Review NUAS 130 SP 2026 Exam 3 T02 Mount Aloysius College
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Free Review NUAS 130 SP 2026 Exam 3 T02 Mount Aloysius College Questions
Identify the correct location for assessing the popliteal pulse.
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Behind the knee in the popliteal fossa
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On the inner aspect of the ankle below the medial malleolus
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On the dorsum of the foot between the first and second metatarsals
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In the groin at the femoral triangle
Explanation
Correct Answer: (A) Behind the knee in the popliteal fossa
The popliteal pulse is located in the popliteal fossa — the hollow space behind the knee joint. To palpate it, the nurse positions the patient supine with the knee slightly flexed, places both thumbs on the front of the knee for support, and presses the fingertips of both hands deeply into the back of the knee. Firm pressure is required because the popliteal artery lies deep within this space. It is assessed to evaluate circulation to the lower extremities and is important in detecting peripheral arterial disease.
Why the other options are incorrect:
B. On the inner aspect of the ankle below the medial malleolus — This describes the location of the posterior tibial pulse, not the popliteal pulse.
C. On the dorsum of the foot between the first and second metatarsals — This describes the location of the dorsalis pedis pulse, not the popliteal pulse.
D. In the groin at the femoral triangle — This describes the location of the femoral pulse, which is found in the groin where the femoral artery passes through the femoral triangle, not behind the knee.
The patient's initial pain scale was an "8" out of 10, after receiving ibuprofen (Motrin) 800 mg orally for hip pain 1 hour ago, the client still states that his pain is "8" out of 10 on the numerical pain scale. Which action should the nurse take next?
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Administer an additional 800 mg oral dose of ibuprofen right away
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Notify the prescriber that the current pain management plan is ineffective
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Do nothing because the client's facial expression indicates he is comfortable
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Use nonpharmacologic therapies while waiting 3 more hours before the next dose
Explanation
Correct Answer: (B) Notify the prescriber that the current pain management plan is ineffective
When a patient's pain remains unchanged at 8/10 one hour after receiving the prescribed analgesic, this indicates the current pain management plan is ineffective. The nurse's responsibility is to reassess and report unrelieved pain to the prescriber so that the medication, dose, or pain management approach can be modified. Advocating for adequate pain control is a fundamental nursing responsibility.
Why the other options are incorrect:
A. Administer an additional 800 mg oral dose right away — Administering an extra dose without a physician's order is outside the nurse's scope of practice and could lead to medication overdose or adverse effects such as GI bleeding.
C. Do nothing because the client's facial expression indicates he is comfortable — Pain is always subjective and must be based on the patient's self-report, not the nurse's observation of facial expressions. Dismissing the patient's reported pain of 8/10 is a serious nursing error.
D. Use nonpharmacologic therapies while waiting 3 more hours — While nonpharmacologic therapies can complement pain management, waiting 3 more hours without addressing the ineffective pain control is inappropriate and leaves the patient in unnecessary pain.
The physician orders Lovenox 6 mg/kg subcutaneous daily. The client weighs 155 lbs. The nurse is supplied with a Lovenox syringe that reads 40mg/0.4mL. How many mL/dose will the nurse administer? Round to the nearest tenth and label your answer.
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1.4mL/dose
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1.4kg/dose
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2.1kg/dose
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4.2 mL/dose
Explanation
Correct Answer: (D) 4.2 mL/dose
Step 1: Convert weight from pounds to kilograms: 155 lbs ÷ 2.2 = 70.5 kg
Step 2: Calculate the required dose in mg: 70.5 kg × 6 mg/kg = 423 mg
Step 3: Determine the concentration of the syringe: 40 mg/0.4 mL = 100 mg/mL
Step 4: Calculate the volume to administer: 423 mg ÷ 100 mg/mL = 4.2 mL/dose
Why the other options are incorrect:
A. 1.4 mL/dose — This does not reflect the correct calculation using the client's actual weight and the supplied concentration. It significantly underdoses the patient, which could result in inadequate anticoagulation therapy. B. 1.4 kg/dose and C. 2.1 kg/dose — Both of these options are labeled in kilograms, which is a unit of weight, not volume. The answer must be expressed in mL since we are measuring a liquid dose to be administered, making both options fundamentally incorrect regardless of the numbers.
