NURSING · OBJECTIVE ASSESSMENT
A+ VERIFIED
NU 155 Exam 3 Medical-Surgical Nursing I — Complete
Official Exam
150 Questions Full Rationales Verified Answers
150 5 100%
QUESTIONS SECTIONS RATIONALES
Complete coverage Core exam domains Every answer explained
WHAT THIS COVERS
01 Cardiac / Perfusion Disorders
02 Comfort, Pain Management & Wound Healing
03 Perioperative Care
04 Infection Control & Prevention
05 Gastrointestinal Disorders
ABOUT THIS ASSESSMENT
Build mastery in medical-surgical nursing — from cardiac perfusion and fluid
balance to wound healing, perioperative care, infection prevention, and
gastrointestinal disorders. This original study bank targets application and
analysis skills for NU 155 Exam 3, with full rationales for every answer.
For review use only; not an institutional proctored assessment.
PASSING SCORE LEVEL FORMAT
80% Intermediate (Nursing Course) Application / Analysis
STUVIA ACTUAL EXAM Page 1
,SECTION 1: Cardiac / Perfusion Disorders
Q1. A 62-year-old patient with a history of hypertension reports sudden chest pressure radiating to the left arm and shortness of
breath. The ECG shows ST-segment elevation in leads II, III, and aVF. Which nursing action takes priority?
A. Encourage the patient to ambulate to relieve anxiety
B. Administer oxygen and prepare for possible reperfusion therapy per protocol
C. Apply a heating pad to the chest wall
D. Delay any intervention until a full lipid panel returns
Correct Answer: B
Rationale: ST-elevation in the inferior leads indicates an acute inferior STEMI. Immediate oxygen and preparation for reperfusion (PCI or
thrombolysis) are priority actions. Ambulation, heat, or waiting for lipids delay critical care.
Q2. A patient receiving a continuous heparin infusion for a deep-vein thrombosis has an aPTT of 120 seconds (therapeutic range
60–80). Which action is most appropriate?
A. Increase the infusion rate to achieve a higher level
B. Continue the current rate and recheck in 24 hours
C. Hold the infusion and notify the provider of the elevated aPTT
D. Switch to subcutaneous low-molecular-weight heparin immediately
Correct Answer: C
Rationale: An aPTT significantly above the therapeutic range indicates excessive anticoagulation and bleeding risk. The infusion should be held and
the provider notified. Increasing the rate or ignoring the value increases harm.
Q3. A patient with heart failure has a daily weight increase of 2.5 kg over 48 hours and reports increased dyspnea. Which
assessment finding is most consistent with fluid volume excess?
A. Bilateral crackles and elevated jugular venous pressure
B. Dry mucous membranes and poor skin turgor
C. Decreased urine specific gravity and hypotension
D. Flat neck veins and clear lung fields
Correct Answer: A
Rationale: Rapid weight gain, dyspnea, crackles, and elevated JVP indicate fluid volume overload in heart failure. Dry membranes and flat veins
suggest deficit, not excess.
Q4. A patient with atrial fibrillation is prescribed warfarin. The nurse is teaching about dietary considerations. Which statement by the
patient indicates correct understanding?
A. I will eliminate all vitamin K–containing foods from my diet
B. I can take extra doses of warfarin if I eat more spinach
C. I will keep my intake of green leafy vegetables consistent rather than avoiding them completely
D. I no longer need INR monitoring once I feel well
Correct Answer: C
Rationale: Consistent vitamin K intake allows stable warfarin dosing. Complete elimination is unnecessary and can cause instability; extra doses and
stopping monitoring are unsafe.
Q5. A patient develops sudden unilateral leg swelling, warmth, and calf pain after surgery. Which diagnostic test is most commonly
ordered first to evaluate for deep-vein thrombosis?
A. Immediate pulmonary angiogram
B. Duplex ultrasound of the affected extremity
C. Cardiac catheterization
D. Electroencephalogram
Correct Answer: B
Rationale: Duplex ultrasound is the first-line, non-invasive test for suspected DVT. Pulmonary angiogram evaluates PE, and the other tests address
cardiac or neurologic conditions.
STUVIA ACTUAL EXAM · Page 2
,Q6. A post-operative patient rates pain as 8/10 and has shallow respirations. Which nursing intervention is most appropriate first?
A. Encourage deep breathing without addressing pain
B. Administer the prescribed opioid analgesic and reassess respiratory status
C. Apply ice to the incision and withhold all analgesia
D. Tell the patient that pain is expected and will resolve on its own
Correct Answer: B
Rationale: Uncontrolled pain leads to shallow breathing and atelectasis risk. Timely analgesia followed by respiratory reassessment is the priority.
Ignoring pain worsens outcomes.
