NU 160 Exam 1 : EXACT exam questions with answers. Students verify these appear on actual nursing math tests.
Nursing Exams
Detailed Answer Explanations Well-structured questions covering all topics, accompanied by organized images.
Purchase For $30/monthNU 160 Exam 1 : EXACT exam questions with answers. Students verify these appear on actual nursing math tests.
A nurse at a rehabilitation center is planning care for a client who had a left hemispheric cerebrovascular accident (CVA) 3 weeks ago. Which of the following goals should the nurse include in the client's rehabilitation program
Establish the ability to communicate effectively.
Compensate for loss of depth perception.
Learn to control impulsive behavior.
Improve left-side motor function.
Correct Answer: A. Establish the ability to communicate effectively.
Explanation:
A left hemispheric cerebrovascular accident (CVA) primarily affects the language centers of the brain, such as Broca’s area (speech production) and Wernicke’s area (language comprehension). Clients with a left-sided stroke often experience aphasia (difficulty speaking or understanding language) and dysarthria (slurred speech). Therefore, re-establishing effective communication is a key rehabilitation goal.
Why the Other Options Are Incorrect:
B. Compensate for loss of depth perception
Right hemispheric strokes more commonly affect visual-spatial perception, including depth perception. A left hemispheric stroke primarily affects language and right-sided motor function rather than visual processing.
C. Learn to control impulsive behavior
Right hemispheric strokes tend to result in impulsive, poor judgment, and risk-taking behavior. Left-sided strokes typically cause cautious and slow behavior rather than impulsivity.
D. Improve left-side motor function
A left hemispheric stroke affects the right side of the body, causing right-sided weakness (hemiparesis) or paralysis (hemiplegia). Improving right-side motor function would be a more relevant goal.
Summary:
For a client with a left hemispheric stroke, speech and language rehabilitation is crucial due to aphasia and other communication difficulties. Establishing effective communication should be a primary goal in their rehabilitation plan.
A nurse is assessing a client who is in skeletal traction. Which of the following findings should the nurse identify as an indication of infection at the pin sites
Serosanguineous drainage
Mild erythema
Warmth
Fever
Correct Answer: D. Fever
Explanation:
A fever is a systemic sign of infection, meaning the body is responding to bacteria or other pathogens at the pin sites. Since skeletal traction involves pins or wires directly inserted into the bone, infection at the pin sites (pin-site osteomyelitis) is a major concern. A fever suggests that the infection may be spreading and requires prompt medical attention.
Why the Other Options Are Incorrect:
A. Serosanguineous drainage
Incorrect because serosanguineous drainage (pinkish-clear fluid with a little blood) is normal at pin sites, especially right after placement. If the drainage becomes purulent (thick, yellow/green), foul-smelling, or excessive, it would indicate infection.
B. Mild erythema
Incorrect because mild redness around the pin site is expected due to normal tissue healing. However, increasing redness, spreading erythema, or swelling would be concerning for infection.
C. Warmth
Incorrect because mild warmth is common at pin sites as part of the body’s natural healing response. However, if the warmth is excessive, spreading, or accompanied by pain and drainage, it could indicate infection.
Summary:
The correct answer is D (fever) because it is a systemic sign of infection. While mild redness, warmth, and serosanguineous drainage are normal after pin insertion, worsening symptoms or purulent drainage would be more concerning.
A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs? pH 7.22 PaCO2 68 mm Hg Base excess -2 PaO2 78 mm Hg Saturation 80% Bicarbonate 26 mEq/L
Respiratory acidosis
Metabolic acidosis
Metabolic alkalosis
Respiratory alkalosis
Correct Answer: A. Respiratory Acidosis
Explanation:
Respiratory acidosis occurs when there is hypoventilation, leading to retention of carbon dioxide (CO₂). This results in low pH and high PaCO₂, which match the given ABG values:
pH 7.22 (Low, indicating acidosis)
PaCO₂ 68 mmHg (High, indicating respiratory cause)
HCO₃⁻ 26 mEq/L (Normal, meaning the kidneys have not yet compensated)
These findings confirm uncompensated respiratory acidosis, likely due to hypoventilation (evidenced by the respiratory rate of 7 breaths per minute).
Why the Other Options Are Incorrect:
B. Metabolic Acidosis
Incorrect. Metabolic acidosis is characterized by a low pH and a low bicarbonate (HCO₃⁻) level. In this case, the HCO₃⁻ is normal (26 mEq/L), ruling out a metabolic cause.