A client is ordered Enoxaparin subcutaneously for DVT prophylaxis. The physician orders 1.4 mg/kg subcutaneously once daily. The client weighs 215 pounds. Based on what is available (Lovenox), how many mLs would the nurse administer? Round to the nearest tenth and label your answer.
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1.4 mL
Explanation
Step 1 — Convert weight from pounds to kilograms: 215 lbs ÷ 2.2 = 97.7 kg
Step 2 — Calculate ordered dose: 97.7 kg × 1.4 mg/kg = 136.8 mg
Step 3 — Calculate volume to administer: Lovenox (Enoxaparin) is available in a standard concentration of 100 mg/mL
136.8 mg ÷ 100 mg/mL = 1.4 mL
Answer: 1.4 mL
The nurse receives report on a patient who is a direct admission from a nursing home. During the assessment, she notes the following on the patient's coccyx area. How would the nurse report this finding?
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Stage 1 Pressure Injury
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Stage 2 Pressure Injury
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Deep Tissue Injury
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Stage 3 Pressure Injury
Explanation
Correct Answer: (C) Deep Tissue Injury
The image shows a localized area of discolored, intact or non-intact skin with a deep purple or maroon color, which is characteristic of a Deep Tissue Pressure Injury (DTPI). This type of injury results from prolonged pressure and shear forces causing damage to the underlying soft tissue beneath an intact skin surface. It is commonly seen in patients from long-term care facilities who have been immobile for extended periods.
Why Other Options are Incorrect:
A. Stage 1 Pressure Injury — A Stage 1 injury presents as non-blanchable redness on intact skin without skin breakdown, typically appearing pink or red. It does not show the deep purple or maroon discoloration seen in this image. B. Stage 2 Pressure Injury — A Stage 2 injury involves partial thickness skin loss presenting as a shallow open ulcer with a pink or red wound bed, or an intact or ruptured blister. The image shows deeper discoloration consistent with tissue damage below the skin surface. D. Stage 3 Pressure Injury — A Stage 3 injury involves full thickness skin loss with visible subcutaneous tissue, slough, or undermining. While serious, it presents differently from the deep purple intact discoloration characteristic of a deep tissue injury.
A solution that has a higher osmolarity than that of body fluids is known as a/an:
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Solvent
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Isotonic solution
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Hypotonic solution
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Hypertonic solution
Explanation
Correct Answer: (D) Hypertonic solution
A hypertonic solution has a higher osmolarity than normal body fluids (greater than 300 mOsm/L). When administered, it draws water out of the cells and into the bloodstream through osmosis, causing cells to shrink. Examples include 3% normal saline and 10% dextrose in water (D10W).
Why Other Options are Incorrect:
A. Solvent — A solvent is the liquid component that dissolves a solute to form a solution. It is not a classification based on osmolarity and has no relation to the comparison with body fluids. B. Isotonic solution — An isotonic solution has the same osmolarity as body fluids (approximately 280–300 mOsm/L), meaning it causes no net movement of water in or out of cells. Examples include 0.9% normal saline and lactated Ringer's. C. Hypotonic solution — A hypotonic solution has a lower osmolarity than body fluids, causing water to move into the cells, leading to cell swelling. Examples include 0.45% normal saline and 0.33% normal saline.
A nurse is teaching a 77-year old about activity. What should be included for teaching in the psychomotor domain?
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The importance of regular exercise
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The potential risks of exercise-induced fractures or heart attack
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The physiological and psychological benefits of physical activity
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The correct procedures for performing several different exercises safely
Explanation
Correct Answer: (D) The correct procedures for performing several different exercises safely
The psychomotor domain of learning involves the development of physical skills, hands-on techniques, and the ability to perform tasks correctly. Teaching a 77-year-old the correct procedures for performing exercises safely directly addresses the psychomotor domain by focusing on the physical execution of skills. This is particularly important for older adults to prevent injury during exercise.
