NU 155 EXAM 2 MEDICAL-SURGICAL NURSING I (PDF) | 2026
QUESTIONS & ANSWERS + RATIONALES | STUDY GUIDE
1. What is the primary focus of the NU 155 Medical-Surgical Nursing I course?
A) Pediatric nursing care for children with acute illnesses
B) The care of adults experiencing common and predictable health problems
C) Psychiatric nursing and mental health assessment
D) Maternal-newborn nursing and obstetrical care
Correct Answer: The care of adults experiencing common and predictable health problems
Rationale: The Galen College NU 155 course focuses on "the care of adults experiencing
common and predictable health problems." Learners are challenged to use critical thinking skills
guided by established professional standards, competencies, and best practices.
2. A nurse is reviewing fluid compartments with a patient. The patient asks which
compartment contains the greatest volume of body fluid. Which response by the nurse is
correct?
A) Intravascular fluid contains the greatest volume because it includes all blood plasma
B) Interstitial fluid contains the greatest volume because it surrounds all cells
C) Intracellular fluid contains the greatest volume, representing approximately two-thirds
of total body water
D) Extracellular fluid contains the greatest volume because it includes both intravascular
and interstitial fluids
Correct Answer: Intracellular fluid contains the greatest volume, representing approximately
two-thirds of total body water
Rationale: Intracellular fluid (ICF) comprises about two-thirds (40% of body weight) of total
body water, while extracellular fluid (ECF) comprises about one-third . This matches standard
fluid compartment distribution physiology.
3. A patient is admitted with severe dehydration after prolonged vomiting and diarrhea.
Which assessment finding best indicates a fluid volume deficit?
A) Distended neck veins and crackles in the lung bases
B) Bounding pulses and hypertension
C) Orthostatic hypotension, tachycardia, and dry mucous membranes
D) Dependent edema and weight gain
Correct Answer: Orthostatic hypotension, tachycardia, and dry mucous membranes
Rationale: Orthostatic hypotension, tachycardia, and dry mucous membranes are classic
indicators of hypovolemia and fluid volume deficit . Guidelines recommend assessing these
parameters when dehydration is suspected.
4. A patient with heart failure develops shortness of breath and weight gain of 3 pounds in
24 hours. The nurse recognizes these findings as indicative of which condition?
, A) Fluid volume deficit
B) Fluid volume excess
C) Respiratory alkalosis
D) Metabolic acidosis
Correct Answer: Fluid volume excess
Rationale: Rapid weight gain and pulmonary symptoms in a patient with heart failure indicate
fluid volume excess . Priority is monitoring daily weights and lung sounds to detect fluid
overload.
5. Which nursing intervention should be included in the care plan for a patient with tented
skin turgor, dry mucous membranes, and decreased urinary output?
A) Administering I.V. and oral fluids
B) Clustering necessary activities throughout the day
C) Assessing color, odor, and amount of sputum
D) Monitoring serum albumin and total protein levels
Correct Answer: Administering I.V. and oral fluids
Rationale: These findings indicate fluid volume deficit/dehydration; fluid administration is the
priority . Clustering activities is appropriate in fatigue but less urgent than hydration. Sputum
assessment is unrelated, and serum proteins are longer-term nutrition markers.
6. A patient's serum sodium level is 170 mEq/L. Which clinical manifestation would the
nurse expect to assess?
A) Tented skin turgor and thirst
B) Muscle twitching and tetany
C) Fruity breath and Kussmaul's respirations
D) Muscle weakness and paresthesia
Correct Answer: Tented skin turgor and thirst
Rationale: Hypernatremia (>145 mEq/L) causes cellular dehydration leading to thirst and poor
skin turgor . Muscle twitching and tetany more commonly occur in hypocalcemia. Fruity breath
and Kussmaul breathing indicate metabolic acidosis (e.g., DKA).
7. A patient with syndrome of inappropriate antidiuretic hormone (SIADH) presents with
confusion, headache, and lethargy. Laboratory results reveal a serum sodium level of 128
mEq/L. Which nursing intervention is the priority?