C. Metabolic Alkalosis
Incorrect. Metabolic alkalosis occurs with high pH and high HCO₃⁻. Here, the pH is low (acidosis) and bicarbonate is normal, so metabolic alkalosis is not present.
D. Respiratory Alkalosis
Incorrect. Respiratory alkalosis occurs with high pH and low PaCO₂, typically due to hyperventilation (rapid breathing). This client has a low pH (acidosis) and high PaCO₂, indicating the opposite condition—respiratory acidosis.
Summary:
The correct answer is A (Respiratory Acidosis) because the client has low pH and high PaCO₂, indicating hypoventilation and CO₂ retention. The other options do not match the given ABG values.
A nurse is providing teaching to a client who has a family history of hypertension. The nurse should inform the client that his blood pressure of 124/79 mm Hg places him in which of the following categories
Within the expected reference range
Stage 1 hypertension
Elevated
Stage 2 hypertension
Correct Answer: Elevated
Explanation
The American Heart Association (AHA) classifies blood pressure into specific categories. The client's blood pressure (124/79 mm Hg) falls into the "Elevated" range because:
Systolic BP (124 mm Hg) is between 120–129 mm Hg, which defines elevated blood pressure.
Diastolic BP (79 mm Hg) is below 80 mm Hg, which remains within the expected range.
The key factor for classification is the systolic BP, which is above normal but not high enough for hypertension.
Why the Other Options Are Incorrect:
"Within the expected reference range"
Expected normal BP:
Systolic BP: Less than 120 mm Hg
Diastolic BP: Less than 80 mm Hg
The client's systolic BP (124 mm Hg) exceeds 120, which means it is not within the normal range.
"Stage 1 Hypertension"
Stage 1 Hypertension is defined as:
Systolic BP: 130–139 mm Hg
Diastolic BP: 80–89 mm Hg
The client’s BP (124/79 mm Hg) does not meet these criteria, as the systolic pressure is below 130 mm Hg and the diastolic pressure is under 80 mm Hg.
"Stage 2 Hypertension"
Stage 2 Hypertension is defined as:
Systolic BP: 140 mm Hg or higher
Diastolic BP: 90 mm Hg or higher
The client’s BP (124/79 mm Hg) does not meet these values, so this classification is incorrect.
Summary:
The correct classification for a BP of 124/79 mm Hg is "Elevated" because the systolic pressure (124 mm Hg) is above the normal range (less than 120 mm Hg) but below Stage 1 hypertension (130 mm Hg or higher). The diastolic pressure (79 mm Hg) is within the normal range.
Key takeaway: Elevated BP increases the risk of developing hypertension and cardiovascular diseases if left unmanaged. The client should adopt lifestyle changes such as reducing sodium intake, increasing physical activity, and monitoring BP regularly.
A nurse is providing teaching to a client about interventions to reduce the risk of developing cardiovascular disease. Which of the following statements by the client should indicate to the nurse the need for further teaching
"A weight loss program can decrease my LDL cholesterol level."
"Increasing my intake of foods containing trans-fatty acids can lower my risk."
"Adding foods containing omega-3 fatty acids to my diet can lower my risk."
"Exercising regularly will increase HDL cholesterol levels."
Correct Answer: "Increasing my intake of foods containing trans-fatty acids can lower my risk."
Explanation:
This statement is incorrect and indicates a need for further teaching because:
Trans-fatty acids (trans fats) are harmful to cardiovascular health.
They increase low-density lipoprotein (LDL) cholesterol (the "bad" cholesterol), which promotes plaque buildup in arteries.
They decrease high-density lipoprotein (HDL) cholesterol (the "good" cholesterol), which helps remove excess cholesterol from the bloodstream.
Consuming trans fats increases the risk of atherosclerosis, heart attacks, and strokes.
Sources of trans fats include:
Processed and fried foods (e.g., french fries, fried chicken)
Commercially baked goods (e.g., pastries, cookies, doughnuts)
Margarine and shortening
Since the client mistakenly believes trans fats can lower cardiovascular risk, the nurse must correct this misconception.
Why the Other Statements Are Correct:
"A weight loss program can decrease my LDL cholesterol level."
Losing excess weight, particularly abdominal fat, helps lower LDL cholesterol and reduces cardiovascular risk. Obesity is linked to high cholesterol, hypertension, and insulin resistance, all of which contribute to heart disease.
"Adding foods containing omega-3 fatty acids to my diet can lower my risk."
