NUR 231 Exam 2 Finger Lakes Community College
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Free NUR 231 Exam 2 Finger Lakes Community College Questions
A client at 38 6/7 weeks gestation is referred to the prenatal clinic for evaluation of blood pressure and lab work. After analysis of the lab results, how does the nurse interpret these results?
Lab Results:
- WBC: 9.9 (Normal range: 4500-11000/mL)
- Hemoglobin: 11.1 g/dL (Normal range: 12-16 g/dL)
- AST: 33 (Normal range: 8-33 U/L)
- ALT: 28 (Normal range: 4-36 U/L)
- Platelets: 188K/L (Normal range: 150K-400K/L)
- LDH: 116 (Normal range: 140-280 U/L)
- Uric acid: 4.5 mg/dL (Normal range: 3.5-7.2 mg/dL)
- Protein: 50 mg (<100 mg)
- Lab values are within normal range for pregnancy
- Lab values are suggestive of gestational hypertension
- Lab values are suggestive of preeclampsia
- Lab values indicate early signs of HELLP syndrome
Explanation
Correct Answer: A) Lab values are within normal range for pregnancy
Upon reviewing the patient's lab results, all the values fall within the normal range for pregnancy. WBC count, hemoglobin, liver enzymes (AST, ALT), platelet count, LDH, uric acid, and protein levels are within normal thresholds for this stage of gestation, indicating no abnormalities or concerns for gestational hypertension, preeclampsia, or HELLP syndrome.
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Perform fundal massage
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Establish venous access
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Prepare the client for surgical intervention
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Catheterize the bladder
Explanation
Correct Answer: (A) Perform fundal massage
In postpartum hemorrhage caused by uterine atony, the uterus has failed to contract adequately. The immediate priority action is fundal massage, which directly stimulates uterine contractions to compress blood vessels at the placental site and control bleeding. This is the first-line, non-invasive intervention that should be performed immediately.
B. Establish venous access — IV access is important and should be established promptly, but fundal massage is the more immediate direct intervention to stop the hemorrhage at its source. C. Prepare the client for surgical intervention — Surgery is considered only after all conservative measures have failed. It is not the first priority at 20 minutes postpartum. D. Catheterize the bladder — A full bladder can displace the uterus and impair contraction, making catheterization important. However, fundal massage takes priority as the most immediate intervention to address active hemorrhage from atony.
A client is 6 weeks pregnant. She had a previous spontaneous abortion at 13 weeks of gestation and a pregnancy that ended at 38 weeks with the birth of a girl. What does the nurse determine is her gravida and para?
- Gravida 2 Para 2
- Gravida 3 Para 3
- Gravida 3 Para 1
- Gravida 1 Para 1
Explanation
Correct Answer: C) Gravida 3 Para 1
Gravida refers to the total number of times a woman has been pregnant, regardless of outcome. Para refers to the number of pregnancies that reached viability (typically 20 weeks or more) and were delivered. This client has had three pregnancies: the current pregnancy at 6 weeks, a spontaneous abortion at 13 weeks, and a prior delivery at 38 weeks — making her Gravida 3. Para counts only the delivery at 38 weeks, as the abortion at 13 weeks did not reach viability — making her Para 1. Therefore, she is Gravida 3, Para 1.
Which vital sign findings would the nurse expect to find in a child with increased intracranial pressure?
- BP 80/50, HR 50, and Kussmaul respirations
- BP 80/50, HR 150 and Cheyne-Stokes respirations
- BP 190/80, HR 50, and an irregular respiratory pattern
- BP 190/80, HR 150, and an irregular respiratory pattern
Explanation
Explanation:
Correct Answer: (D) BP 190/80, HR 150, and an irregular respiratory pattern
Increased intracranial pressure in children produces Cushing's triad, which classically includes hypertension (elevated BP), bradycardia, and irregular respirations. However, in pediatric patients, the presentation can differ from adults. The combination of elevated blood pressure with tachycardia and irregular respirations represents the early compensatory response to rising ICP in children, particularly before full Cushing's triad develops.