A) Administer intravenous 3% saline rapidly to correct the sodium level
B) Restrict oral fluids and monitor neurologic status closely
C) Encourage oral sodium intake and increase fluid consumption
D) Administer potassium-sparing diuretics immediately
Correct Answer: Restrict oral fluids and monitor neurologic status closely
, Rationale: SIADH causes dilutional hyponatremia; fluid restriction is the primary intervention .
Priority is monitoring neurologic status since hyponatremia can cause seizures.
8. A patient with renal failure receiving potassium supplements develops peaked T waves
on cardiac monitoring and muscle weakness. The serum potassium is 6.2 mEq/L. Which
intervention should the nurse implement first?
A) Administer oral kayexalate as prescribed
B) Initiate dialysis immediately
C) Administer calcium gluconate to stabilize the cardiac membrane
D) Insert a nasogastric tube for potassium removal
Correct Answer: Administer calcium gluconate to stabilize the cardiac membrane
Rationale: Peaked T waves indicate hyperkalemia with cardiac involvement. Calcium gluconate
is the priority to protect the myocardium from life-threatening dysrhythmias .
9. A patient is being treated for fluid overload. Which interventions should the nurse include
in the care plan? (Select all that apply)
A) Place the patient on fluid restrictions
B) Place the patient on a sodium-restricted diet
C) Encourage the patient to drink 1500 mL of water daily
D) Provide patient education on checking food labels for sodium content
Correct Answer: A, B, and D
Rationale: Fluid overload commonly results from excess sodium and fluid intake, which can
exacerbate edema and cardiovascular strain . Fluid restrictions and sodium restrictions are
essential components of therapy. Patient education on reading sodium content in foods helps
ensure ongoing adherence. Encouraging increased fluid intake is contraindicated in fluid
overload.
10. The client who was started on total parenteral nutrition (TPN) yesterday has the
following morning lab results. Which result indicates the greatest urgency for the nurse's
collaboration with the physician?
A) Potassium of 3.5 mEq/L
B) Serum glucose of 328 mg/dL
C) BUN of 60 mg/dL
D) Prealbumin of 15 mg/dL
Correct Answer: Serum glucose of 328 mg/dL
Rationale: Hyperglycemia (serum glucose 328) is a common and serious complication of TPN
requiring immediate intervention . Potassium of 3.5 is at the normal lower limit, BUN of 60 is
elevated but less urgent, and prealbumin 15 is suboptimal but not immediately urgent.
11. A patient who has a colostomy is complaining about having excess gas. The nurse asks
the patient what has been eaten in the past 48 hours. Which food would the nurse suspect
is causing the excessive gas?
QUESTIONS & ANSWERS + RATIONALES | STUDY GUIDE
1. What is the primary focus of the NU 155 Medical-Surgical Nursing I course?
A) Pediatric nursing care for children with acute illnesses
B) The care of adults experiencing common and predictable health problems
C) Psychiatric nursing and mental health assessment
D) Maternal-newborn nursing and obstetrical care
Correct Answer: The care of adults experiencing common and predictable health problems
Rationale: The Galen College NU 155 course focuses on "the care of adults experiencing
common and predictable health problems." Learners are challenged to use critical thinking skills
guided by established professional standards, competencies, and best practices.
2. A nurse is reviewing fluid compartments with a patient. The patient asks which
compartment contains the greatest volume of body fluid. Which response by the nurse is
correct?
A) Intravascular fluid contains the greatest volume because it includes all blood plasma
B) Interstitial fluid contains the greatest volume because it surrounds all cells
C) Intracellular fluid contains the greatest volume, representing approximately two-thirds
of total body water
D) Extracellular fluid contains the greatest volume because it includes both intravascular
and interstitial fluids
Correct Answer: Intracellular fluid contains the greatest volume, representing approximately
two-thirds of total body water
Rationale: Intracellular fluid (ICF) comprises about two-thirds (40% of body weight) of total
body water, while extracellular fluid (ECF) comprises about one-third . This matches standard
fluid compartment distribution physiology.
