NUR 155 EXAM 2, 3 AND 4 COMBINED |
QUESTIONS AND ANSWERS WITH
DETAILED RATIONALES LATEST
UPDATE
1. A nurse is assessing a patient who has dry mucous membranes, poor skin turgor,
and a heart rate of 110 beats per minute. Which of the following fluid imbalances
should the nurse suspect?
A. Hypervolemia
B. Fluid volume deficit
C. Hyperkalemia
D. Hyponatremia
Answer: B. Fluid volume deficit
Rationale: Dry mucous membranes, poor skin turgor, and tachycardia are classic
signs of fluid volume deficit (hypovolemia). Hypervolemia would present with
edema and bounding pulses. Hyperkalemia and hyponatremia are electrolyte
imbalances that do not directly cause these specific findings.
2. A nurse is preparing to insert a urinary catheter. Which of the following actions
is most important to prevent infection?
A. Using sterile technique throughout the procedure
B. Applying lubricant to the catheter tip
C. Inflating the balloon with the correct amount of sterile water
D. Securing the catheter to the patient's thigh
Answer: A. Using sterile technique throughout the procedure
1
,Rationale: Sterile technique is critical during catheter insertion to prevent the
introduction of microorganisms into the urinary tract, which can lead to a catheter-
associated urinary tract infection (CAUTI).
3. A patient is ordered a clear liquid diet. Which of the following items is
appropriate to include on the tray?
A. Orange juice with pulp
B. Cream of chicken soup
C. Apple juice
D. Vanilla pudding
Answer: C. Apple juice
Rationale: Clear liquids are transparent fluids that are easily digested and leave
minimal residue in the gastrointestinal tract. Apple juice, broth, and gelatin are
examples. Orange juice with pulp, cream soups, and pudding are not considered
clear liquids.
4. A nurse is providing postmortem care. Which of the following actions is
appropriate?
A. Placing the patient in a supine position with a pillow under the head
B. Removing all tubes and dressings before the family views the body
C. Ensuring that the body is properly identified before transport to the morgue
D. Performing a complete bath and shave before the family arrives
Answer: C. Ensuring that the body is properly identified before transport to the
morgue
Rationale: Proper identification of the body is essential for legal and ethical
reasons. The body is typically placed in a supine position with a small pillow or
head elevation to prevent discoloration, but tubes are usually left in place until the
family has viewed the body if they wish.
2
,5. A patient is experiencing anxiety related to an upcoming surgery. Which nursing
intervention is most appropriate to help the patient cope?
A. Tell the patient not to worry because the surgery is routine
B. Encourage the patient to express feelings and ask questions
C. Leave the patient alone to process their thoughts
D. Administer a sedative without further assessment
Answer: B. Encourage the patient to express feelings and ask questions
Rationale: Encouraging the patient to verbalize feelings and ask questions helps
alleviate anxiety by providing an opportunity to address concerns and
misconceptions. Dismissing feelings or leaving the patient alone does not provide
therapeutic support.
6. A nurse is reviewing the Six Rights of medication administration. Which of the
following is NOT one of the Six Rights?
A. Right patient
B. Right diagnosis
C. Right dose
D. Right route
Answer: B. Right diagnosis
Rationale: The Six Rights of medication administration are: right patient, right
drug, right dose, right route, right time, and right documentation. Right diagnosis is
not one of them.
7. A patient has a serum potassium level of 3.0 mEq/L. Which of the following
findings should the nurse expect?
A. Hyperactive bowel sounds
B. Muscle weakness and leg cramps
C. Increased deep tendon reflexes
3
, D. Cardiac dysrhythmias with tall, peaked T waves
Answer: B. Muscle weakness and leg cramps
Rationale: A potassium level of 3.0 mEq/L indicates hypokalemia. Signs include
muscle weakness, leg cramps, fatigue, and cardiac dysrhythmias with flattened T
waves. Tall, peaked T waves are associated with hyperkalemia.
8. A nurse is assessing a patient's wound and notes purulent drainage. Which of the
following terms describes this type of drainage?
A. Serous
B. Sanguineous
C. Purulent
D. Serosanguineous
Answer: C. Purulent
Rationale: Purulent drainage is thick, yellow, green, or brown and indicates
infection. Serous drainage is clear and watery. Sanguineous drainage is bloody.
Serosanguineous is a mixture of blood and serum.
9. Which of the following is an example of a nursing diagnosis?
A. Pneumonia
B. Risk for falls
C. Coronary artery disease
D. Diabetes mellitus
Answer: B. Risk for falls
Rationale: A nursing diagnosis describes a patient's response to a health problem
and is within the nurse's scope of practice to treat. "Risk for falls" is a nursing
diagnosis. Pneumonia, coronary artery disease, and diabetes mellitus are medical
diagnoses.
