,NU 155/NU155 Exam 3 – Medical-Surgical
Nursing I – Actual Q&A (GCN) (Updated PDF)
.1. A patient is experiencing a pounding heart, shakiness, and a narrowed
perceptual field but can still follow directions. Which level of anxiety is this?
A) Moderate
B) Mild
C) Severe
D) Panic
Correct Answer: A) Moderate
Rationale: Moderate anxiety narrows the perceptual field and causes physical
symptoms such as tachycardia and tremors, but the client can still process
information with direction. Severe anxiety impairs problem-solving; panic
involves loss of reality contact.
2. A patient on bedrest becomes dizzy when first assisted to stand. What should
the nurse do first?
A) Ambulate the patient slowly
B) Apply a gait belt
C) Help the patient sit on the side of the bed
D) Notify the healthcare provider
Correct Answer: C) Help the patient sit on the side of the bed
,Rationale: Orthostatic hypotension is common after bedrest. The nurse should
first help the client sit and dangle the legs before standing to allow the body to
adjust to the upright position.
3. Which oxygen delivery device provides the most precise oxygen
concentration?
A) Non-rebreather mask
B) Simple face mask
C) Nasal cannula
D) Venturi mask
Correct Answer: D) Venturi mask
Rationale: The Venturi mask delivers a precise FiO₂ and is ideal for clients with
COPD who require controlled oxygen therapy. The other devices deliver less
precise concentrations.
4. A patient with a new colostomy has a red, moist stoma. What should the
nurse do?
A) Notify the provider immediately
B) Document the finding as normal
C) Clean it with alcohol
D) Apply ice
Correct Answer: B) Document the finding as normal
, Rationale: A red, moist stoma indicates healthy tissue with adequate blood
supply. This is a normal postoperative finding and should be documented.
5. Which task can the RN delegate to unlicensed assistive personnel?
A) Assessing lung sounds
B) Administering oral medications
C) Measuring and recording intake and output
D) Providing discharge teaching
Correct Answer: B) Measuring and recording intake and output
Rationale: UAPs can perform routine, standardized tasks that do not require
clinical judgment, such as measuring intake and output. Assessment, medication
administration, and teaching require the RN.
6. A patient with impaired tissue perfusion has decreased capillary refill,
cyanosis, and edema in the lower extremities. What is the priority nursing
action?
A) Apply heat to the area
B) Elevate the extremities
C) Administer oxygen
D) Assess and notify the provider
Correct Answer: D) Assess and notify the provider
Nursing I – Actual Q&A (GCN) (Updated PDF)
.1. A patient is experiencing a pounding heart, shakiness, and a narrowed
perceptual field but can still follow directions. Which level of anxiety is this?
A) Moderate
B) Mild
C) Severe
D) Panic
Correct Answer: A) Moderate
Rationale: Moderate anxiety narrows the perceptual field and causes physical
symptoms such as tachycardia and tremors, but the client can still process
information with direction. Severe anxiety impairs problem-solving; panic
involves loss of reality contact.
2. A patient on bedrest becomes dizzy when first assisted to stand. What should
the nurse do first?
A) Ambulate the patient slowly
B) Apply a gait belt
C) Help the patient sit on the side of the bed
D) Notify the healthcare provider
Correct Answer: C) Help the patient sit on the side of the bed
,Rationale: Orthostatic hypotension is common after bedrest. The nurse should
first help the client sit and dangle the legs before standing to allow the body to
adjust to the upright position.
3. Which oxygen delivery device provides the most precise oxygen
concentration?
A) Non-rebreather mask
B) Simple face mask
C) Nasal cannula
D) Venturi mask
Correct Answer: D) Venturi mask
Rationale: The Venturi mask delivers a precise FiO₂ and is ideal for clients with
COPD who require controlled oxygen therapy. The other devices deliver less
precise concentrations.
4. A patient with a new colostomy has a red, moist stoma. What should the
nurse do?
A) Notify the provider immediately
B) Document the finding as normal
C) Clean it with alcohol
D) Apply ice
Correct Answer: B) Document the finding as normal
, Rationale: A red, moist stoma indicates healthy tissue with adequate blood
supply. This is a normal postoperative finding and should be documented.
5. Which task can the RN delegate to unlicensed assistive personnel?
A) Assessing lung sounds
B) Administering oral medications
C) Measuring and recording intake and output
D) Providing discharge teaching
Correct Answer: B) Measuring and recording intake and output
Rationale: UAPs can perform routine, standardized tasks that do not require
clinical judgment, such as measuring intake and output. Assessment, medication
administration, and teaching require the RN.
6. A patient with impaired tissue perfusion has decreased capillary refill,
cyanosis, and edema in the lower extremities. What is the priority nursing
action?
A) Apply heat to the area
B) Elevate the extremities
C) Administer oxygen
D) Assess and notify the provider
Correct Answer: D) Assess and notify the provider
