NU 155 Exam 2 Medical-Surgical Nursing I 2026
Comprehensive Questions And Answers With Detailed
Rationales
QUESTION 1
A patient is receiving a blood transfusion and develops sudden chills, fever, and lower back pain. What is
the nurse's priority action?
A. Slow the infusion rate
B. Stop the transfusion immediately
C. Notify the healthcare provider
D. Administer an antihistamine
Correct Answer: B. Stop the transfusion immediately
Expert Rationale: Chills, fever, and lower back pain are classic signs of an acute hemolytic transfusion
reaction. The priority action is to stop the transfusion immediately to prevent further reaction and
hemodynamic compromise. After stopping the transfusion, the nurse should maintain IV access with
normal saline, notify the healthcare provider, and send the blood bag and tubing to the blood bank for
analysis .
QUESTION 2
A patient with chronic kidney disease (CKD) is admitted with hyperkalemia. Which ECG finding is most
concerning and requires immediate intervention?
A. Flat T waves
B. Absent P waves
C. Widened QRS complex
D. Shortened PR interval
Correct Answer: C. Widened QRS complex
,Expert Rationale: Hyperkalemia causes progressive ECG changes including tall, peaked T waves,
prolonged PR interval, and widened QRS complexes. A widened QRS complex indicates severe cardiac
toxicity and can progress to ventricular fibrillation or asystole, requiring immediate intervention with
calcium gluconate, insulin with glucose, or sodium bicarbonate .
QUESTION 3
A patient with COPD is prescribed home oxygen therapy. The nurse teaches the patient that the goal
oxygen saturation is:
A. 98–100%
B. 88–92%
C. 95–100%
D. 85–88%
Correct Answer: B. 88–92%
Expert Rationale: In COPD patients with chronic hypercapnia, the goal SpO₂ is 88–92% to maintain the
hypoxic drive for breathing. Excessive oxygen can suppress the respiratory drive, worsen hypercapnia,
and precipitate respiratory acidosis. This is a critical safety consideration for COPD patients receiving
supplemental oxygen .
QUESTION 4
A patient with a pneumothorax has a chest tube inserted. The nurse observes continuous bubbling in the
water seal chamber. The nurse recognizes this as:
A. Normal functioning of the chest tube
B. An air leak that requires assessment of the tubing connections and patient condition
C. Evidence of fluid accumulation
D. An indication to clamp the chest tube
, Correct Answer: B. An air leak that requires assessment of the tubing connections and patient condition
Expert Rationale: Continuous bubbling in the water seal chamber indicates an air leak, which may
originate from the patient (bronchopleural fistula) or the system (loose connections). The nurse must
assess tubing connections, patient respiratory status, and notify the provider if the leak persists. Clamping
the chest tube is contraindicated as it could lead to tension pneumothorax .
QUESTION 5
A patient is receiving peritoneal dialysis. During the dialysate outflow, the nurse notes the fluid is cloudy.
What is the most appropriate nursing action?
A. Document the finding as expected
B. Send a sample of the effluent to the laboratory for culture
C. Warm the next bag of dialysate before instillation
D. Increase the dwell time for the next exchange
Correct Answer: B. Send a sample of the effluent to the laboratory for culture
Expert Rationale: Cloudy effluent is a classic sign of peritonitis, a severe complication of peritoneal
dialysis. The nurse should obtain a culture specimen, notify the healthcare provider, and prepare to
administer antibiotics. Cloudy effluent is never considered an expected finding and requires immediate
investigation .
QUESTION 6
The nurse is assessing a client with late-stage heart failure. Which sign indicates right-sided heart failure?
A. Crackles in the lungs
B. Frothy, pink sputum
C. Jugular venous distension
D. Orthopnea
Comprehensive Questions And Answers With Detailed
Rationales
QUESTION 1
A patient is receiving a blood transfusion and develops sudden chills, fever, and lower back pain. What is
the nurse's priority action?
A. Slow the infusion rate
B. Stop the transfusion immediately
C. Notify the healthcare provider
D. Administer an antihistamine
Correct Answer: B. Stop the transfusion immediately
Expert Rationale: Chills, fever, and lower back pain are classic signs of an acute hemolytic transfusion
reaction. The priority action is to stop the transfusion immediately to prevent further reaction and
hemodynamic compromise. After stopping the transfusion, the nurse should maintain IV access with
normal saline, notify the healthcare provider, and send the blood bag and tubing to the blood bank for
analysis .
QUESTION 2
A patient with chronic kidney disease (CKD) is admitted with hyperkalemia. Which ECG finding is most
concerning and requires immediate intervention?
A. Flat T waves
B. Absent P waves
C. Widened QRS complex
D. Shortened PR interval
Correct Answer: C. Widened QRS complex
,Expert Rationale: Hyperkalemia causes progressive ECG changes including tall, peaked T waves,
prolonged PR interval, and widened QRS complexes. A widened QRS complex indicates severe cardiac
toxicity and can progress to ventricular fibrillation or asystole, requiring immediate intervention with
calcium gluconate, insulin with glucose, or sodium bicarbonate .
QUESTION 3
A patient with COPD is prescribed home oxygen therapy. The nurse teaches the patient that the goal
oxygen saturation is:
A. 98–100%
B. 88–92%
C. 95–100%
D. 85–88%
Correct Answer: B. 88–92%
Expert Rationale: In COPD patients with chronic hypercapnia, the goal SpO₂ is 88–92% to maintain the
hypoxic drive for breathing. Excessive oxygen can suppress the respiratory drive, worsen hypercapnia,
and precipitate respiratory acidosis. This is a critical safety consideration for COPD patients receiving
supplemental oxygen .
QUESTION 4
A patient with a pneumothorax has a chest tube inserted. The nurse observes continuous bubbling in the
water seal chamber. The nurse recognizes this as:
A. Normal functioning of the chest tube
B. An air leak that requires assessment of the tubing connections and patient condition
C. Evidence of fluid accumulation
D. An indication to clamp the chest tube
, Correct Answer: B. An air leak that requires assessment of the tubing connections and patient condition
Expert Rationale: Continuous bubbling in the water seal chamber indicates an air leak, which may
originate from the patient (bronchopleural fistula) or the system (loose connections). The nurse must
assess tubing connections, patient respiratory status, and notify the provider if the leak persists. Clamping
the chest tube is contraindicated as it could lead to tension pneumothorax .
QUESTION 5
A patient is receiving peritoneal dialysis. During the dialysate outflow, the nurse notes the fluid is cloudy.
What is the most appropriate nursing action?
A. Document the finding as expected
B. Send a sample of the effluent to the laboratory for culture
C. Warm the next bag of dialysate before instillation
D. Increase the dwell time for the next exchange
Correct Answer: B. Send a sample of the effluent to the laboratory for culture
Expert Rationale: Cloudy effluent is a classic sign of peritonitis, a severe complication of peritoneal
dialysis. The nurse should obtain a culture specimen, notify the healthcare provider, and prepare to
administer antibiotics. Cloudy effluent is never considered an expected finding and requires immediate
investigation .
QUESTION 6
The nurse is assessing a client with late-stage heart failure. Which sign indicates right-sided heart failure?
A. Crackles in the lungs
B. Frothy, pink sputum
C. Jugular venous distension
D. Orthopnea
