NU 155 EXAM 3 MEDICAL-SURGICAL
NURSING I QUESTIONS AND VERIFIED
ANSWERS WITH RATIONALES 100%
GUARANTEED PASS GRADED A+ LATEST
GALEN COLLEGE OF NURSING
Question 1
A patient with chronic heart failure reports increased shortness of breath,
especially when lying flat. Which intervention should the nurse implement first?
A. Administer a prescribed diuretic
B. Place the patient in high Fowler’s position
C. Encourage the patient to perform incentive spirometry
D. Monitor intake and output
Answer: B. Place the patient in high Fowler’s position
Rationale: High Fowler’s position helps alleviate dyspnea by allowing maximum
lung expansion and improving ventilation. Diuretics may be administered after
positioning. Incentive spirometry is beneficial but not first-line for acute dyspnea.
Monitoring I&O is important but does not immediately relieve symptoms.
Question 2
A patient is scheduled for a colonoscopy. Which pre-procedure instruction is most
important for the nurse to emphasize?
A. Avoid all dairy products for 48 hours before the procedure
B. Maintain NPO status starting at midnight
C. Increase daily fiber intake for one week before the procedure
D. Take all regular medications as usual
Answer: B. Maintain NPO status starting at midnight
,Rationale: NPO status prevents aspiration during sedation. Dietary modifications
and medication adjustments may be required, but the immediate concern is patient
safety during anesthesia.
Question 3
A patient with COPD is admitted with an exacerbation. ABG results show: pH
7.30, PaCO₂ 55 mmHg, HCO₃⁻ 28 mEq/L. Which interpretation is correct?
A. Metabolic acidosis
B. Respiratory acidosis
C. Metabolic alkalosis
D. Respiratory alkalosis
Answer: B. Respiratory acidosis
Rationale: The pH is low (acidic), PaCO₂ is elevated, and HCO₃⁻ is slightly
elevated as compensation. This indicates respiratory acidosis with partial metabolic
compensation, typical in COPD exacerbations.
Question 4
A postoperative patient has a temperature of 38.9°C (102°F), heart rate 110 bpm,
and purulent drainage from the surgical site. Which action should the nurse take
first?
A. Administer prescribed acetaminophen
B. Obtain a wound culture and notify the provider
C. Apply a warm compress to the surgical site
D. Encourage the patient to ambulate
Answer: B. Obtain a wound culture and notify the provider
Rationale: The patient shows signs of infection. Obtaining a culture is priority to
identify the pathogen and guide antibiotic therapy. Antipyretics and comfort
measures may follow, but infection management is the priority.
,Question 5
A patient with chronic kidney disease is prescribed erythropoietin. The nurse
should monitor which lab value to evaluate effectiveness?
A. Serum creatinine
B. Hemoglobin and hematocrit
C. Platelet count
D. Serum potassium
Answer: B. Hemoglobin and hematocrit
Rationale: Erythropoietin stimulates red blood cell production. Hemoglobin and
hematocrit levels indicate treatment effectiveness. Creatinine evaluates kidney
function, not directly the drug’s effect.
Question 6
A patient with newly diagnosed type 2 diabetes asks about hypoglycemia
prevention. Which statement by the patient indicates understanding?
A. “I will take my insulin only when my blood sugar is over 200 mg/dL.”
B. “I will eat regularly and carry a fast-acting carbohydrate.”
C. “I should avoid all sugars to prevent low blood sugar.”
D. “I will skip meals if I feel dizzy to lower my blood sugar.”
Answer: B. “I will eat regularly and carry a fast-acting carbohydrate.”
Rationale: Regular meals and having a fast-acting carb available prevent
hypoglycemia. Skipping meals or limiting sugar indiscriminately can increase risk.
Insulin should be taken as prescribed, not based on current glucose alone.
Question 7
A patient receiving IV potassium chloride (KCl) develops a burning sensation at
the IV site. What is the nurse’s best action?
A. Increase the infusion rate
B. Apply a cold compress to the site
, C. Stop the infusion and assess the IV site
D. Administer oral potassium instead
Answer: C. Stop the infusion and assess the IV site
Rationale: IV KCl is irritating to veins and can cause phlebitis. The infusion
should be stopped immediately, and the site assessed. The solution can be restarted
through a new IV if prescribed.
Question 8
A patient with a peptic ulcer reports sudden, severe abdominal pain and vomiting
blood. What is the nurse’s priority intervention?
A. Administer a proton pump inhibitor
B. Prepare the patient for endoscopy
C. Assess vital signs and initiate IV fluids
D. Encourage the patient to rest in bed
Answer: C. Assess vital signs and initiate IV fluids
Rationale: These symptoms suggest a hemorrhage. Stabilizing the patient’s
hemodynamic status is the priority. Medications and diagnostic procedures follow
stabilization.
Question 9
A patient is being discharged after a cholecystectomy. Which instruction is most
important for preventing postoperative complications?
