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
The nurse is assessing the right dorsalis pedis of a client and is unable to palpate the pulse. What action should the nurse take next?
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Have another nurse check before documenting in the medical record.
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Obtain a doppler to confirm the presence of the pulse.
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Inform the charge nurse regarding the finding.
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Document the finding in the medical record.
Explanation
Correct Answer: (B) Obtain a doppler to confirm the presence of the pulse
When a peripheral pulse cannot be palpated, the next appropriate action is to use a Doppler ultrasound device to confirm whether the pulse is present. The dorsalis pedis pulse can be difficult to palpate in some individuals, and a Doppler provides an objective, reliable method to detect blood flow before escalating the situation or documenting an absence of pulse.
Why Other Options are Incorrect:
A. Have another nurse check before documenting — While peer verification may be helpful, the standard clinical practice is to use a Doppler device first to objectively confirm the finding rather than relying solely on manual palpation by another nurse. C. Inform the charge nurse — This step may be appropriate after confirming the absence of the pulse with a Doppler, but it is premature before objective confirmation is obtained. D. Document the finding in the medical record — Documentation should only occur after the finding has been confirmed using a Doppler. Documenting an absent pulse without confirmation could lead to unnecessary interventions or inaccurate records.
What is the best rationale to gather data about a client's use of herbal products?
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Client's medication records are not important
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Many herbs are known to interact with medications
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Herbal products need to be evaluated for research purposes
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The nurse practice act requires RNs to monitor all drug dosages
Explanation
The primary clinical reason to gather data about a client's use of herbal products is that many herbs have known pharmacological interactions with prescribed medications. For example, St. John's Wort can reduce the effectiveness of anticoagulants and antidepressants, garlic supplements can increase bleeding risk, and ginkgo biloba can potentiate antiplatelet medications. Identifying herbal use is essential for patient safety and preventing adverse drug interactions.
Why the other options are incorrect:
A. Client's medication records are not important — This statement is completely incorrect; medication records including all supplements and herbal products are critically important for safe patient care.
C. Herbal products need to be evaluated for research purposes — While research on herbal products is valuable, this is not the primary clinical rationale for asking patients about their herbal use during a nursing assessment.
D. The nurse practice act requires RNs to monitor all drug dosages — While nurses are responsible for medication management, the specific rationale for gathering herbal product data is the risk of drug interactions, not a regulatory requirement about drug dosages.
Which infection control statements are true? (Select all that apply)
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Healthcare-Associated Infections often result from unclean surfaces, such as hands
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Standard precautions need to be used for only the elderly and immunocompromised patients
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Viruses are the most commonly found infection-causing agent in health care facilities
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Medical asepsis decreases the potential for the spread of infections
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Jewelry with small stones is permitted
Explanation
Correct Answer: (A) Healthcare-Associated Infections often result from unclean surfaces, such as hands and (D) Medical asepsis decreases the potential for the spread of infections
Hand hygiene is consistently identified as the single most important factor in preventing healthcare-associated infections. Contaminated hands are a primary vehicle for transmitting pathogens between patients and surfaces. Medical asepsis, which includes practices such as handwashing, wearing gloves, and maintaining clean environments, directly reduces the transmission of microorganisms and lowers infection risk.
Why the other options are incorrect:
B. Standard precautions need to be used for only the elderly and immunocompromised patients — Standard precautions must be applied with every patient, regardless of age, diagnosis, or immune status. They are the baseline level of infection prevention for all patient care. C. Viruses are the most commonly found infection-causing agent in healthcare facilities — Bacteria, not viruses, are the most commonly found infection-causing agents in healthcare settings. Common culprits include MRSA, C. difficile, and E. coli. E. Jewelry with small stones is permitted — Jewelry, including rings with stones, is not permitted in clinical settings because stones and crevices harbor microorganisms that cannot be adequately removed with handwashing, increasing the risk of infection transmission.
The nurse is assessing an older client for nutritional status. Which action will the nurse take?
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Inquire about the client's sleep patterns
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Obtain subjective and objective data
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Focus on the chronic disease only
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Medicate the client for anxiety
Explanation
Correct Answer: (B) Obtain subjective and objective data
A comprehensive nutritional assessment requires collecting both subjective data (what the patient reports — food preferences, appetite changes, difficulty swallowing, recent weight changes) and objective data (measurable findings — weight, BMI, laboratory values such as albumin and prealbumin, skin turgor, and physical signs of malnutrition). Using both types of data provides the most complete and accurate nutritional assessment, especially in older adults who are at higher risk for malnutrition.