4
QUESTIONS AND ANSWERS WITH
DETAILED RATIONALES LATEST
UPDATE
1. A nurse is assessing a patient who has dry mucous membranes, poor skin turgor,
and a heart rate of 110 beats per minute. Which of the following fluid imbalances
should the nurse suspect?
A. Hypervolemia
B. Fluid volume deficit
C. Hyperkalemia
D. Hyponatremia
Answer: B. Fluid volume deficit
Rationale: Dry mucous membranes, poor skin turgor, and tachycardia are classic
signs of fluid volume deficit (hypovolemia). Hypervolemia would present with
edema and bounding pulses. Hyperkalemia and hyponatremia are electrolyte
imbalances that do not directly cause these specific findings.
2. A nurse is preparing to insert a urinary catheter. Which of the following actions
is most important to prevent infection?
A. Using sterile technique throughout the procedure
B. Applying lubricant to the catheter tip
C. Inflating the balloon with the correct amount of sterile water
D. Securing the catheter to the patient's thigh
Answer: A. Using sterile technique throughout the procedure
1
,Rationale: Sterile technique is critical during catheter insertion to prevent the
introduction of microorganisms into the urinary tract, which can lead to a catheter-
associated urinary tract infection (CAUTI).
3. A patient is ordered a clear liquid diet. Which of the following items is
appropriate to include on the tray?
A. Orange juice with pulp
B. Cream of chicken soup
C. Apple juice
D. Vanilla pudding
Answer: C. Apple juice
Rationale: Clear liquids are transparent fluids that are easily digested and leave
minimal residue in the gastrointestinal tract. Apple juice, broth, and gelatin are
examples. Orange juice with pulp, cream soups, and pudding are not considered
clear liquids.
4. A nurse is providing postmortem care. Which of the following actions is
appropriate?
A. Placing the patient in a supine position with a pillow under the head
B. Removing all tubes and dressings before the family views the body
C. Ensuring that the body is properly identified before transport to the morgue
D. Performing a complete bath and shave before the family arrives
Answer: C. Ensuring that the body is properly identified before transport to the
morgue
Rationale: Proper identification of the body is essential for legal and ethical
reasons. The body is typically placed in a supine position with a small pillow or
head elevation to prevent discoloration, but tubes are usually left in place until the
family has viewed the body if they wish.
2
,5. A patient is experiencing anxiety related to an upcoming surgery. Which nursing
intervention is most appropriate to help the patient cope?
A. Tell the patient not to worry because the surgery is routine
B. Encourage the patient to express feelings and ask questions
C. Leave the patient alone to process their thoughts
D. Administer a sedative without further assessment
Answer: B. Encourage the patient to express feelings and ask questions
Rationale: Encouraging the patient to verbalize feelings and ask questions helps
alleviate anxiety by providing an opportunity to address concerns and
misconceptions. Dismissing feelings or leaving the patient alone does not provide
therapeutic support.
6. A nurse is reviewing the Six Rights of medication administration. Which of the
following is NOT one of the Six Rights?
A. Right patient
B. Right diagnosis
C. Right dose
D. Right route
Answer: B. Right diagnosis
Rationale: The Six Rights of medication administration are: right patient, right
drug, right dose, right route, right time, and right documentation. Right diagnosis is
not one of them.
7. A patient has a serum potassium level of 3.0 mEq/L. Which of the following
findings should the nurse expect?
A. Hyperactive bowel sounds
B. Muscle weakness and leg cramps
C. Increased deep tendon reflexes
3
, D. Cardiac dysrhythmias with tall, peaked T waves
Answer: B. Muscle weakness and leg cramps
Rationale: A potassium level of 3.0 mEq/L indicates hypokalemia. Signs include
muscle weakness, leg cramps, fatigue, and cardiac dysrhythmias with flattened T
waves. Tall, peaked T waves are associated with hyperkalemia.
8. A nurse is assessing a patient's wound and notes purulent drainage. Which of the
following terms describes this type of drainage?
A. Serous
B. Sanguineous
C. Purulent
D. Serosanguineous
Answer: C. Purulent
Rationale: Purulent drainage is thick, yellow, green, or brown and indicates
infection. Serous drainage is clear and watery. Sanguineous drainage is bloody.
Serosanguineous is a mixture of blood and serum.
9. Which of the following is an example of a nursing diagnosis?
A. Pneumonia
B. Risk for falls
C. Coronary artery disease
D. Diabetes mellitus
Answer: B. Risk for falls
Rationale: A nursing diagnosis describes a patient's response to a health problem
and is within the nurse's scope of practice to treat. "Risk for falls" is a nursing
diagnosis. Pneumonia, coronary artery disease, and diabetes mellitus are medical
diagnoses.
4
