NUR 230 Exam 3 Questions and Correct Answers plus
Rationale| New 2026-2027 Update | Graded A+
1. Which of the following best describes the primary purpose of the nursing
process?
A) To provide a systematic framework for delivering individualized, evidence-
based care
B) To document tasks completed during a shift for legal purposes
C) To determine the medical diagnosis for a patient
D) To establish the financial cost of patient care
Correct Answer: To provide a systematic framework for delivering individualized,
evidence-based care
Rationale: The nursing process is a critical thinking model used by nurses to
deliver holistic, patient-centered care. It consists of assessment, diagnosis,
planning, implementation, and evaluation. It is not used to determine medical
diagnoses, document tasks, or establish costs.
2. What is the primary function of the assessment phase in the nursing
process?
A) Collecting comprehensive data pertinent to the patient's health situation
B) Analyzing data to determine nursing diagnoses
C) Developing a plan of care
D) Evaluating progress toward outcomes
Correct Answer: Collecting comprehensive data pertinent to the patient's health
situation
Rationale: Assessment is the first step of the nursing process, where the nurse
collects subjective and objective data. This data forms the foundation for
subsequent phases. Analysis and diagnosis occur after assessment is complete. It
is an ongoing process that requires critical thinking.
, 3. According to the exam blueprint, what does the SMART acronym stand for
in outcome planning?
A) Specific, Measurable, Achievable, Relevant, Time-bound
B) Simple, Manageable, Achievable, Realistic, Timely
C) Specific, Meaningful, Actionable, Relevant, Testable
D) Standard, Measurable, Achievable, Relevant, Time-bound
Correct Answer: Specific, Measurable, Achievable, Relevant, Time-bound
Rationale: SMART goals ensure outcomes are clear and evaluable. Specific means
the goal is well-defined, Measurable means it can be quantified, Achievable
means it is realistic, Relevant means it matters to the patient, and Time-bound
means it has a deadline.
4. Which finding is most consistent with magnesium sulfate toxicity in a
patient receiving the medication for preeclampsia?
A) Increased urinary output
B) Hyperactive deep tendon reflexes
C) Respiratory rate of 10 breaths per minute
D) Blood pressure of 150/95 mm Hg
Correct Answer: Respiratory rate of 10 breaths per minute
Rationale: Magnesium sulfate is a central nervous system depressant used to
prevent seizures in preeclamptic patients. Signs of toxicity include a respiratory
rate less than 12 per minute, loss of deep tendon reflexes, and decreased urinary
output. Calcium gluconate is the antagonist.
5. What is the primary purpose of administering betamethasone to a patient
at 32 weeks gestation in preterm labor?
A) To stop uterine contractions
B) To promote fetal lung maturity
C) To prevent infection
D) To lower blood pressure
Correct Answer: To promote fetal lung maturity
,Rationale: Betamethasone is a corticosteroid that stimulates fetal lung surfactant
production and reduces the risk of respiratory distress syndrome, intraventricular
hemorrhage, and necrotizing enterocolitis in preterm infants. It does not stop
contractions or treat infection.
6. A postpartum patient's fundus is boggy and displaced to the right. Which
action should the nurse take first?
A) Massage the fundus firmly until it contracts
B) Notify the healthcare provider of the finding
C) Assist the client to the bathroom to void
D) Administer oxytocin as prescribed
Correct Answer: Assist the client to the bathroom to void
Rationale: A boggy uterus displaced to the right is a classic sign of a full bladder,
which prevents the uterus from contracting effectively. Having the client void is
the priority, as this allows the uterus to return to the midline and contract.
Massaging the fundus is indicated only after the bladder is empty.
7. Which finding is most consistent with a positive contraction stress test?
A) Late decelerations with 50% or more of contractions
B) No decelerations with contractions
C) Early decelerations with contractions
D) Accelerations with fetal movement
Correct Answer: Late decelerations with 50% or more of contractions
Rationale: A positive contraction stress test shows late decelerations with at least
50% of contractions, indicating uteroplacental insufficiency and fetal hypoxia.
Negative results show no late decelerations. Early decelerations are benign and
related to head compression.
8. A 4-year-old child with Tetralogy of Fallot suddenly becomes cyanotic and
dyspneic. In which position should the nurse place the child?
A) Knee-chest position
B) Semi-Fowler's position
, C) High-Fowler's position
D) Supine position
Correct Answer: Knee-chest position
Rationale: The knee-chest position increases systemic vascular resistance, which
decreases the right-to-left shunt and improves pulmonary blood flow in a child
experiencing a tet spell. Semi-Fowler's, High-Fowler's, and supine positions do not
provide this benefit.
9. Which finding is most consistent with respiratory syncytial virus (RSV) in a 6-
month-old infant?
A) Barking cough and inspiratory stridor
B) Wheezing and poor feeding
C) High fever and petechial rash
D) Bradycardia and hypertension
Correct Answer: Wheezing and poor feeding
Rationale: RSV typically presents with bronchiolitis, characterized by wheezing,
tachypnea, and poor feeding in infants. A barking cough and stridor suggest croup.
High fever and petechial rash suggest a different infectious process.
10.What is the primary purpose of the APGAR score?
A) To assess long-term cognitive development
B) To evaluate the newborn's immediate adjustment to extrauterine life
C) To determine the need for surgical intervention
D) To measure the newborn's birth weight and length
Correct Answer: To evaluate the newborn's immediate adjustment to extrauterine
life
Rationale: The APGAR score assesses heart rate, respiratory effort, muscle tone,
reflex irritability, and color at 1 and 5 minutes after birth. It provides a
standardized evaluation of the newborn's transition to life outside the uterus and
identifies those needing immediate resuscitation.
