NUR 242 PRACTICE EXAM 1 ()
- ADVANCED NURSING CONCEPTS
QUESTIONS & VERIFIED ANSWERS |
GALEN COLLEGE (A+ GUARANTEE)
1. A 10-month-old infant is admitted with suspected Intussusception. Which assessment
finding should the nurse prioritize as the most characteristic clinical manifestation of this
condition?
A. Projectile vomiting immediately after feeding
B. Ribbon-like, foul-smelling stools
C. Palpable olive-shaped mass in the right upper quadrant
D. Stool mixed with blood and mucus resembling currant jelly
Answer: D
Conceptual Explanation: Intussusception occurs when one portion of the bowel
telescopes into another, leading to ischemia and the passage of ‘currant jelly’ stools (blood
and mucus). Projectile vomiting and olive-shaped masses are typical of Pyloric Stenosis,
while ribbon-like stools are associated with Hirschsprung’s disease.
2. A laboring client at 38 weeks gestation is receiving a Magnesium Sulfate infusion for
preeclampsia. Which finding requires the nurse to stop the infusion immediately?
A. Blood pressure of 150/98 mmHg
,B. Absence of deep tendon reflexes
C. Urine output of 40 mL/hour
D. Respiratory rate of 14 breaths/min
Answer: B
Conceptual Explanation: Loss of deep tendon reflexes is an early sign of magnesium
toxicity. Other toxic signs include respiratory depression (typically below 12/min) and
decreased urine output (less than 30 mL/hr). A blood pressure of 150/98 is expected in
preeclampsia and does not warrant stopping the magnesium.
3. When assessing a newborn with Tetralogy of Fallot, the nurse notes the infant is becoming
cyanotic and agitated while crying. Which action should the nurse perform first?
A. Administer 100% oxygen via blow-by
B. Prepare for immediate administration of morphine sulfate
C. Obtain an arterial blood gas sample
D. Place the infant in a knee-chest position
Answer: D
Conceptual Explanation: Placing the infant in the knee-chest position (or squatting for
older children) increases systemic vascular resistance, which decreases the right-to-left
shunt and improves oxygenation during a ‘Tet spell.’ This is the priority intervention.
, 4. A 4-year-old child is brought to the emergency department with a high fever, drooling, and
sitting in a ‘tripod’ position. Which action is contraindicated for this patient?
A. Applying humidified oxygen
B. Inserting a tongue blade to visualize the throat
C. Initiating intravenous access for fluids
D. Obtaining a portable lateral neck X-ray
Answer: B
Conceptual Explanation: These symptoms suggest Epiglottitis. Any attempt to visualize
the throat with a tongue blade or swab can trigger laryngospasm and complete airway
obstruction. This should only be done in an operating room with intubation equipment
ready.
5. A nurse is caring for a client with abruptio placentae. Which clinical finding is the most
significant indicator of this condition?
A. Painless, bright red vaginal bleeding
B. Soft, non-tender uterus
C. Fetal heart rate accelerations
D. Board-like, rigid abdomen with severe pain
Answer: D
- ADVANCED NURSING CONCEPTS
QUESTIONS & VERIFIED ANSWERS |
GALEN COLLEGE (A+ GUARANTEE)
1. A 10-month-old infant is admitted with suspected Intussusception. Which assessment
finding should the nurse prioritize as the most characteristic clinical manifestation of this
condition?
A. Projectile vomiting immediately after feeding
B. Ribbon-like, foul-smelling stools
C. Palpable olive-shaped mass in the right upper quadrant
D. Stool mixed with blood and mucus resembling currant jelly
Answer: D
Conceptual Explanation: Intussusception occurs when one portion of the bowel
telescopes into another, leading to ischemia and the passage of ‘currant jelly’ stools (blood
and mucus). Projectile vomiting and olive-shaped masses are typical of Pyloric Stenosis,
while ribbon-like stools are associated with Hirschsprung’s disease.
2. A laboring client at 38 weeks gestation is receiving a Magnesium Sulfate infusion for
preeclampsia. Which finding requires the nurse to stop the infusion immediately?
A. Blood pressure of 150/98 mmHg
,B. Absence of deep tendon reflexes
C. Urine output of 40 mL/hour
D. Respiratory rate of 14 breaths/min
Answer: B
Conceptual Explanation: Loss of deep tendon reflexes is an early sign of magnesium
toxicity. Other toxic signs include respiratory depression (typically below 12/min) and
decreased urine output (less than 30 mL/hr). A blood pressure of 150/98 is expected in
preeclampsia and does not warrant stopping the magnesium.
3. When assessing a newborn with Tetralogy of Fallot, the nurse notes the infant is becoming
cyanotic and agitated while crying. Which action should the nurse perform first?
A. Administer 100% oxygen via blow-by
B. Prepare for immediate administration of morphine sulfate
C. Obtain an arterial blood gas sample
D. Place the infant in a knee-chest position
Answer: D
Conceptual Explanation: Placing the infant in the knee-chest position (or squatting for
older children) increases systemic vascular resistance, which decreases the right-to-left
shunt and improves oxygenation during a ‘Tet spell.’ This is the priority intervention.
, 4. A 4-year-old child is brought to the emergency department with a high fever, drooling, and
sitting in a ‘tripod’ position. Which action is contraindicated for this patient?
A. Applying humidified oxygen
B. Inserting a tongue blade to visualize the throat
C. Initiating intravenous access for fluids
D. Obtaining a portable lateral neck X-ray
Answer: B
Conceptual Explanation: These symptoms suggest Epiglottitis. Any attempt to visualize
the throat with a tongue blade or swab can trigger laryngospasm and complete airway
obstruction. This should only be done in an operating room with intubation equipment
ready.
5. A nurse is caring for a client with abruptio placentae. Which clinical finding is the most
significant indicator of this condition?
A. Painless, bright red vaginal bleeding
B. Soft, non-tender uterus
C. Fetal heart rate accelerations
D. Board-like, rigid abdomen with severe pain
Answer: D