Omega-3 fatty acids are heart-healthy fats found in fish (e.g., salmon, mackerel), flaxseeds, and walnuts. They help reduce inflammation, lower triglycerides, and decrease blood pressure, all of which reduce cardiovascular disease risk.
"Exercising regularly will increase HDL cholesterol levels."
Physical activity boosts HDL cholesterol (the "good" cholesterol), which helps remove excess cholesterol from arteries. Regular aerobic exercise (e.g., brisk walking, cycling, swimming) strengthens the heart and reduces the risk of heart disease.
Summary:
The incorrect statement is: "Increasing my intake of foods containing trans-fatty acids can lower my risk."
Trans fats increase LDL, decrease HDL, and promote heart disease. The nurse should educate the client about avoiding trans fats and choosing healthier fats, such as omega-3s and unsaturated fats. All other statements are correct and support heart health.
Nurse Betty is assigned to the following clients. The client that the nurse would see first after endorsement
A 34 year-old postoperative appendectomy client of five hours who is complaining of pain.
A 44 year-old myocardial infarction (MI) client who is complaining of nausea.
A 26 year-old client admitted for dehydration whose intravenous(IV) has infiltrated.
A 63 year-old post operative's abdominal hysterectomy client of three days whose incisional dressing is saturated with serosanguinous fluid.
Correct Answer: b. A 44-year-old myocardial infarction (MI) client who is complaining of nausea.
Explanation:
When prioritizing which client to see first, the nurse should use the ABC (Airway, Breathing, Circulation) approach and consider potential life-threatening conditions
A 44-year-old myocardial infarction (MI) client who is complaining of nausea.
Nausea is a serious concern in a client with a recent MI. It may indicate ongoing myocardial ischemia or infarction progression, which can lead to cardiogenic shock or life-threatening dysrhythmias. Cardiac complications take priority over post-op pain, IV infiltration, or surgical wound concerns.
A 34-year-old post-op appendectomy client (5 hours) complaining of pain.
Post-operative pain is expected and can be managed. Assess pain, but this is not immediately life-threatening.
A 26-year-old client with dehydration whose IV has infiltrated.
IV infiltration requires intervention, but it does not pose an immediate life threat. The nurse can restart the IV and monitor for complications, but it is not the highest priority.
A 63-year-old post-op hysterectomy client (3 days) with a saturated serosanguinous dressing.
Serosanguinous drainage is common post-op. Although excessive drainage may indicate a wound complication, it is not immediately life-threatening compared to potential cardiac deterioration.
Summary:
The MI client with nausea is the highest priority because nausea can be a sign of ongoing cardiac ischemia, worsening infarction, or complications like cardiogenic shock. Pain, IV infiltration, and surgical wound drainage are important but not immediately life-threatening. Always prioritize conditions that affect the heart, brain, or airway first.
A nurse is teaching a client who is starting to take alendronate effervescent tablets to treat osteoporosis. Which of the following information should the nurse include
"Sit upright or stand for at least 30 minutes after taking this medication."
"Take this medication with food."
"Take this medication with orange juice."
"Chew or suck on the tablet."
Correct Answer: A. "Sit upright or stand for at least 30 minutes after taking this medication."
Explanation:
Alendronate is a bisphosphonate used to treat and prevent osteoporosis by inhibiting bone resorption. However, it can cause severe esophageal irritation, ulceration, and reflux. To reduce this risk, the patient must remain upright for at least 30 minutes after taking it to prevent reflux and esophageal damage.
Why the Other Options Are Incorrect:
B. "Take this medication with food." – Incorrect because food interferes with the absorption of alendronate. It should be taken on an empty stomach with a full glass of water at least 30 minutes before eating or drinking anything else.
C. "Take this medication with orange juice." – Incorrect because orange juice (or any acidic drink) can interfere with the medication’s absorption. Alendronate should only be taken with plain water.
D. "Chew or suck on the tablet." – Incorrect because alendronate tablets must be swallowed whole. Chewing or sucking on them increases the risk of oropharyngeal and esophageal irritation.
Summary:
The correct answer is A because sitting upright for at least 30 minutes helps prevent esophageal irritation. The other options are incorrect because food and acidic drinks affect absorption, and chewing increases the risk of irritation.
A nurse is caring for a client who has deep vein thrombosis (DVT) of their right lower leg. Which of the following manifestations should the nurse expect
Warmth
Erythema
Swelling
Numbness
Correct Answers:
Warmth
erythema
swelling.
