NUR 155 Exam 3 V3 | NUR 155
Foundations of Nursing | Q&A with
Rationale (NUR155 Exam 3) | Galen
College of Nursing
1. A nurse is assessing a patient with a serum potassium level of 3.2 mEq/L. Which clinical
finding should the nurse anticipate?
A. Peaked T-waves on ECG
B. Hyperactive bowel sounds
C. Muscle weakness and leg cramps
D. Hyperreflexia
Answer: C
Rationale: Hypokalemia is characterized by a serum potassium level lower than 3.5
mEq/L. Low potassium levels interfere with the transmission of nerve impulses to the
muscles, resulting in weakness and cramping. The nurse should prioritize monitoring for
cardiac dysrhythmias and respiratory depression in these patients.
2. The nurse is interpreting ABG results: pH 7.30, PaCO2 52 mmHg, and HCO3 24 mEq/L. What
is the correct interpretation?
A. Metabolic Acidosis
B. Respiratory Alkalosis
,C. Metabolic Alkalosis
D. Respiratory Acidosis
Answer: D
Rationale: A pH below 7.35 indicates acidosis, and an elevated PaCO2 indicates a
respiratory origin. Because the bicarbonate level is within the normal range, the condition
is uncompensated. This pattern is commonly seen in patients with hypoventilation or
obstructive lung diseases.
3. A patient has a localized area of intact skin with non-blanchable redness over the sacrum.
How should the nurse document this pressure injury?
A. Stage 2
B. Stage 1
C. Stage 3
D. Deep Tissue Injury
Answer: B
Rationale: A Stage 1 pressure injury is defined by skin that is intact but displays non-
blanchable erythema. This occurs because the microcirculation is compromised by
prolonged pressure over a bony prominence. Early intervention at this stage can prevent
further tissue breakdown and skin loss.
, 4. Which action is most appropriate when teaching a patient how to use an incentive
spirometer?
A. Instruct the patient to exhale forcefully into the device.
B. Advise the patient to use the device once every 4 hours.
C. Encourage the patient to take a deep, slow breath in.
D. Tell the patient to hold their breath for 30 seconds after inhalation.
Answer: C
Rationale: Incentive spirometry is designed to encourage voluntary deep breathing by
providing visual feedback. The patient should perform a slow, deep inspiration to maximize
lung expansion and prevent atelectasis. This exercise should typically be repeated 10 times
every hour while the patient is awake.
5. A nurse is caring for a patient receiving oxygen via a nasal cannula at 4 L/min. Which
intervention is necessary to maintain skin and mucosal integrity?
A. Apply petroleum jelly to the nares.
B. Attach humidification to the oxygen source.
C. Switch the patient to a simple face mask.
D. Increase the flow rate to 8 L/min.
Answer: B
Foundations of Nursing | Q&A with
Rationale (NUR155 Exam 3) | Galen
College of Nursing
1. A nurse is assessing a patient with a serum potassium level of 3.2 mEq/L. Which clinical
finding should the nurse anticipate?
A. Peaked T-waves on ECG
B. Hyperactive bowel sounds
C. Muscle weakness and leg cramps
D. Hyperreflexia
Answer: C
Rationale: Hypokalemia is characterized by a serum potassium level lower than 3.5
mEq/L. Low potassium levels interfere with the transmission of nerve impulses to the
muscles, resulting in weakness and cramping. The nurse should prioritize monitoring for
cardiac dysrhythmias and respiratory depression in these patients.
2. The nurse is interpreting ABG results: pH 7.30, PaCO2 52 mmHg, and HCO3 24 mEq/L. What
is the correct interpretation?
A. Metabolic Acidosis
B. Respiratory Alkalosis
,C. Metabolic Alkalosis
D. Respiratory Acidosis
Answer: D
Rationale: A pH below 7.35 indicates acidosis, and an elevated PaCO2 indicates a
respiratory origin. Because the bicarbonate level is within the normal range, the condition
is uncompensated. This pattern is commonly seen in patients with hypoventilation or
obstructive lung diseases.
3. A patient has a localized area of intact skin with non-blanchable redness over the sacrum.
How should the nurse document this pressure injury?
A. Stage 2
B. Stage 1
C. Stage 3
D. Deep Tissue Injury
Answer: B
Rationale: A Stage 1 pressure injury is defined by skin that is intact but displays non-
blanchable erythema. This occurs because the microcirculation is compromised by
prolonged pressure over a bony prominence. Early intervention at this stage can prevent
further tissue breakdown and skin loss.
, 4. Which action is most appropriate when teaching a patient how to use an incentive
spirometer?
A. Instruct the patient to exhale forcefully into the device.
B. Advise the patient to use the device once every 4 hours.
C. Encourage the patient to take a deep, slow breath in.
D. Tell the patient to hold their breath for 30 seconds after inhalation.
Answer: C
Rationale: Incentive spirometry is designed to encourage voluntary deep breathing by
providing visual feedback. The patient should perform a slow, deep inspiration to maximize
lung expansion and prevent atelectasis. This exercise should typically be repeated 10 times
every hour while the patient is awake.
5. A nurse is caring for a patient receiving oxygen via a nasal cannula at 4 L/min. Which
intervention is necessary to maintain skin and mucosal integrity?
A. Apply petroleum jelly to the nares.
B. Attach humidification to the oxygen source.
C. Switch the patient to a simple face mask.
D. Increase the flow rate to 8 L/min.
Answer: B