Why Other Options are Incorrect:
A. BP 80/50, HR 50, and Kussmaul respirations — Hypotension is not associated with increased ICP; Kussmaul respirations are a pattern associated with metabolic acidosis, not increased ICP.
B. BP 80/50, HR 150 and Cheyne-Stokes respirations — Hypotension is inconsistent with increased ICP; Cheyne-Stokes respirations can occur with ICP changes but the low blood pressure makes this combination incorrect.
C. BP 190/80, HR 50, and an irregular respiratory pattern — Hypertension with bradycardia and irregular respirations represent the classic Cushing's triad seen in adults with late-stage severely elevated ICP; in children early ICP elevation more often presents with tachycardia before bradycardia develops.
A nurse is caring for a premature newborn. On assessment the newborn is exhibiting signs of cyanosis, tachypnea, nasal flaring, and grunting. Respiratory distress syndrome is diagnosed, and the provider prescribes surfactant replacement therapy. How would the nurse anticipate that the surfactant would be administered?
- Administration through an endotracheal tube (ETT)
- Intravenous administration
- Subcutaneous injection
- Intramuscular injection
Explanation
Explanation:
Correct Answer: (A) Administration through an endotracheal tube (ETT)
Surfactant replacement therapy is administered directly into the lungs via an endotracheal tube. This allows the surfactant to be instilled into the airways and distributed throughout the alveoli, where it reduces surface tension, prevents alveolar collapse, and improves lung compliance in premature infants with RDS.
Why Other Options are Incorrect:
B. Intravenous administration — Surfactant is a substance that works locally within the lungs; IV administration would not deliver it to the alveoli where it is needed and would be ineffective.
C. Subcutaneous injection — Subcutaneous injection delivers medication into the fatty tissue beneath the skin and would not allow surfactant to reach the lungs.
D. Intramuscular injection — Intramuscular injection delivers medication into muscle tissue and similarly cannot deliver surfactant to the alveolar surfaces where it must act.
A client at 38 6/7 weeks gestation is referred to the prenatal clinic for evaluation of blood pressure and lab work. After analysis of the lab results, how does the nurse interpret these results?
Lab Results:
- WBC: 9.9 (Normal range: 4500-11000/mL)
- Hemoglobin: 11.1 g/dL (Normal range: 12-16 g/dL)
- AST: 33 (Normal range: 8-33 U/L)
- ALT: 28 (Normal range: 4-36 U/L)
- Platelets: 188K/L (Normal range: 150K-400K/L)
- LDH: 116 (Normal range: 140-280 U/L)
- Uric acid: 4.5 mg/dL (Normal range: 3.5-7.2 mg/dL)
- Protein: 50 mg (<100 mg)
- Lab values are within normal range for pregnancy
- Lab values are suggestive of gestational hypertension
- Lab values are suggestive of preeclampsia
- Lab values indicate early signs of HELLP syndrome
Explanation
Correct Answer: A) Lab values are within normal range for pregnancy
Upon reviewing the patient's lab results, all the values fall within the normal range for pregnancy. WBC count, hemoglobin, liver enzymes (AST, ALT), platelet count, LDH, uric acid, and protein levels are within normal thresholds for this stage of gestation, indicating no abnormalities or concerns for gestational hypertension, preeclampsia, or HELLP syndrome.
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Wear a mask when taking vital signs.
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Wear a gown and gloves when changing the client's incontinent briefs.
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Wear gloves when providing perineal care.
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Wear gloves when asking the client about food choices for lunch.
Explanation
Correct Answer: (C) Wear gloves when providing perineal care
Hepatitis A is transmitted via the fecal-oral route. Standard and contact precautions require the UAP to wear gloves when providing perineal care due to potential contact with fecal material, which is the primary mode of transmission for hepatitis A.
