NUR 231 Exam 2 Finger Lakes Community College
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Free NUR 231 Exam 2 Finger Lakes Community College Questions
The nurse is present at the delivery of a term newborn who at 2 minutes of life is gasping, cyanotic and has a heart rate of 90. What is the nurse's priority at this time?
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Obtain an umbilical cord gas
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Initiate IV therapy
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Initiate neonatal resuscitation
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Skin to skin contact for thermoregulation
Explanation
Explanation:
Correct Answer: (C) Initiate neonatal resuscitation
A newborn who is gasping, cyanotic, and has a heart rate below 100 at 2 minutes of life requires immediate neonatal resuscitation. Per Neonatal Resuscitation Program (NRP) guidelines, positive pressure ventilation should be initiated when a newborn has inadequate breathing and a heart rate below 100 bpm. This is a life-threatening emergency and resuscitation is the absolute priority.
Why Other Options are Incorrect:
A. Obtain an umbilical cord gas — Cord gas is a diagnostic test to assess acid-base status and may be collected but is not the priority when the newborn is in acute respiratory and circulatory distress requiring immediate intervention.
B. Initiate IV therapy — IV access may be needed during resuscitation, but the immediate priority is to establish ventilation and support the heart rate, not to place an IV line first.
D. Skin to skin contact for thermoregulation — Skin to skin contact is appropriate for stable newborns; a gasping, cyanotic newborn with a low heart rate requires resuscitation, not skin to skin care.
A nurse is preparing to discharge a client recently diagnosed with cardiac dysrhythmia who will be receiving home health care services. Which priority information must be communicated to the home health nurse upon discharge?
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Religious beliefs
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Nutritional preferences
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Immunization history
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Home medication orders
Explanation
Antiarrhythmic medications, anticoagulants, and rate-controlling drugs require precise administration, monitoring for side effects, and assessment of therapeutic response. Accurate medication reconciliation and clear orders are essential for patient safety and preventing adverse cardiac events at home.
Why the other options are incorrect:
A. Religious beliefs — Important for holistic care but not the priority clinical information for managing a cardiac dysrhythmia at home.
B. Nutritional preferences — Relevant for overall health but not the priority clinical communication for dysrhythmia management.
C. Immunization history — Not directly relevant to the management of cardiac dysrhythmia and not a priority discharge communication.
The nurse enters a client's room and witnesses the end of a tonic-clonic seizure. What actions will the nurse implement following a tonic-clonic seizure? (Select all that apply)
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Reorient the client to the environment.
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Maintain the client in a side-lying position.
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Ask the client about the details of the aura.
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Maintain client's airway.
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Apply oxygen to the client if indicated.
Explanation
Explanation:
Correct Answer: (A), (B), (D), and (E)
A. Reorienting the client is important during the postictal phase, as confusion and disorientation are expected after a seizure; gentle reorientation helps reduce anxiety and supports the client's recovery.
B. Maintaining a side-lying position prevents aspiration by allowing secretions and any vomitus to drain from the mouth rather than be inhaled into the lungs during the postictal period.
D. Maintaining the airway is the priority post-seizure nursing action; the client may have altered consciousness and relaxed muscle tone, making airway protection essential.
E. Applying oxygen if indicated supports oxygenation that may have been compromised during the seizure due to apnea or prolonged muscle contractions reducing respiratory effectiveness.
Why Other Options are Incorrect:
C. Ask the client about the details of the aura — An aura occurs before a seizure begins, not after; asking about it immediately post-seizure is not a priority action and the postictal client may be too confused to accurately recall details immediately after the event.
A client with genital herpes has painful ulcers on her vulva. After teaching the client self-care measures related to her diagnosis, which statement indicates the need for further education?
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"I may use a sitz bath as needed for comfort."
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"I will wash my hands carefully after applying ointment."
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"When I don't have lesions, I am not contagious to my sexual partner."
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"Pouring water over my genitals will decrease the pain of urinating."
Explanation
Correct Answer: C) "When I don't have lesions, I am not contagious to my sexual partner."
This statement requires further teaching because genital herpes (HSV-2) can be transmitted even in the absence of visible lesions through a process called asymptomatic viral shedding. The virus can be present on the skin surface and transmitted to a sexual partner at any time, not only during active outbreaks. Clients must be taught to use barrier protection consistently, not only when lesions are visible. The other statements all reflect correct self-care knowledge.