Why the other options are incorrect:
A. The importance of regular exercise — This falls under the affective domain, which involves attitudes, values, and motivations toward health behaviors.
B. The potential risks of exercise-induced fractures or heart attack — This falls under the cognitive domain, which involves knowledge, understanding, and critical thinking about health information.
C. The physiological and psychological benefits of physical activity — This also falls under the cognitive domain, as it involves understanding and comprehension of factual health information.
The nurse is evaluating the effectiveness of the intravenous fluid therapy in a patient with hypernatremia. Which finding indicates goal achievement?
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Urine output increases to 170 mL/hr
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Systolic and diastolic blood pressure decreases
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Serum sodium concentration returns to normal
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Large amounts of emesis and diarrhea decrease
Explanation
Correct Answer: (C) Serum sodium concentration returns to normal
Hypernatremia is defined as an elevated serum sodium level (above 145 mEq/L). The primary goal of IV fluid therapy in hypernatremia is to correct the elevated sodium level and restore normal fluid balance. A serum sodium concentration returning to the normal range (135–145 mEq/L) directly indicates that the treatment goal has been achieved.
Why the other options are incorrect:
A. Urine output increases to 170 mL/hr — A urine output of 170 mL/hr is excessively high and would indicate too-rapid fluid replacement, which can cause cerebral edema. Normal urine output is 30–60 mL/hr.
B. Systolic and diastolic blood pressure decreases — A decrease in blood pressure is not a goal of hypernatremia treatment and could indicate fluid deficit or cardiovascular compromise rather than treatment success.
D. Large amounts of emesis and diarrhea decrease — While reducing fluid losses is important, this finding does not directly indicate correction of the hypernatremia itself and is not the primary measure of treatment effectiveness.
Who makes the actual determination of whether a client is in pain?
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The nurse
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The client
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The physician
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The family
Explanation
Correct Answer: (B) The client
Pain is a subjective experience and is defined as whatever the experiencing person says it is, occurring whenever they say it does. The client is the only authority on their own pain experience. This is a foundational principle of pain management in nursing, supported by the widely accepted definition that pain is always subjective. The nurse's role is to believe the patient's report of pain and advocate for appropriate management.
Why the other options are incorrect:
A. The nurse — While the nurse assesses and documents pain, they cannot determine whether a client is actually experiencing pain; only the client can report their subjective pain experience.
C. The physician — Physicians diagnose conditions and prescribe pain management, but they do not determine whether a patient is in pain; that determination belongs solely to the patient.
D. The family — Family members may observe behavioral signs of pain, but they cannot make the actual determination of whether their loved one is experiencing pain; the patient's self-report is always the primary source.
Shortly after taking medications, a client notifies the nurse that they are experiencing itchiness and a rash. What effect does the nurse determine the client is experiencing from the medication?
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A toxic effect
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An allergic effect
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A synergistic effect
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An idiosyncratic effect
Explanation
Correct Answer: (B) An allergic effect
Itchiness (pruritus) and a rash are classic signs of an allergic reaction to a medication. Allergic drug reactions occur when the immune system identifies the drug as a foreign substance and mounts an immune response. These reactions can range from mild skin manifestations such as urticaria and rash to severe anaphylaxis. The nurse must stop the medication immediately and report the reaction.
Why Other Options are Incorrect:
A. A toxic effect — A toxic effect results from excessive drug levels in the body causing harmful effects on organs or tissues, not an immune-mediated response with rash and itching.
C. A synergistic effect — A synergistic effect occurs when two or more drugs interact to produce an effect greater than the sum of their individual effects; it does not describe a single-drug reaction with rash and itching.
D. An idiosyncratic effect — An idiosyncratic effect is an unexpected, abnormal reaction unique to an individual that is not immune-mediated and not predictable based on the drug's known pharmacology; it differs from a classic allergic response.
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