Q7. A patient has a Stage 3 pressure injury with moderate drainage. Which dressing type is most appropriate?
A. Dry gauze changed only once weekly
B. Transparent film alone over heavy drainage
C. Occlusive petroleum gauze that traps all moisture without absorption
D. Alginate or foam dressing that manages exudate while maintaining a moist environment
Correct Answer: D
Rationale: Alginate or foam dressings absorb moderate-to-heavy exudate while keeping a moist wound bed. Dry gauze or transparent film alone are
inadequate for draining Stage 3 wounds.
Q8. A patient is scheduled for elective abdominal surgery. Which pre-operative teaching point is most important for preventing
post-operative respiratory complications?
A. Instruct the patient to remain completely still for 24 hours after surgery
B. Demonstrate and practice incentive spirometry and deep-breathing exercises
C. Advise against any ambulation until discharge
D. Recommend holding all fluids until the first post-operative day
Correct Answer: B
Rationale: Incentive spirometry and deep breathing reduce atelectasis risk. Immobility and fluid restriction increase rather than prevent
complications.
Q9. A patient in the post-anesthesia care unit has a respiratory rate of 8 breaths/min and is difficult to arouse after receiving
morphine. Which action is the priority?
A. Support ventilation and prepare to administer naloxone per protocol
B. Increase the morphine dose to deepen sedation
C. Document the finding and reassess in one hour
D. Encourage the patient to sleep off the medication
Correct Answer: A
Rationale: Opioid-induced respiratory depression requires immediate ventilatory support and naloxone. Further opioid, delayed reassessment, or
passive observation risk respiratory arrest.
Q10. A surgical wound shows separation of the wound edges with visible underlying tissue on post-operative day 5. The nurse
recognizes this as which complication?
A. Dehiscence
B. Evisceration
C. Normal healing by primary intention
D. Superficial abrasion only
Correct Answer: A
Rationale: Dehiscence is separation of wound edges. Evisceration involves protrusion of organs. The finding is not normal primary-intention healing.
STUVIA ACTUAL EXAM · Page 3
, Q11. A patient is admitted with suspected pulmonary tuberculosis. Which isolation precaution is required?
A. Standard precautions only
B. Contact precautions with gown and gloves solely
C. Airborne precautions with an N95 respirator and negative-pressure room
D. Droplet precautions with a surgical mask only
Correct Answer: C
Rationale: TB requires airborne precautions: N95 (or higher) respirator and negative-pressure room. Standard, contact, or droplet precautions alone
are insufficient.
Q12. A nurse is preparing to insert an indwelling urinary catheter. Which action best reduces the risk of catheter-associated urinary
tract infection?
A. Irrigate the catheter daily with antibiotic solution
B. Change the catheter every 24 hours regardless of indication
C. Maintain sterile technique during insertion and keep the drainage bag below bladder level
D. Disconnect the tubing frequently to empty the bag
Correct Answer: C
Rationale: Sterile insertion and a closed system with the bag below the bladder are key CAUTI prevention measures. Routine irrigation, daily
changes, and disconnection increase infection risk.
Q13. A patient develops a fever, tachycardia, and a new infiltrate on chest radiograph 48 hours after intubation. Which type of
infection is most likely?
A. Ventilator-associated pneumonia
B. Community-acquired pneumonia only
C. Simple viral upper-respiratory infection
D. Uncomplicated cystitis
Correct Answer: A
Rationale: New infiltrate plus systemic signs after 48 hours of mechanical ventilation meet criteria for ventilator-associated pneumonia. The other
options do not fit the timeline or setting.
Q14. A nurse is caring for a patient on contact precautions for Clostridium difficile. Which hand-hygiene method is required after
patient contact?
A. Use alcohol-based hand rub only
B. Wash hands with soap and water; alcohol-based rub is not sufficient
C. Rinse hands with water without soap
D. No hand hygiene is needed if gloves were worn
Correct Answer: B
Rationale: C. difficile spores are not reliably killed by alcohol; soap-and-water hand washing is required. Alcohol alone, water rinse, or skipping
hygiene are inadequate.
Q15. A post-operative patient has a temperature of 38.9 °C (102 °F) on day 2, along with wound erythema and purulent drainage.
Which action is most appropriate?
A. Apply ice and document as normal post-operative fever
B. Notify the provider, obtain cultures if ordered, and monitor for systemic signs of infection
C. Increase the patient’s activity level immediately
D. Remove all dressings permanently to allow air drying
Correct Answer: B
Rationale: Fever with local wound signs on day 2 suggests surgical-site infection. Provider notification and culture are indicated. Ice alone, increased
activity, or permanent dressing removal are inappropriate.