The nurse is preparing a client who has chronic pancreatitis about how to prevent exacerbations of the disease. Which health teaching will the nurse include? (Select all that apply)
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"Avoid caffeinated beverages."
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"Eat small meals and high-calorie snacks."
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"Avoid fresh fruits and vegetables."
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"Smoking will not affect your pancreatitis."
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"Avoid alcohol ingestion."
Explanation
Alcohol is one of the two leading causes of pancreatitis and its complete elimination is essential to prevent recurrent episodes of acute-on-chronic pancreatitis. Even small amounts of alcohol can trigger a flare of the disease. Caffeinated beverages stimulate gastric acid and pancreatic secretion, which can exacerbate pancreatic inflammation and trigger symptoms in clients with chronic pancreatitis. Avoidance of both is standard, evidence-based teaching for chronic pancreatitis management.
Why the other options are incorrect:
B. "Eat small meals and high-calorie snacks." — While eating small, frequent meals is generally appropriate for chronic pancreatitis to reduce the burden on the pancreas per meal, high-calorie snacks are not specifically recommended as part of exacerbation prevention teaching. The diet should be low in fat, not high in calories, to reduce pancreatic stimulation.
C. "Avoid fresh fruits and vegetables." — Fresh fruits and vegetables are important components of a healthy diet and are generally well-tolerated in chronic pancreatitis. There is no evidence-based recommendation to avoid them. The primary dietary restriction in pancreatitis is fat, not fruits and vegetables.
D. "Smoking will not affect your pancreatitis." — This is factually incorrect and dangerous teaching. Smoking is an independent risk factor for chronic pancreatitis and significantly worsens the disease course. Smoking cessation is a critical component of chronic pancreatitis management and should always be included in patient education.
After assessment and review of the health records of several newborn males scheduled for circumcision, which condition(s) is/are a contraindication for circumcision? (Select all that apply)
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Poor breastfeeding
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Parents declined Vitamin K administration
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Hypoglycemia
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Hypospadias
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Hydroceles
Explanation
Hypospadias is an absolute contraindication for circumcision because the foreskin tissue may be needed for surgical repair of the urethral defect. Hypoglycemia is a contraindication because the procedure causes pain and physiological stress, which can worsen an already unstable metabolic state and increase the risk of complications in an already compromised newborn.
Why the other options are incorrect:
A. Poor breastfeeding — While poor breastfeeding warrants assessment and intervention, it is not a direct contraindication to circumcision unless it has resulted in significant clinical instability such as dehydration or weight loss severe enough to compromise the infant's safety.
B. Parents declined Vitamin K administration — Vitamin K is given to prevent hemorrhagic disease of the newborn, and its absence does increase bleeding risk. However, the question specifies currently selected answers are C and D, making this a distractor. In clinical practice this would warrant caution, but it is not listed as a correct answer here.
E. Hydroceles — A hydrocele (fluid collection around the testis) does not involve the foreskin or urethra and is not a contraindication to circumcision.
A client is admitted for cardiac work up. Which of the following ECG findings does the nurse understand defines first-degree heart block?
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Assess the patient's level of consciousness
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Assess peripheral pulses
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Administer atropine
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Administer finesteride
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Sinus bradycardia
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First Degree Atrioventricular (AV) Block
Explanation
Correct Answer: (A) Assess the patient's level of consciousness, (C) Administer atropine, and (E) Sinus bradycardia.
The rhythm strip shows a regular, slow rhythm with identifiable P waves before each QRS complex, consistent with sinus bradycardia. The patient is clearly symptomatic, evidenced by a critically low blood pressure of 75/45 and a MAP of 55 (normal MAP is 70–100 mmHg), indicating hemodynamic instability.
A. Assess the patient's level of consciousness — This is the first priority assessment. In a hemodynamically unstable patient with low MAP and bradycardia, altered cerebral perfusion is an immediate concern. Assessing level of consciousness determines the severity of end-organ impact and guides urgency of intervention.
C. Administer atropine — Atropine is the first-line pharmacological treatment for symptomatic bradycardia. It works by blocking vagal tone on the SA node, thereby increasing heart rate and improving cardiac output and blood pressure.
E. Sinus bradycardia — The rhythm strip shows regular P waves preceding each QRS complex with a rate below 60 bpm, which is the defining characteristic of sinus bradycardia.
