperkalemia b) Hyponatremia c) Hypokalemia d) Hypercalcemia Vomiting leads to loss of gastric contents rich in potassium, causing hypokalemia.
- When assessing a patient's pain, which scale is most appropriate? a) Glasgow Coma Scale b) Apgar Score c) Numeric Rating Scale (0-10)
d) Braden Scale The Numeric Rating Scale is commonly used to quantify pain intensity.
- What is the normal range for adult heart rate? a) 30-50 bpm b) 60 - 100 bpm c) 100-120 bpm d) 120-140 bpm The normal adult heart rate ranges between 60 and 100 beats per minute.
- Which of the following is a sign of hypoxia? a) Bradycardia b) Cyanosis c) Hyperthermia d) Hypotension Cyanosis, a bluish discoloration of the skin, indicates inadequate oxygenation of tissues.
- The first action when a patient has an obstructed airway is to: a) Administer oxygen b) Perform the Heimlich maneuver c) Call a code d) Start chest compressions Removing the obstruction is the priority to restore airway patency.
- What is the purpose of a chest tube? a) Administer medications b) Remove air or fluid from the pleural space
b) Sitting upright c) Trendelenburg position d) Prone position Trendelenburg position helps increase venous return to the heart. 12.The nurse notes a patient has a positive Babinski reflex. This finding is: a) Normal in adults b) Indicative of normal neurological function c) Abnormal in adults, may indicate neurological damage d) A sign of dehydration Babinski reflex is normal in infants but indicates CNS damage if present in adults. 13.Which of the following is an appropriate nursing intervention for a patient with a fever? a) Limit fluid intake b) Encourage fluids and monitor temperature c) Avoid aspirin d) Restrict activity Fluids help prevent dehydration and assist in temperature regulation. 14.What type of isolation precautions are required for a patient with tuberculosis? a) Contact precautions b) Airborne precautions c) Droplet precautions d) Standard precautions only
TB is transmitted via airborne particles; thus airborne precautions are necessary. 15.Which finding indicates effective pain management? a) Patient avoids movement b) Patient reports pain at a tolerable level c) Patient shows no facial expression d) Patient refuses medication Effective pain management means the patient reports pain within a manageable range. 16.What is the priority action when a patient exhibits signs of anaphylaxis? a) Administer antihistamines b) Administer epinephrine immediately c) Provide oxygen only d) Monitor vital signs every hour Epinephrine reverses airway constriction and shock quickly during anaphylaxis. 17.The most common cause of chronic kidney disease is: a) Infection b) Trauma c) Diabetes mellitus d) Hypertension Diabetes is the leading cause of CKD due to high blood sugar damaging nephrons.
c) Used for all patients to prevent infection transmission d) Used only for bloodborne pathogens Standard precautions are applied universally to all patient care. 22.A patient on a low-sodium diet should avoid: a) Fresh vegetables b) Processed foods c) Lean meats d) Whole grains Processed foods often contain high levels of sodium. 23.Which is the best method to assess for dehydration in an elderly patient? a) Heart rate b) Blood pressure c) Skin turgor on the sternum or forehead d) Respiratory rate Skin turgor on less elastic areas like sternum is more reliable in elderly. 24.What is the correct site for an intramuscular injection in an adult? a) Deltoid b) Ventrogluteal c) Vastus lateralis d) All of the above depending on volume and medication These sites are common IM injection sites chosen based on medication and volume. 25.A patient with a hemoglobin of 8 g/dL most likely has: a) Infection
b) Anemia c) Hyperglycemia d) Thrombocytopenia Low hemoglobin indicates anemia. 26.Which symptom is characteristic of hypoglycemia? a) Polyuria b) Polydipsia c) Sweating and shakiness d) Dry mouth Hypoglycemia typically presents with autonomic symptoms like sweating and tremors. 27.What is the appropriate nursing intervention for a patient with a nasogastric tube? a) Leave the tube open to air b) Check placement before feeding or medication administration c) Flush with cold water only d) Remove after 2 days Confirming tube placement prevents aspiration. 28.What does a pulse oximeter measure? a) Heart rate only b) Blood pressure c) Oxygen saturation of hemoglobin d) Carbon dioxide levels
c) Forearm d) Palm Fingertip capillary refill reflects peripheral perfusion. 33.A patient has a blood glucose level of 250 mg/dL. What is the best immediate nursing action? a) Administer insulin as ordered b) Provide a sugary snack c) Check for signs of diabetic ketoacidosis d) Restrict fluids High glucose requires assessment for complications like DKA. 34.What is the primary goal of palliative care? a) Cure the disease b) Relieve symptoms and improve quality of life c) Prolong hospital stay d) Perform surgery Palliative care focuses on comfort and symptom management. 35.Which vitamin deficiency causes scurvy? a) Vitamin A b) Vitamin C c) Vitamin D d) Vitamin B Vitamin C deficiency leads to scurvy. 36.What is the first step in performing CPR on an adult? a) Give breaths
b) Check responsiveness and call for help c) Start chest compressions immediately d) Open airway Ensuring safety and responsiveness before CPR is standard protocol. 37.Which of the following drugs is classified as a beta-blocker? a) Lisinopril b) Furosemide c) Metoprolol d) Digoxin Metoprolol is a beta-blocker used to treat hypertension and heart conditions. 38.A patient has a serum potassium level of 6.2 mEq/L. The nurse should: a) Administer potassium supplements b) Prepare to administer potassium-lowering interventions c) Restrict sodium intake d) Encourage fluids Hyperkalemia requires urgent treatment to prevent cardiac arrhythmias. 39.Which nursing action is appropriate for preventing deep vein thrombosis (DVT)? a) Encourage bed rest b) Promote early ambulation and leg exercises c) Restrict fluid intake d) Apply tight compression stockings Mobilization helps prevent venous stasis and clot formation.