Why the other options are incorrect:
A. Inquire about the client's sleep patterns — While sleep is important for overall health, it is not a primary component of a nutritional status assessment.
C. Focus on the chronic disease only — A nutritional assessment must be comprehensive and holistic, considering all factors that affect nutrition including medications, social situation, dental health, and functional ability — not just chronic disease alone.
D. Medicate the client for anxiety — Medicating for anxiety is a treatment intervention unrelated to conducting a nutritional assessment and would not be an appropriate nursing action in this context.
A nurse is caring for a group of patients at high risk for fluid volume imbalances. Which assessment finding is expected to be found within each imbalance? Each assessment finding has to have 1 selection.
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Hyponatremia
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Full (distended) neck veins upon sitting up
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Crackles within the bilateral lung bases
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Dark yellow urine
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Bounding pulse rate
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Thirst reflex present
Explanation
Correct Answer:
Fluid Volume Overload: (A) Hyponatremia, (B) Full (distended) neck veins upon sitting up, (C) Crackles within the bilateral lung bases, (E) Bounding pulse rate
In fluid volume overload, excess fluid accumulates in the vascular and interstitial spaces, causing distended neck veins from increased venous pressure, crackles from fluid accumulating in the lungs, a bounding pulse from increased vascular volume, and dilutional hyponatremia as sodium becomes diluted by excess fluid.
In fluid volume deficit, the body is dehydrated, triggering the thirst reflex as the brain signals the need for fluid intake, and producing concentrated dark yellow urine as the kidneys conserve water to restore volume.
Why the other options are incorrect:
D. Dark yellow urine and F. Thirst reflex are classic signs of dehydration and would not be present in fluid overload, where urine is typically pale and dilute and the thirst mechanism is not triggered. A. Hyponatremia, B. Distended neck veins, C. Crackles, and E. Bounding pulse are all caused by excess fluid volume and would not be present in a fluid deficit state where the vascular system is depleted and under-filled.
A doctor recommends a yearly mammogram for women over 40 years of age to detect breast cancer early. This is an example of what type of prevention?
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Secondary prevention
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Primary prevention
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Unilateral prevention
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Tertiary prevention
Explanation
Correct Answer: (A) Secondary prevention
Secondary prevention involves early detection and screening for disease in order to identify it at an early stage when treatment is most effective. A yearly mammogram is a screening tool designed to detect breast cancer early — before symptoms develop — allowing for timely treatment and improved outcomes. Other examples of secondary prevention include Pap smears, colonoscopies, and blood pressure screenings.
Why Other Options are Incorrect:
B. Primary prevention — Primary prevention focuses on preventing a disease from occurring in the first place by addressing risk factors in healthy individuals (e.g., vaccination, smoking cessation). A mammogram does not prevent breast cancer; it detects it early.
C. Unilateral prevention — This is not a recognized level of prevention in public health or nursing practice.
D. Tertiary prevention — Tertiary prevention focuses on managing and reducing the impact of an already diagnosed disease to prevent complications and improve quality of life (e.g., chemotherapy, cardiac rehabilitation). A mammogram screens for disease, not manages it.
To use a fire extinguisher, use PASS sequence. What does PASS stand for?
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Pull the pin, aim at the top of the fire, squeeze the handle, sweep the extinguisher side to side, covering the area of the fire
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Pull the pin, aim at the base of the fire, squeeze the handle, sweep the extinguisher side to side, covering the area of the fire
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Plug the pin, aim at the base of the fire, squeeze the handle, sweep the extinguisher side to side, covering the area of the fire
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Plug the pin, aim at the top of the fire, squeeze the handle, sweep the extinguisher side to side, covering the area of the fire
Explanation
Correct Answer: (B) Pull the pin, aim at the base of the fire, squeeze the handle, sweep the extinguisher side to side, covering the area of the fire
The PASS acronym stands for: Pull the pin, Aim at the base of the fire, Squeeze the handle, Sweep side to side. Aiming at the BASE of the fire is critical because the extinguishing agent must reach the fuel source to effectively extinguish the fire. Aiming at the flames or top of the fire is ineffective as it does not address the fuel feeding the fire.
Why the other options are incorrect:
A. Pull the pin, aim at the top of the fire — Aiming at the top rather than the base of the fire is incorrect; the extinguishing agent must be directed at the fuel source at the base.
