NUR 155 Comprehensive Practice Examination Combined Questions Covering Exam 2, 3 & 4 Concepts

NUR 155 Comprehensive Practice Examination Combined Questions Covering Exam 2, 3 & 4 Concepts 1. The nurse is teaching a group of young adult clients about health promotion strategies. Which intervention should the nurse recommend as a primary prevention measure? A. Scheduling a colonoscopy at age 50 B. Obtaining an annual mammogram C. Receiving recommended immunizations D. Participating in cardiac rehabilitation Correct Answer: C. Receiving recommended immunizations Rationale: Primary prevention focuses on preventing disease before it occurs. Immunizations are a classic example of primary prevention. Screening tests like colonoscopy and mammography are secondary prevention, and cardiac rehabilitation is tertiary prevention. 2. The nurse is developing a plan of care that addresses the client’s physical, emotional, social, and spiritual needs. Which nursing concept is the nurse demonstrating? A. Homeostasis B. Individuality C. Health promotion D. Holism Correct Answer: D. Holism Rationale: Holism considers the whole person, including physical, emotional, social, and spiritual dimensions. Homeostasis refers to the body’s ability to maintain internal balance. Individuality recognizes each person’s uniqueness. Health promotion focuses on behaviors that improve well-being. 3. The community health nurse is planning an educational session for teenagers. Which topic is most developmentally appropriate for this age group? A. Menopause management B. Safe driving practices C. Smoking cessation techniques D. Fall prevention strategies Correct Answer: B. Safe driving practices Rationale: Adolescents are at high risk for motor vehicle accidents, making safe driving education developmentally appropriate. Menopause management is for middle-aged adults, smoking cessation applies to adults, and fall prevention targets older adults. 4. The nurse receives a laboratory report indicating the client has a low serum albumin level. Which interpretation by the nurse is most accurate? A. “The client has acute kidney injury.” B. “The client is experiencing fluid volume overload.” C. “The client may have chronic malnutrition.” D. “The client has developed anemia.” Correct Answer: C. “The client may have chronic malnutrition.” Rationale: Low serum albumin is a marker of prolonged protein-calorie malnutrition. It does not directly indicate kidney injury, fluid overload, or anemia. Albumin has a long half-life, so low levels suggest chronic rather than acute issues. 5. The nurse is preparing discharge teaching for an elderly client at risk for aspiration. Which instruction should the nurse include? A. Drink thin liquids to prevent dehydration B. Tilt the head backward when swallowing C. Sit upright at a 90-degree angle during meals D. Lie flat for 30 minutes after eating Correct Answer: C. Sit upright at a 90-degree angle during meals Rationale: Maintaining an upright position during and after meals helps prevent aspiration by promoting proper swallowing mechanics and reducing reflux. Thin liquids increase aspiration risk in dysphagic clients. Head tilting backward can worsen swallowing difficulties. 6. The nurse is preparing to administer an intermittent enteral feeding through a gastrostomy tube. Which action should the nurse take first? A. Flush the tube with 100 mL of water B. Verify tube placement by aspirating gastric contents C. Heat the formula to body temperature D. Position the client in a supine position Correct Answer: B. Verify tube placement by aspirating gastric contents Rationale: Confirming correct tube placement is the priority before administering any enteral feeding to prevent aspiration and ensure delivery to the stomach. Flushing, warming formula, and positioning are also important but follow verification. 7. The nurse assesses an IV site that is swollen, cool, and pale. What is the nurse’s priority action? A. Apply a warm compress to the site B. Slow the infusion rate and continue monitoring C. Stop the infusion and remove the IV catheter D. Elevate the extremity above heart level Correct Answer: C. Stop the infusion and remove the IV catheter Rationale: Swelling and coolness at an IV site indicate infiltration. The priority is to stop the infusion and remove the catheter to prevent further tissue damage. Application of heat or elevation may be appropriate after removal. 8. The nurse is caring for a client with a decreased serum phosphorus level. Which dietary recommendation should the nurse include in the plan of care? A. Encourage intake of green leafy vegetables B. Increase consumption of milk and yogurt C. Recommend high-protein meat selections D. Suggest increased intake of citrus fruits Correct Answer: B. Increase consumption of milk and yogurt Rationale: Dairy products like milk and yogurt are excellent sources of phosphorus. Green leafy vegetables are not high in phosphorus. Meat contains phosphorus but dairy is more concentrated. Citrus fruits are not significant phosphorus sources. 9. The nurse is caring for a client who is 7 days post-operative and has been on bed rest. Which intervention is most effective for preventing hypercalcemia? A. Encourage increased oral fluid intake B. Assist the client with passive range-of-motion exercises C. Ambulate the client three times daily D. Administer calcium supplements as ordered Correct Answer: C. Ambulate the client three times daily Rationale: Weight-bearing activity stimulates bone remodeling and reduces bone resorption, which decreases the release of calcium into the bloodstream. Fluid intake helps but does not address the underlying cause of hypercalcemia related to immobility. 10. A client with diarrhea for 48 hours develops fatigue, restlessness, and disorientation. Which electrolyte imbalance should the nurse suspect? A. Hypernatremia B. Hyponatremia C. Hypercalcemia D. Hypomagnesemia Correct Answer: B. Hyponatremia Rationale: Prolonged diarrhea causes loss of sodium and water, leading to hyponatremia. Neurological symptoms like disorientation and restlessness are characteristic of sodium imbalances. Hypokalemia may also occur but the symptoms described are more consistent with sodium disturbance.