d) Bradycardia COPD exacerbations present with worsening respiratory symptoms. 44.The nurse is caring for a patient with a Foley catheter. Which action reduces the risk of infection? a) Disconnect catheter tubing frequently b) Maintain a closed drainage system c) Irrigate catheter daily d) Keep drainage bag above bladder level A closed system minimizes introduction of pathogens. 45.What is the recommended site for subcutaneous injections? a) Deltoid muscle b) Ventrogluteal muscle c) Abdomen, thigh, or upper arm d) Vastus lateralis Subcutaneous injections are given in fatty tissue such as the abdomen or thigh. 46.A patient with hypovolemic shock is most likely to have: a) Bradycardia b) Hypertension c) Tachycardia and hypotension d) Normal vital signs Shock leads to decreased blood volume, causing low blood pressure and compensatory tachycardia.
47.Which of the following best describes a focused nursing assessment? a) Comprehensive assessment of all body systems b) Assessment limited to a specific problem or complaint c) Assessment only done on admission d) Quick head-to-toe assessment Focused assessment targets a specific concern or symptom. 48.What is the normal urinary output per hour in adults? a) 10-20 mL/hr b) 20-30 mL/hr c) 30 - 50 mL/hr d) 50-70 mL/hr Normal adult urine output is approximately 30-50 mL/hr. 49.Which of the following best describes the term “aseptic technique”? a) Use of sterile gloves only b) Procedures that prevent contamination by pathogens c) Cleaning the skin with soap d) Wearing a surgical mask Aseptic technique encompasses all practices to prevent infection. 50.A patient receiving IV therapy reports pain and swelling at the insertion site. The nurse suspects: a) Phlebitis b) Infiltration c) Air embolism d) Hematoma
54.What is the primary purpose of prophylactic antibiotics? a) Treat existing infection b) Prevent infection c) Relieve pain d) Reduce fever Prophylactic antibiotics are given to prevent infection, especially before surgeries. 55.The Glasgow Coma Scale assesses: a) Cardiac function b) Neurological status c) Respiratory function d) Pain level The Glasgow Coma Scale evaluates eye, verbal, and motor responses. 56.Which immunization is recommended annually for healthcare workers? a) Hepatitis B vaccine b) Influenza vaccine c) MMR vaccine d) Tetanus booster Annual flu vaccination protects both workers and patients. 57.What is the most important nursing action when suctioning a tracheostomy? a) Suction during insertion b) Limit suctioning to 10-15 seconds c) Use sterile gloves only
d) Suction continuously Prolonged suctioning can cause hypoxia; hence, time is limited. 58.What is the purpose of pursed-lip breathing in COPD patients? a) Increase oxygen intake b) Prevent airway collapse and improve ventilation c) Slow heart rate d) Increase sputum production Pursed-lip breathing maintains airway pressure and eases breathing. 59.Which lab value indicates infection? a) Hemoglobin 12 g/dL b) Platelets 250, c) White blood cell count elevated (leukocytosis) d) Serum potassium 4.0 mEq/L An elevated WBC count is a common marker of infection. 60.Which is the priority nursing diagnosis for a patient with impaired swallowing? a) Risk for infection b) Risk for aspiration c) Impaired mobility d) Acute pain Impaired swallowing increases aspiration risk, which can cause pneumonia. 61.What is the action of a loop diuretic like furosemide? a) Retain sodium
b) Hypocalcemia c) Hyperkalemia d) Hypernatremia Hyperkalemia causes characteristic ECG changes including peaked T waves. 66.The correct order for donning personal protective equipment (PPE) is: a) Gloves, mask, gown, goggles b) Gown, gloves, mask, goggles c) Gown, mask, goggles, gloves d) Mask, gown, gloves, goggles Gown is donned first, followed by mask, eye protection, and gloves last. 67.Which of the following is a symptom of congestive heart failure? a) Polyuria b) Dyspnea on exertion c) Bradycardia d) Hypothermia Dyspnea is a common symptom due to fluid accumulation in lungs. 68.Which vital sign change is expected in shock? a) Decreased heart rate b) Increased heart rate and decreased blood pressure c) Elevated blood pressure d) Bradycardia and hypertension Shock causes compensatory tachycardia and hypotension.
69.A patient is prescribed oxygen therapy at 4 L/min via nasal cannula. What is a nursing priority? a) Check for nasal irritation and maintain skin integrity b) Use humidification only if rate exceeds 10 L/min c) Remove oxygen at night d) Restrict fluid intake Oxygen can dry nasal mucosa causing irritation; skin should be monitored. 70.Which lab test best evaluates liver function? a) Creatinine b) ALT (alanine aminotransferase) c) Hemoglobin d) BUN ALT is an enzyme elevated with liver injury. 71.What is the purpose of incentive spirometry? a) Deliver medication b) Prevent atelectasis by encouraging deep breathing c) Measure oxygen saturation d) Promote coughing Incentive spirometry helps expand the lungs and prevent collapse. 72.Which of the following is a contraindication for taking aspirin? a) History of asthma b) Active gastrointestinal bleeding c) Diabetes