STUVIA ACTUAL EXAM · Page 4
A+ VERIFIED
NU 155 Exam 3 Medical-Surgical Nursing I — Complete
Official Exam
150 Questions Full Rationales Verified Answers
150 5 100%
QUESTIONS SECTIONS RATIONALES
Complete coverage Core exam domains Every answer explained
WHAT THIS COVERS
01 Cardiac / Perfusion Disorders
02 Comfort, Pain Management & Wound Healing
03 Perioperative Care
04 Infection Control & Prevention
05 Gastrointestinal Disorders
ABOUT THIS ASSESSMENT
Build mastery in medical-surgical nursing — from cardiac perfusion and fluid
balance to wound healing, perioperative care, infection prevention, and
gastrointestinal disorders. This original study bank targets application and
analysis skills for NU 155 Exam 3, with full rationales for every answer.
For review use only; not an institutional proctored assessment.
PASSING SCORE LEVEL FORMAT
80% Intermediate (Nursing Course) Application / Analysis
STUVIA ACTUAL EXAM Page 1
,SECTION 1: Cardiac / Perfusion Disorders
Q1. A 62-year-old patient with a history of hypertension reports sudden chest pressure radiating to the left arm and shortness of
breath. The ECG shows ST-segment elevation in leads II, III, and aVF. Which nursing action takes priority?
A. Encourage the patient to ambulate to relieve anxiety
B. Administer oxygen and prepare for possible reperfusion therapy per protocol
C. Apply a heating pad to the chest wall
D. Delay any intervention until a full lipid panel returns
Correct Answer: B
Rationale: ST-elevation in the inferior leads indicates an acute inferior STEMI. Immediate oxygen and preparation for reperfusion (PCI or
thrombolysis) are priority actions. Ambulation, heat, or waiting for lipids delay critical care.
Q2. A patient receiving a continuous heparin infusion for a deep-vein thrombosis has an aPTT of 120 seconds (therapeutic range
60–80). Which action is most appropriate?
A. Increase the infusion rate to achieve a higher level
B. Continue the current rate and recheck in 24 hours
C. Hold the infusion and notify the provider of the elevated aPTT
D. Switch to subcutaneous low-molecular-weight heparin immediately
Correct Answer: C
Rationale: An aPTT significantly above the therapeutic range indicates excessive anticoagulation and bleeding risk. The infusion should be held and
the provider notified. Increasing the rate or ignoring the value increases harm.
Q3. A patient with heart failure has a daily weight increase of 2.5 kg over 48 hours and reports increased dyspnea. Which
assessment finding is most consistent with fluid volume excess?
A. Bilateral crackles and elevated jugular venous pressure
B. Dry mucous membranes and poor skin turgor
C. Decreased urine specific gravity and hypotension
D. Flat neck veins and clear lung fields
Correct Answer: A
Rationale: Rapid weight gain, dyspnea, crackles, and elevated JVP indicate fluid volume overload in heart failure. Dry membranes and flat veins
suggest deficit, not excess.
Q4. A patient with atrial fibrillation is prescribed warfarin. The nurse is teaching about dietary considerations. Which statement by the
patient indicates correct understanding?
A. I will eliminate all vitamin K–containing foods from my diet
B. I can take extra doses of warfarin if I eat more spinach
C. I will keep my intake of green leafy vegetables consistent rather than avoiding them completely
D. I no longer need INR monitoring once I feel well
Correct Answer: C
Rationale: Consistent vitamin K intake allows stable warfarin dosing. Complete elimination is unnecessary and can cause instability; extra doses and
stopping monitoring are unsafe.
Q5. A patient develops sudden unilateral leg swelling, warmth, and calf pain after surgery. Which diagnostic test is most commonly
ordered first to evaluate for deep-vein thrombosis?
A. Immediate pulmonary angiogram
B. Duplex ultrasound of the affected extremity
C. Cardiac catheterization
D. Electroencephalogram
Correct Answer: B
Rationale: Duplex ultrasound is the first-line, non-invasive test for suspected DVT. Pulmonary angiogram evaluates PE, and the other tests address
cardiac or neurologic conditions.
STUVIA ACTUAL EXAM · Page 2
,Q6. A post-operative patient rates pain as 8/10 and has shallow respirations. Which nursing intervention is most appropriate first?
A. Encourage deep breathing without addressing pain
B. Administer the prescribed opioid analgesic and reassess respiratory status
C. Apply ice to the incision and withhold all analgesia
D. Tell the patient that pain is expected and will resolve on its own
Correct Answer: B
Rationale: Uncontrolled pain leads to shallow breathing and atelectasis risk. Timely analgesia followed by respiratory reassessment is the priority.
Ignoring pain worsens outcomes.