C. Plug the pin — The correct action is to PULL the pin, not plug it. Plugging the pin makes no sense in the context of fire extinguisher operation.
D. Plug the pin, aim at the top — Both components of this answer are incorrect; the pin must be pulled, and the aim must be directed at the base of the fire.
A client is ordered to receive continuous tube feedings through a small-bore nasogastric tube. Following placement of the tube, which action would ensure correct placement of the tube?
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Measurement of gastric aspirate pH
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A radiographic examination of the tube placement
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Measurement of the amount of residual in the tube
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Auscultate the abdomen while injecting air into the tube
Explanation
Correct Answer: (B) A radiographic examination of the tube placement
Radiographic (X-ray) confirmation is the gold standard for verifying correct placement of a small-bore nasogastric feeding tube before initiating tube feedings. X-ray provides definitive visual confirmation that the tube tip is positioned in the stomach or small intestine and has not been inadvertently placed in the lungs or bronchi. This is especially critical for small-bore tubes which are more likely to migrate into the respiratory tract without the patient coughing or gagging.
Why Other Options are Incorrect:
A. Measurement of gastric aspirate pH — While pH testing of aspirate (pH ≤ 5.5 suggests gastric placement) is a useful bedside verification method, it is not the gold standard and can give false results. X-ray remains the definitive confirmation method, especially for initial placement.
C. Measurement of the amount of residual in the tube — Checking gastric residual volume is done to assess feeding tolerance after placement is confirmed, not to verify initial tube placement.
D. Auscultate the abdomen while injecting air into the tube — This method (whoosh test) is no longer considered reliable for confirming tube placement as air can be heard over the epigastrium even when the tube is misplaced in the lungs. This method is not recommended by current evidence-based guidelines.
A nurse educator is observing a student nurse administer an intradermal (ID) injection. Which of the following demonstrates correct technique?
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Selects a 1-inch 23-gauge needle with a 3 mL syringe.
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Inserts the needle with the bevel down at a 15- to 20-degree angle.
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Slowly injects the medication to form a small wheal or bleb.
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Withdraws the needle and gently massages the injection site.
Explanation
Correct Answer: (C) Slowly injects the medication to form a small wheal or bleb
The hallmark of a correctly performed intradermal injection is the formation of a small raised wheal or bleb at the injection site. This confirms that the medication has been deposited into the dermal layer rather than subcutaneous tissue, which is essential for accurate results, particularly in tuberculin skin testing and allergy testing.
Why Other Options are Incorrect:
A. Selects a 1-inch 23-gauge needle with a 3 mL syringe — An intradermal injection requires a short needle, typically 3/8 to 5/8 inch, and a fine 25- to 27-gauge needle with a 1 mL tuberculin syringe. A 1-inch 23-gauge needle with a 3 mL syringe is too large and would deliver medication too deeply. B. Inserts the needle with the bevel down at a 15- to 20-degree angle — The bevel must face UP, not down, during an intradermal injection. The bevel-up position at a 5- to 15-degree angle ensures the medication is deposited into the dermis and forms a wheal. D. Withdraws the needle and gently massages the injection site — The injection site should never be massaged after an intradermal injection as it can disperse the medication into surrounding tissue, invalidating the test results and altering absorption.
During the auscultation of breath sounds, the nurse should correctly use the stethoscope in which of the following ways?
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Listen over the patient's gown to maintain modesty
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Listening to breath sounds when the patient only on inhalation
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Instructing the patient to breathe in and out rapidly while listening to the breath sounds
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Listening to at least one full respiration in each location
Explanation
Correct Answer: (D) Listening to at least one full respiration in each location
When auscultating breath sounds, the nurse must listen to at least one complete respiratory cycle (both inhalation and exhalation) at each stethoscope placement site. This ensures that all phases of breathing are assessed and that any abnormal sounds — which may only occur during one phase — are not missed.
Why the other options are incorrect:
A. Listen over the patient's gown to maintain modesty — The stethoscope must be placed directly on the skin, not over clothing. Clothing can muffle sounds and create artifact noises that interfere with accurate assessment.
B. Listening to breath sounds on inhalation only — Both inhalation and exhalation must be assessed, as abnormal sounds such as wheezes or crackles can occur during either phase and must not be missed.
C. Instructing the patient to breathe in and out rapidly — The patient should be instructed to breathe slowly and deeply through the mouth, not rapidly. Rapid breathing can cause dizziness and hyperventilation and does not improve sound quality.
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