11.Which finding indicates a potential complication of thyroidectomy?
Rationale| New 2026-2027 Update | Graded A+
1. Which of the following best describes the primary purpose of the nursing
process?
A) To provide a systematic framework for delivering individualized, evidence-
based care
B) To document tasks completed during a shift for legal purposes
C) To determine the medical diagnosis for a patient
D) To establish the financial cost of patient care
Correct Answer: To provide a systematic framework for delivering individualized,
evidence-based care
Rationale: The nursing process is a critical thinking model used by nurses to
deliver holistic, patient-centered care. It consists of assessment, diagnosis,
planning, implementation, and evaluation. It is not used to determine medical
diagnoses, document tasks, or establish costs.
2. What is the primary function of the assessment phase in the nursing
process?
A) Collecting comprehensive data pertinent to the patient's health situation
B) Analyzing data to determine nursing diagnoses
C) Developing a plan of care
D) Evaluating progress toward outcomes
Correct Answer: Collecting comprehensive data pertinent to the patient's health
situation
Rationale: Assessment is the first step of the nursing process, where the nurse
collects subjective and objective data. This data forms the foundation for
subsequent phases. Analysis and diagnosis occur after assessment is complete. It
is an ongoing process that requires critical thinking.
, 3. According to the exam blueprint, what does the SMART acronym stand for
in outcome planning?
A) Specific, Measurable, Achievable, Relevant, Time-bound
B) Simple, Manageable, Achievable, Realistic, Timely
C) Specific, Meaningful, Actionable, Relevant, Testable
D) Standard, Measurable, Achievable, Relevant, Time-bound
Correct Answer: Specific, Measurable, Achievable, Relevant, Time-bound
Rationale: SMART goals ensure outcomes are clear and evaluable. Specific means
the goal is well-defined, Measurable means it can be quantified, Achievable
means it is realistic, Relevant means it matters to the patient, and Time-bound
means it has a deadline.
4. Which finding is most consistent with magnesium sulfate toxicity in a
patient receiving the medication for preeclampsia?
A) Increased urinary output
B) Hyperactive deep tendon reflexes
C) Respiratory rate of 10 breaths per minute
D) Blood pressure of 150/95 mm Hg
Correct Answer: Respiratory rate of 10 breaths per minute
Rationale: Magnesium sulfate is a central nervous system depressant used to
prevent seizures in preeclamptic patients. Signs of toxicity include a respiratory
rate less than 12 per minute, loss of deep tendon reflexes, and decreased urinary
output. Calcium gluconate is the antagonist.
5. What is the primary purpose of administering betamethasone to a patient
at 32 weeks gestation in preterm labor?
A) To stop uterine contractions
B) To promote fetal lung maturity
C) To prevent infection
D) To lower blood pressure
Correct Answer: To promote fetal lung maturity
,Rationale: Betamethasone is a corticosteroid that stimulates fetal lung surfactant
production and reduces the risk of respiratory distress syndrome, intraventricular
hemorrhage, and necrotizing enterocolitis in preterm infants. It does not stop
contractions or treat infection.
6. A postpartum patient's fundus is boggy and displaced to the right. Which
action should the nurse take first?
A) Massage the fundus firmly until it contracts
B) Notify the healthcare provider of the finding
C) Assist the client to the bathroom to void
D) Administer oxytocin as prescribed
Correct Answer: Assist the client to the bathroom to void
Rationale: A boggy uterus displaced to the right is a classic sign of a full bladder,
which prevents the uterus from contracting effectively. Having the client void is
the priority, as this allows the uterus to return to the midline and contract.
Massaging the fundus is indicated only after the bladder is empty.
7. Which finding is most consistent with a positive contraction stress test?
A) Late decelerations with 50% or more of contractions
B) No decelerations with contractions
C) Early decelerations with contractions
D) Accelerations with fetal movement
Correct Answer: Late decelerations with 50% or more of contractions
Rationale: A positive contraction stress test shows late decelerations with at least
50% of contractions, indicating uteroplacental insufficiency and fetal hypoxia.
Negative results show no late decelerations. Early decelerations are benign and
related to head compression.
8. A 4-year-old child with Tetralogy of Fallot suddenly becomes cyanotic and
dyspneic. In which position should the nurse place the child?
A) Knee-chest position
B) Semi-Fowler's position
, C) High-Fowler's position
D) Supine position
Correct Answer: Knee-chest position
Rationale: The knee-chest position increases systemic vascular resistance, which
decreases the right-to-left shunt and improves pulmonary blood flow in a child
experiencing a tet spell. Semi-Fowler's, High-Fowler's, and supine positions do not
provide this benefit.
9. Which finding is most consistent with respiratory syncytial virus (RSV) in a 6-
month-old infant?
A) Barking cough and inspiratory stridor
B) Wheezing and poor feeding
C) High fever and petechial rash
D) Bradycardia and hypertension
Correct Answer: Wheezing and poor feeding
Rationale: RSV typically presents with bronchiolitis, characterized by wheezing,
tachypnea, and poor feeding in infants. A barking cough and stridor suggest croup.
High fever and petechial rash suggest a different infectious process.
10.What is the primary purpose of the APGAR score?
A) To assess long-term cognitive development
B) To evaluate the newborn's immediate adjustment to extrauterine life
C) To determine the need for surgical intervention
D) To measure the newborn's birth weight and length
Correct Answer: To evaluate the newborn's immediate adjustment to extrauterine
life
Rationale: The APGAR score assesses heart rate, respiratory effort, muscle tone,
reflex irritability, and color at 1 and 5 minutes after birth. It provides a
standardized evaluation of the newborn's transition to life outside the uterus and
identifies those needing immediate resuscitation.
11.Which finding indicates a potential complication of thyroidectomy?