Q7. A patient has a Stage 3 pressure injury with moderate drainage. Which dressing type is most appropriate?
A. Dry gauze changed only once weekly
B. Transparent film alone over heavy drainage
C. Occlusive petroleum gauze that traps all moisture without absorption
D. Alginate or foam dressing that manages exudate while maintaining a moist environment
Correct Answer: D
Rationale: Alginate or foam dressings absorb moderate-to-heavy exudate while keeping a moist wound bed. Dry gauze or transparent film alone are
inadequate for draining Stage 3 wounds.
Q8. A patient is scheduled for elective abdominal surgery. Which pre-operative teaching point is most important for preventing
post-operative respiratory complications?
A. Instruct the patient to remain completely still for 24 hours after surgery
B. Demonstrate and practice incentive spirometry and deep-breathing exercises
C. Advise against any ambulation until discharge
D. Recommend holding all fluids until the first post-operative day
Correct Answer: B
Rationale: Incentive spirometry and deep breathing reduce atelectasis risk. Immobility and fluid restriction increase rather than prevent
complications.
Q9. A patient in the post-anesthesia care unit has a respiratory rate of 8 breaths/min and is difficult to arouse after receiving
morphine. Which action is the priority?
A. Support ventilation and prepare to administer naloxone per protocol
B. Increase the morphine dose to deepen sedation
C. Document the finding and reassess in one hour
D. Encourage the patient to sleep off the medication
Correct Answer: A
Rationale: Opioid-induced respiratory depression requires immediate ventilatory support and naloxone. Further opioid, delayed reassessment, or
passive observation risk respiratory arrest.
Q10. A surgical wound shows separation of the wound edges with visible underlying tissue on post-operative day 5. The nurse
recognizes this as which complication?
A. Dehiscence
B. Evisceration
C. Normal healing by primary intention
D. Superficial abrasion only
Correct Answer: A
Rationale: Dehiscence is separation of wound edges. Evisceration involves protrusion of organs. The finding is not normal primary-intention healing.
STUVIA ACTUAL EXAM · Page 3
, Q11. A patient is admitted with suspected pulmonary tuberculosis. Which isolation precaution is required?
A. Standard precautions only
B. Contact precautions with gown and gloves solely
C. Airborne precautions with an N95 respirator and negative-pressure room
D. Droplet precautions with a surgical mask only
Correct Answer: C
Rationale: TB requires airborne precautions: N95 (or higher) respirator and negative-pressure room. Standard, contact, or droplet precautions alone
are insufficient.
Q12. A nurse is preparing to insert an indwelling urinary catheter. Which action best reduces the risk of catheter-associated urinary
tract infection?
A. Irrigate the catheter daily with antibiotic solution
B. Change the catheter every 24 hours regardless of indication
C. Maintain sterile technique during insertion and keep the drainage bag below bladder level
D. Disconnect the tubing frequently to empty the bag
Correct Answer: C
Rationale: Sterile insertion and a closed system with the bag below the bladder are key CAUTI prevention measures. Routine irrigation, daily
changes, and disconnection increase infection risk.
Q13. A patient develops a fever, tachycardia, and a new infiltrate on chest radiograph 48 hours after intubation. Which type of
infection is most likely?
A. Ventilator-associated pneumonia
B. Community-acquired pneumonia only
C. Simple viral upper-respiratory infection
D. Uncomplicated cystitis
Correct Answer: A
Rationale: New infiltrate plus systemic signs after 48 hours of mechanical ventilation meet criteria for ventilator-associated pneumonia. The other
options do not fit the timeline or setting.
Q14. A nurse is caring for a patient on contact precautions for Clostridium difficile. Which hand-hygiene method is required after
patient contact?
A. Use alcohol-based hand rub only
B. Wash hands with soap and water; alcohol-based rub is not sufficient
C. Rinse hands with water without soap
D. No hand hygiene is needed if gloves were worn
Correct Answer: B
Rationale: C. difficile spores are not reliably killed by alcohol; soap-and-water hand washing is required. Alcohol alone, water rinse, or skipping
hygiene are inadequate.
Q15. A post-operative patient has a temperature of 38.9 °C (102 °F) on day 2, along with wound erythema and purulent drainage.
Which action is most appropriate?
A. Apply ice and document as normal post-operative fever
B. Notify the provider, obtain cultures if ordered, and monitor for systemic signs of infection
C. Increase the patient’s activity level immediately
D. Remove all dressings permanently to allow air drying
Correct Answer: B
Rationale: Fever with local wound signs on day 2 suggests surgical-site infection. Provider notification and culture are indicated. Ice alone, increased
activity, or permanent dressing removal are inappropriate.
STUVIA ACTUAL EXAM · Page 4