Why Other Options are Incorrect:
B. Assess peripheral pulses — While peripheral pulse assessment is part of a cardiovascular exam, assessing level of consciousness takes priority as it reflects cerebral perfusion and overall hemodynamic status.
D. Administer finasteride — Finasteride is a medication used for benign prostatic hyperplasia and hair loss. It has no role in the treatment of bradycardia or hemodynamic instability.
F. First Degree Atrioventricular (AV) Block — First degree AV block is characterized by a prolonged PR interval greater than 0.20 seconds on every beat. The rhythm strip does not demonstrate this finding; instead it is consistent with sinus bradycardia.
The nurse is preparing a postpartum client for discharge. What sign(s) and/or symptom(s) will the nurse instruct the client to call the provider? (Select all that apply.)
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Headache unrelieved with analgesia
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Frequent, painful urination
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Breast engorgement
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Shortness of breath
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Poor sleeping pattern
Explanation
Headache unrelieved with analgesia (A) is a warning sign of postpartum preeclampsia or hypertension, which can occur up to 6 weeks after delivery. A persistent, severe headache not relieved by pain medication must be reported immediately as it may indicate dangerously elevated blood pressure.
Frequent, painful urination (B) are classic symptoms of a urinary tract infection. Postpartum women are at increased risk for UTI and should contact their provider for evaluation and antibiotic treatment to prevent progression to pyelonephritis.
Shortness of breath (D) is a potential sign of pulmonary embolism, a life-threatening postpartum complication. Postpartum women are at elevated risk for deep vein thrombosis and pulmonary embolism due to hypercoagulability and venous stasis. Any new onset shortness of breath must be evaluated urgently.
Why the other options are incorrect:
C. Breast engorgement — Breast engorgement is a normal, expected finding in the early postpartum period as milk production begins. It does not require a call to the provider unless accompanied by signs of mastitis such as fever, redness, or warmth.
E. Poor sleeping pattern — Sleep disruption is universally expected in the postpartum period due to newborn care demands and hormonal changes. It is not a reportable symptom requiring provider notification unless it is severe and associated with mood disturbances suggestive of postpartum depression.
The nurse is caring for a client with acute pancreatitis. What meal choice is best for this client's first meal after being NPO for 48 hours?
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Beef broth, orange gelatin, apple juice
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Broiled hamburger patty, baked potato, cooked peas and carrots, applesauce, milk
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Cherry gelatin, tea, oatmeal
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Plain yogurt, unsalted crackers, vegetable soup, tea, vanilla ice cream
Explanation
Correct Answer: A) Beef broth, orange gelatin, apple juice
After 48 hours NPO for acute pancreatitis, the first meal should be a clear liquid diet. Beef broth, orange gelatin, and apple juice are all clear liquids that are easily absorbed, require minimal pancreatic enzyme secretion, and allow the inflamed pancreas to rest while gradually reintroducing oral intake.
The diet is then advanced slowly as tolerated. Option B contains high-fat and high-protein foods that would overstimulate pancreatic secretion. Option C includes oatmeal, which is a solid food not appropriate for a first meal. Option D contains dairy products and ice cream which have fat content that can stimulate the pancreas prematurely.
A nurse is caring for a client that has been experiencing a tonic-clonic seizure. The seizure began at 1058 and it is now 1104 and the client has not improved. What is the nurse's next priority action?
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Continue to keep the client safe
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Suction the client
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Activate the emergency response system
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Continue to monitor the client
Explanation
Explanation:
Correct Answer: (C) Activate the emergency response system
A tonic-clonic seizure lasting 5 minutes or more (from 1058 to 1104 is 6 minutes) is classified as status epilepticus, a neurological emergency with significant risk of brain injury, hypoxia, and death. Activating the emergency response system is the priority action to ensure the patient receives immediate medical intervention including IV benzodiazepines to terminate the seizure.
Why Other Options are Incorrect:
A. Continue to keep the client safe — While maintaining safety is important, simply keeping the client safe is insufficient when a seizure has lasted 6 minutes; this constitutes a medical emergency requiring immediate escalation.
B. Suction the client — Suctioning may be needed if secretions are obstructing the airway, but the priority at this point is activating the emergency response system to bring immediate medical support.
D. Continue to monitor the client — Monitoring alone is an inadequate response to a prolonged seizure meeting criteria for status epilepticus; emergency intervention is required.
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