NUR 155 COMPREHENSIVE EXAM
(UNITS 2, 3, AND 4) QUESTIONS AND
ANSWERS
1. A nurse is preparing to administer an intramuscular injection to a client with a high body
mass index. Which technique should the nurse use to ensure the medication reaches the
muscle tissue effectively?
A. Use a 5/8-inch needle at a 45-degree angle.
B. Pinch the skin tightly to reduce the distance to the muscle.
C. Use the Z-track method and a longer needle.
D. Administer the injection in the deltoid site only.
Answer: C
Conceptual Explanation: The Z-track method prevents leakage into subcutaneous tissue,
and a longer needle is required for obese patients to ensure the medication reaches the
deep muscle layer.
2. When assessing a client with metabolic alkalosis, which of the following arterial blood gas
(ABG) results would the nurse expect?
A. pH 7.30, PaCO2 50, HCO3 24
,B. pH 7.50, PaCO2 25, HCO3 22
C. pH 7.32, PaCO2 30, HCO3 18
D. pH 7.48, PaCO2 40, HCO3 30
Answer: D
Conceptual Explanation: Metabolic alkalosis is characterized by a high pH (>7.45) and a
high bicarbonate level (HCO3 >26). Option B reflects these values.
3. A client is receiving total parenteral nutrition (TPN). Which assessment finding is the most
critical for the nurse to report to the healthcare provider?
A. A weight gain of 0.5 lbs in 24 hours.
B. Fingerstick glucose of 210 mg/dL.
C. Occasional dry mouth.
D. Oral temperature of 101.2 F (38.4 C).
Answer: D
Conceptual Explanation: Fever in a client receiving TPN is a major indicator of catheter-
related bloodstream infection (CRBSI), which is a serious complication.
4. A nurse is caring for a postoperative client who has developed an evisceration. Which
action should the nurse take first?
A. Call the surgeon immediately before doing anything else.
B. Place the client in a high-Fowler’s position.
, C. Attempt to re-insert the protruding organs gently.
D. Apply a sterile dressing moistened with sterile normal saline.
Answer: D
Conceptual Explanation: The priority is to protect the exposed organs from drying and
infection using sterile saline-soaked dressings. The client should be kept supine with knees
flexed.
5. A client has a potassium level of 6.2 mEq/L. Which EKG change should the nurse closely
monitor for?
A. U-waves
B. Tall, peaked T-waves
C. Prolonged PR interval
D. ST-segment depression
Answer: B
Conceptual Explanation: Hyperkalemia (K > 5.0) causes characteristic tall, peaked T-
waves on an EKG due to rapid repolarization.
6. Which nursing intervention is a priority for a client with a Braden Scale score of 10?
A. Implementing a turning schedule every 2 hours.
B. Increasing fluid intake to 3000 mL/day.
C. Applying a transparent film dressing to the coccyx.
(UNITS 2, 3, AND 4) QUESTIONS AND
ANSWERS
1. A nurse is preparing to administer an intramuscular injection to a client with a high body
mass index. Which technique should the nurse use to ensure the medication reaches the
muscle tissue effectively?
A. Use a 5/8-inch needle at a 45-degree angle.
B. Pinch the skin tightly to reduce the distance to the muscle.
C. Use the Z-track method and a longer needle.
D. Administer the injection in the deltoid site only.
Answer: C
Conceptual Explanation: The Z-track method prevents leakage into subcutaneous tissue,
and a longer needle is required for obese patients to ensure the medication reaches the
deep muscle layer.
2. When assessing a client with metabolic alkalosis, which of the following arterial blood gas
(ABG) results would the nurse expect?
A. pH 7.30, PaCO2 50, HCO3 24
,B. pH 7.50, PaCO2 25, HCO3 22
C. pH 7.32, PaCO2 30, HCO3 18
D. pH 7.48, PaCO2 40, HCO3 30
Answer: D
Conceptual Explanation: Metabolic alkalosis is characterized by a high pH (>7.45) and a
high bicarbonate level (HCO3 >26). Option B reflects these values.
3. A client is receiving total parenteral nutrition (TPN). Which assessment finding is the most
critical for the nurse to report to the healthcare provider?
A. A weight gain of 0.5 lbs in 24 hours.
B. Fingerstick glucose of 210 mg/dL.
C. Occasional dry mouth.
D. Oral temperature of 101.2 F (38.4 C).
Answer: D
Conceptual Explanation: Fever in a client receiving TPN is a major indicator of catheter-
related bloodstream infection (CRBSI), which is a serious complication.
4. A nurse is caring for a postoperative client who has developed an evisceration. Which
action should the nurse take first?
A. Call the surgeon immediately before doing anything else.
B. Place the client in a high-Fowler’s position.
, C. Attempt to re-insert the protruding organs gently.
D. Apply a sterile dressing moistened with sterile normal saline.
Answer: D
Conceptual Explanation: The priority is to protect the exposed organs from drying and
infection using sterile saline-soaked dressings. The client should be kept supine with knees
flexed.
5. A client has a potassium level of 6.2 mEq/L. Which EKG change should the nurse closely
monitor for?
A. U-waves
B. Tall, peaked T-waves
C. Prolonged PR interval
D. ST-segment depression
Answer: B
Conceptual Explanation: Hyperkalemia (K > 5.0) causes characteristic tall, peaked T-
waves on an EKG due to rapid repolarization.
6. Which nursing intervention is a priority for a client with a Braden Scale score of 10?
A. Implementing a turning schedule every 2 hours.
B. Increasing fluid intake to 3000 mL/day.
C. Applying a transparent film dressing to the coccyx.