A. Wear a mask when taking vital signs — Hepatitis A is not transmitted via respiratory droplets or airborne particles; a mask is not required for routine vital sign assessment. B. Wear a gown and gloves when changing incontinent briefs — While gloves are appropriate for handling fecal material, a full gown is not required for standard hepatitis A precautions unless soiling of clothing is anticipated. D. Wear gloves when asking about food choices — There is no contact with bodily fluids during a verbal conversation about food choices; gloves are unnecessary in this situation.
During a resuscitation of a newborn the nurse auscultates the apical pulse counting 10 beats over 6 seconds. What is the heart rate the nurse will document?
- 100 beats per minute
- 60 beats per minute
- 30 beats per minute
- 120 beats per minute
Explanation
Explanation:
Correct Answer: (A) 100 beats per minute
To calculate the heart rate, divide the number of beats counted by the number of seconds, then multiply by 60: 10 beats ÷ 6 seconds × 60 seconds = 100 beats per minute.
Why Other Options are Incorrect:
B. 60 beats per minute — This would result from counting 6 beats in 6 seconds (6 ÷ 6 × 60 = 60), which does not match the 10 beats counted.
C. 30 beats per minute — This would result from counting 3 beats in 6 seconds, which does not match the data given.
D. 120 beats per minute — This would result from counting 12 beats in 6 seconds (12 ÷ 6 × 60 = 120), which does not match the 10 beats counted.
A client with multiple sexual partners has been assessed for symptoms of dysuria and green, malodorous vaginal discharge. The nurse administers an injection of ceftriaxone and an oral dose of azithromycin. The client asks why two drugs are needed. What answer by the nurse is best?
- "Giving two medications increases the chance of curing the infection"
- "Some people are not affected by the injection and need more medication"
- "This will prevent you from needing a 3-month follow-up test"
- "It is very common to be infected with both gonorrhea and chlamydia"
Explanation
Correct Answer: D) "It is very common to be infected with both gonorrhea and chlamydia"
The combination of ceftriaxone (IM) and azithromycin (oral) is the standard dual-therapy regimen for treating gonorrhea and chlamydia simultaneously. This is because coinfection with both gonorrhea and chlamydia is extremely common — studies show that a significant percentage of patients diagnosed with gonorrhea are also infected with chlamydia.
Treating both simultaneously prevents complications such as pelvic inflammatory disease, infertility, and further transmission. This explanation is the most accurate, educational, and clinically relevant response. The other options are inaccurate — dual therapy is about treating two different pathogens, not about increasing cure rates for one infection or avoiding follow-up.
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Diaphoresis
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Chest palpitations
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Increased urinary output
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Confusion
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Tinnitus
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Syncope
Explanation
Correct Answers: (A) Diaphoresis, (B) Chest palpitations, (D) Confusion, and (F) Syncope
The rhythm strip shows a slow, irregular rhythm with identifiable but infrequent QRS complexes and a flat baseline between beats, consistent with severe bradycardia or a heart block. This rhythm results in significantly reduced cardiac output, which causes the following signs and symptoms:
Diaphoresis (A) occurs due to sympathetic nervous system activation in response to decreased cardiac output and hemodynamic compromise. The body attempts to compensate by releasing catecholamines, leading to sweating.
Chest palpitations (B) are commonly reported by patients experiencing abnormal heart rhythms, including bradyarrhythmias and heart blocks, as the heart's irregular or slow beating is perceived as an uncomfortable sensation in the chest.
Confusion (D) results from decreased cerebral perfusion secondary to reduced cardiac output. When the brain does not receive adequate oxygenated blood, altered mental status and confusion develop.
Syncope (F) occurs when cardiac output drops severely enough to cause a transient loss of consciousness due to inadequate cerebral blood flow, which is a classic presentation of significant bradyarrhythmias and heart block.
Why the other options are incorrect:
C. Increased urinary output — Decreased cardiac output leads to reduced renal perfusion, causing decreased urinary output (oliguria), not increased output. E. Tinnitus — Tinnitus (ringing in the ears) is not a characteristic symptom associated with bradyarrhythmias or heart block and is more commonly linked to auditory conditions or medication toxicity such as salicylate toxicity.
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