NU 155 EXAM 1 /NU 155 MEDICAL SURGICAL
NURSING I EXAM 1 WITH ACTUAL CORRECT
QUESTIONS AND VERIFIED DETAILED
ANSWERS| CURRENTLY TESTING VERSION |
ALREADY GRADED A+|NEWEST|EXPERT
VERIFIED FOR GUARANTEED PASS 2026/2027
The nurse assesses the patient's IV insertion site and observes that the vein is hard, the
skin is red and tender, and a blood return in the IV line. After removing the IV catheter,
which action should the nurse take next?
1. Obtain an arm board to properly secure the IV.
2. Elevate the arm above the level of the heart.
3. Clean the site with alcohol and apply cool compresses.
4. Apply a warm moist pack.
Apply a warm moist pack.
Rationale: These are signs and symptoms of phlebitis and should be treated with a
warm moist pack to increase blood flow to the area. The IV has been discontinued,
so an arm board for stabilization is unnecessary. Elevation of the arm would be
helpful to reduce swelling. A cool compress would be indicated for other issues
related to IV infusion problems, such as extravasation.
1|Page
,The nurse is caring for a patient who has been on total parenteral nutrition (TPN) for 48
h. Which action demonstrates effective nursing care?
1. Checking the patient's blood glucose level according to facility protocol
2. Increasing the infusion rate if the prescribed intake falls behind
3. Informing the patient that TPN can only be administered via a central line for 1 week
4. Monitoring the peripheral IV site of TPN infusion for signs of infiltration at least every 8
h
Checking the patient's blood glucose level according to facility protocol
Rationale: The hypertonic solution causes difficulty with glucose tolerance, so
monitoring of blood glucose level is imperative. The infusion rate should never be
increased to "catch up" because of the likelihood of fluid overload caused by the
hypertonicity of the TPN. TPN can be administered for more than 1 week and it is
almost always administered via a central line rather than a peripheral line.
The nurse is reviewing standing orders for a patient who was admitted for evaluation of
chest pain. The patient has a history of COPD (Chronic obstructive pulmonary disorder)
and his laboratory results indicate that he has mild respiratory acidosis. The nurse
would question which order?
1. Encourage oral fluids
2. Oxygen therapy 4L/min as needed
3. Keep head of the bed elevated
4. Bedrest with bathroom privileges only
2|Page
,Oxygen therapy 4L/min
Rationale: Bedrest will help conserve energy. Keeping the bed elevated will help
open the airways. Increasing the fluid intake will help thin lung secretions when
coughing and help remove mucus from the lungs. Giving too much oxygen to a
COPD patient will decrease their respiratory drive, because CO2 gives humans
drive to breathe. This may cause them to stop bleeding. Give 1-2L of oxygen for
COPD.
A nurse assesses clients on the medical-surgical unit. Which client is at greatest
risk for the development of bacterial cystitis?
1. A 36-year-old female who has never been pregnant
2. A 42-year-old male who is prescribed cyclophosphamide
3. A 58-year-old female who is not taking estrogen replacement
4. A 77-year-old male with mild congestive heart failure
A 58-year-old female who is not taking estrogen replacement
The nurse is caring for a patient with a potassium level of 2.9 mEq/L. The nurse should
carefully monitor the patient for which potential problem?
3|Page
, 1. Excessive urinary output
2. Increased reflexes
3. Hyperactive bowel sounds
4. Abdominal distention
Abdominal distention
Rationale: A potassium level lower than 3.5 mEq/L results in reduced urine output,
cardiac dysrhythmia, muscle weakness, abdominal pain and distention, paralytic
ileus, lethargy, and confusion.
The nurse is caring for an 80-year-old patient. Which finding is the best early indicator of
dehydration in this patient?
1. Reduced skin turgor
2. Increased temperature
3. Constipation
4. Thirst
Constipation
Rationale: The nurse understands that this patient's age places him at greater risk
for dehydration.Constipation is the best early indicator of dehydration in the older
adult. Older adults have age-related poor skin turgor. Increased temperature and
thirst are later signs of dehydration.