A. Avoid lifting heavy objects for 4–6 weeks
B. Take only clear liquids for the next month
C. Perform vigorous abdominal exercises daily
D. Resume a high-fat diet to promote digestion
Answer: A. Avoid lifting heavy objects for 4–6 weeks
NURSING I QUESTIONS AND VERIFIED
ANSWERS WITH RATIONALES 100%
GUARANTEED PASS GRADED A+ LATEST
GALEN COLLEGE OF NURSING
Question 1
A patient with chronic heart failure reports increased shortness of breath,
especially when lying flat. Which intervention should the nurse implement first?
A. Administer a prescribed diuretic
B. Place the patient in high Fowler’s position
C. Encourage the patient to perform incentive spirometry
D. Monitor intake and output
Answer: B. Place the patient in high Fowler’s position
Rationale: High Fowler’s position helps alleviate dyspnea by allowing maximum
lung expansion and improving ventilation. Diuretics may be administered after
positioning. Incentive spirometry is beneficial but not first-line for acute dyspnea.
Monitoring I&O is important but does not immediately relieve symptoms.
Question 2
A patient is scheduled for a colonoscopy. Which pre-procedure instruction is most
important for the nurse to emphasize?
A. Avoid all dairy products for 48 hours before the procedure
B. Maintain NPO status starting at midnight
C. Increase daily fiber intake for one week before the procedure
D. Take all regular medications as usual
Answer: B. Maintain NPO status starting at midnight
,Rationale: NPO status prevents aspiration during sedation. Dietary modifications
and medication adjustments may be required, but the immediate concern is patient
safety during anesthesia.
Question 3
A patient with COPD is admitted with an exacerbation. ABG results show: pH
7.30, PaCO₂ 55 mmHg, HCO₃⁻ 28 mEq/L. Which interpretation is correct?
A. Metabolic acidosis
B. Respiratory acidosis
C. Metabolic alkalosis
D. Respiratory alkalosis
Answer: B. Respiratory acidosis
Rationale: The pH is low (acidic), PaCO₂ is elevated, and HCO₃⁻ is slightly
elevated as compensation. This indicates respiratory acidosis with partial metabolic
compensation, typical in COPD exacerbations.
Question 4
A postoperative patient has a temperature of 38.9°C (102°F), heart rate 110 bpm,
and purulent drainage from the surgical site. Which action should the nurse take
first?
A. Administer prescribed acetaminophen
B. Obtain a wound culture and notify the provider
C. Apply a warm compress to the surgical site
D. Encourage the patient to ambulate
Answer: B. Obtain a wound culture and notify the provider
Rationale: The patient shows signs of infection. Obtaining a culture is priority to
identify the pathogen and guide antibiotic therapy. Antipyretics and comfort
measures may follow, but infection management is the priority.
,Question 5
A patient with chronic kidney disease is prescribed erythropoietin. The nurse
should monitor which lab value to evaluate effectiveness?
A. Serum creatinine
B. Hemoglobin and hematocrit
C. Platelet count
D. Serum potassium
Answer: B. Hemoglobin and hematocrit
Rationale: Erythropoietin stimulates red blood cell production. Hemoglobin and
hematocrit levels indicate treatment effectiveness. Creatinine evaluates kidney
function, not directly the drug’s effect.
Question 6
A patient with newly diagnosed type 2 diabetes asks about hypoglycemia
prevention. Which statement by the patient indicates understanding?
A. “I will take my insulin only when my blood sugar is over 200 mg/dL.”
B. “I will eat regularly and carry a fast-acting carbohydrate.”
C. “I should avoid all sugars to prevent low blood sugar.”
D. “I will skip meals if I feel dizzy to lower my blood sugar.”
Answer: B. “I will eat regularly and carry a fast-acting carbohydrate.”
Rationale: Regular meals and having a fast-acting carb available prevent
hypoglycemia. Skipping meals or limiting sugar indiscriminately can increase risk.
Insulin should be taken as prescribed, not based on current glucose alone.
Question 7
A patient receiving IV potassium chloride (KCl) develops a burning sensation at
the IV site. What is the nurse’s best action?
A. Increase the infusion rate
B. Apply a cold compress to the site
, C. Stop the infusion and assess the IV site
D. Administer oral potassium instead
Answer: C. Stop the infusion and assess the IV site
Rationale: IV KCl is irritating to veins and can cause phlebitis. The infusion
should be stopped immediately, and the site assessed. The solution can be restarted
through a new IV if prescribed.
Question 8
A patient with a peptic ulcer reports sudden, severe abdominal pain and vomiting
blood. What is the nurse’s priority intervention?
A. Administer a proton pump inhibitor
B. Prepare the patient for endoscopy
C. Assess vital signs and initiate IV fluids
D. Encourage the patient to rest in bed
Answer: C. Assess vital signs and initiate IV fluids
Rationale: These symptoms suggest a hemorrhage. Stabilizing the patient’s
hemodynamic status is the priority. Medications and diagnostic procedures follow
stabilization.
Question 9
A patient is being discharged after a cholecystectomy. Which instruction is most
important for preventing postoperative complications?
A. Avoid lifting heavy objects for 4–6 weeks
B. Take only clear liquids for the next month
C. Perform vigorous abdominal exercises daily
D. Resume a high-fat diet to promote digestion
Answer: A. Avoid lifting heavy objects for 4–6 weeks