Explanation:
Deep vein thrombosis (DVT) is a condition where a blood clot forms in a deep vein, usually in the leg. This blockage causes inflammation and venous congestion, leading to specific symptoms.
Warmth occurs because of increased blood flow and inflammation around the clot.
Erythema (redness) develops due to irritation and swelling of the surrounding tissues.
Swelling happens because the clot disrupts normal circulation, leading to fluid accumulation in the leg.
Why the Other Options Are Incorrect:
Numbness is not a typical symptom of DVT. It is more commonly associated with nerve damage or arterial insufficiency rather than a venous clot.
Bleeding does not occur as a direct symptom of DVT. However, anticoagulant medications used to treat DVT can increase the risk of bleeding, but the clot itself does not cause bleeding.
Summary:
A client with DVT will typically experience warmth, redness, and swelling in the affected leg. Numbness and bleeding are not characteristic of this condition and may indicate other medical issues. Recognizing these symptoms early is essential to prevent complications such as pulmonary embolism.
A nurse is providing teaching about a heart healthy diet to a group of clients with hypertension. Which of the following statements by one of the clients indicates a need for further teaching
"I may eat 10 ounces of lean protein each day."
"Fresh fruits make a good snack option."
"I will replace table salt with dried herbs."
"I may thicken gravies with cornstarch as I cook."
Correct Answer: "I may eat 10 ounces of lean protein each day."
Explanation:
For clients with hypertension, a heart-healthy diet typically emphasizes moderation and balance in all food groups. The statement about consuming 10 ounces of lean protein each day indicates a need for further teaching because 10 ounces is an excessive amount of protein, which could lead to increased intake of calories and fats, even if the protein is lean. Typically, a healthy serving of protein for an adult would be about 3-6 ounces per meal, depending on individual dietary needs.
Why the Other Statements Are Correct:
"Fresh fruits make a good snack option."
This is correct. Fresh fruits are naturally low in sodium, high in fiber, and rich in vitamins and minerals, making them a great choice for a heart-healthy diet.
"I will replace table salt with dried herbs."
This is also correct. Reducing sodium intake is essential for managing hypertension. Replacing table salt with dried herbs and spices is a good strategy to enhance flavor without adding sodium.
"I may thicken gravies with cornstarch as I cook."
This is correct. Cornstarch is a low-sodium thickening agent and can be used to thicken gravies without adding unnecessary sodium, making it a better option than using pre-made gravies or high-sodium thickeners.
Summary:
The statement about consuming 10 ounces of lean protein daily indicates a need for further teaching. A heart-healthy diet for clients with hypertension emphasizes portion control, particularly for protein, and focuses on fresh fruits, reducing sodium intake, and using low-sodium alternatives for flavoring and thickening foods.
A nurse is caring for an older adult client who has a urinary tract infection (UTI). Which of the following manifestations should the nurse identify as a finding specifically associated with this client
Low back pain
Urinary retention
Confusion
Incontinence
The correct answer is C. Confusion.
Explanation
In older adult clients, a urinary tract infection (UTI) may not present with the typical symptoms seen in younger adults, such as dysuria (painful urination) or fever. Instead, older adults may exhibit more generalized or atypical symptoms, such as confusion or altered mental status. This is often referred to as "delirium" associated with infections, and it can be one of the most common signs of a UTI in the elderly population. The infection may cause an inflammatory response that affects the central nervous system, leading to confusion, agitation, or disorientation.
why the other choices are incorrect:
A. Low back pain
Low back pain can occur with a UTI, especially if there is involvement of the kidneys (such as in pyelonephritis), but it is not specifically associated with UTIs in older adults. Older clients with a UTI may not always present with classic flank pain or low back pain.
B. Urinary retention
Urinary retention can occur with a UTI, especially if there is obstruction or a more complicated urinary tract issue. However, urinary retention is not a hallmark sign of UTI in older adults. More commonly, older adults with UTIs experience confusion or incontinence rather than urinary retention.
D. Incontinence
Incontinence can be a symptom of a UTI, particularly in older adults, but it is not as specific to UTI as confusion. Incontinence can also be caused by other factors, such as age-related changes, neurological disorders, or cognitive decline. Although incontinence may be a presenting symptom, it is not as distinctively associated with UTIs as confusion is.
Summary:
For older adult clients with urinary tract infections, confusion is the manifestation that is most specifically associated with UTIs in this population. Due to age-related changes and potential coexisting conditions, UTIs in older adults often present with atypical symptoms, and confusion is one of the primary signs to look out for.
Trusted by thousands of nursing students worldwide for exam success.