4|Page
NURSING I EXAM 1 WITH ACTUAL CORRECT
QUESTIONS AND VERIFIED DETAILED
ANSWERS| CURRENTLY TESTING VERSION |
ALREADY GRADED A+|NEWEST|EXPERT
VERIFIED FOR GUARANTEED PASS 2026/2027
The nurse assesses the patient's IV insertion site and observes that the vein is hard, the
skin is red and tender, and a blood return in the IV line. After removing the IV catheter,
which action should the nurse take next?
1. Obtain an arm board to properly secure the IV.
2. Elevate the arm above the level of the heart.
3. Clean the site with alcohol and apply cool compresses.
4. Apply a warm moist pack.
Apply a warm moist pack.
Rationale: These are signs and symptoms of phlebitis and should be treated with a
warm moist pack to increase blood flow to the area. The IV has been discontinued,
so an arm board for stabilization is unnecessary. Elevation of the arm would be
helpful to reduce swelling. A cool compress would be indicated for other issues
related to IV infusion problems, such as extravasation.
1|Page
,The nurse is caring for a patient who has been on total parenteral nutrition (TPN) for 48
h. Which action demonstrates effective nursing care?
1. Checking the patient's blood glucose level according to facility protocol
2. Increasing the infusion rate if the prescribed intake falls behind
3. Informing the patient that TPN can only be administered via a central line for 1 week
4. Monitoring the peripheral IV site of TPN infusion for signs of infiltration at least every 8
h
Checking the patient's blood glucose level according to facility protocol
Rationale: The hypertonic solution causes difficulty with glucose tolerance, so
monitoring of blood glucose level is imperative. The infusion rate should never be
increased to "catch up" because of the likelihood of fluid overload caused by the
hypertonicity of the TPN. TPN can be administered for more than 1 week and it is
almost always administered via a central line rather than a peripheral line.
The nurse is reviewing standing orders for a patient who was admitted for evaluation of
chest pain. The patient has a history of COPD (Chronic obstructive pulmonary disorder)
and his laboratory results indicate that he has mild respiratory acidosis. The nurse
would question which order?
1. Encourage oral fluids
2. Oxygen therapy 4L/min as needed
3. Keep head of the bed elevated
4. Bedrest with bathroom privileges only
2|Page
,Oxygen therapy 4L/min
Rationale: Bedrest will help conserve energy. Keeping the bed elevated will help
open the airways. Increasing the fluid intake will help thin lung secretions when
coughing and help remove mucus from the lungs. Giving too much oxygen to a
COPD patient will decrease their respiratory drive, because CO2 gives humans
drive to breathe. This may cause them to stop bleeding. Give 1-2L of oxygen for
COPD.
A nurse assesses clients on the medical-surgical unit. Which client is at greatest
risk for the development of bacterial cystitis?
1. A 36-year-old female who has never been pregnant
2. A 42-year-old male who is prescribed cyclophosphamide
3. A 58-year-old female who is not taking estrogen replacement
4. A 77-year-old male with mild congestive heart failure
A 58-year-old female who is not taking estrogen replacement
The nurse is caring for a patient with a potassium level of 2.9 mEq/L. The nurse should
carefully monitor the patient for which potential problem?
3|Page
, 1. Excessive urinary output
2. Increased reflexes
3. Hyperactive bowel sounds
4. Abdominal distention
Abdominal distention
Rationale: A potassium level lower than 3.5 mEq/L results in reduced urine output,
cardiac dysrhythmia, muscle weakness, abdominal pain and distention, paralytic
ileus, lethargy, and confusion.
The nurse is caring for an 80-year-old patient. Which finding is the best early indicator of
dehydration in this patient?
1. Reduced skin turgor
2. Increased temperature
3. Constipation
4. Thirst
Constipation
Rationale: The nurse understands that this patient's age places him at greater risk
for dehydration.Constipation is the best early indicator of dehydration in the older
adult. Older adults have age-related poor skin turgor. Increased temperature and
thirst are later signs of dehydration.
4|Page