3. A patient is admitted with severe dehydration after prolonged vomiting and diarrhea.
Which assessment finding best indicates a fluid volume deficit?
A) Distended neck veins and crackles in the lung bases
B) Bounding pulses and hypertension
C) Orthostatic hypotension, tachycardia, and dry mucous membranes
D) Dependent edema and weight gain
Correct Answer: Orthostatic hypotension, tachycardia, and dry mucous membranes
Rationale: Orthostatic hypotension, tachycardia, and dry mucous membranes are classic
indicators of hypovolemia and fluid volume deficit . Guidelines recommend assessing these
parameters when dehydration is suspected.
4. A patient with heart failure develops shortness of breath and weight gain of 3 pounds in
24 hours. The nurse recognizes these findings as indicative of which condition?
, A) Fluid volume deficit
B) Fluid volume excess
C) Respiratory alkalosis
D) Metabolic acidosis
Correct Answer: Fluid volume excess
Rationale: Rapid weight gain and pulmonary symptoms in a patient with heart failure indicate
fluid volume excess . Priority is monitoring daily weights and lung sounds to detect fluid
overload.
5. Which nursing intervention should be included in the care plan for a patient with tented
skin turgor, dry mucous membranes, and decreased urinary output?
A) Administering I.V. and oral fluids
B) Clustering necessary activities throughout the day
C) Assessing color, odor, and amount of sputum
D) Monitoring serum albumin and total protein levels
Correct Answer: Administering I.V. and oral fluids
Rationale: These findings indicate fluid volume deficit/dehydration; fluid administration is the
priority . Clustering activities is appropriate in fatigue but less urgent than hydration. Sputum
assessment is unrelated, and serum proteins are longer-term nutrition markers.
6. A patient's serum sodium level is 170 mEq/L. Which clinical manifestation would the
nurse expect to assess?
A) Tented skin turgor and thirst
B) Muscle twitching and tetany
C) Fruity breath and Kussmaul's respirations
D) Muscle weakness and paresthesia
Correct Answer: Tented skin turgor and thirst
Rationale: Hypernatremia (>145 mEq/L) causes cellular dehydration leading to thirst and poor
skin turgor . Muscle twitching and tetany more commonly occur in hypocalcemia. Fruity breath
and Kussmaul breathing indicate metabolic acidosis (e.g., DKA).
7. A patient with syndrome of inappropriate antidiuretic hormone (SIADH) presents with
confusion, headache, and lethargy. Laboratory results reveal a serum sodium level of 128
mEq/L. Which nursing intervention is the priority?
A) Administer intravenous 3% saline rapidly to correct the sodium level
B) Restrict oral fluids and monitor neurologic status closely
C) Encourage oral sodium intake and increase fluid consumption
D) Administer potassium-sparing diuretics immediately
Correct Answer: Restrict oral fluids and monitor neurologic status closely
, Rationale: SIADH causes dilutional hyponatremia; fluid restriction is the primary intervention .
Priority is monitoring neurologic status since hyponatremia can cause seizures.
8. A patient with renal failure receiving potassium supplements develops peaked T waves
on cardiac monitoring and muscle weakness. The serum potassium is 6.2 mEq/L. Which
intervention should the nurse implement first?
A) Administer oral kayexalate as prescribed
B) Initiate dialysis immediately
C) Administer calcium gluconate to stabilize the cardiac membrane
D) Insert a nasogastric tube for potassium removal
Correct Answer: Administer calcium gluconate to stabilize the cardiac membrane
Rationale: Peaked T waves indicate hyperkalemia with cardiac involvement. Calcium gluconate
is the priority to protect the myocardium from life-threatening dysrhythmias .
9. A patient is being treated for fluid overload. Which interventions should the nurse include
in the care plan? (Select all that apply)
A) Place the patient on fluid restrictions
B) Place the patient on a sodium-restricted diet
C) Encourage the patient to drink 1500 mL of water daily
D) Provide patient education on checking food labels for sodium content
Correct Answer: A, B, and D
Rationale: Fluid overload commonly results from excess sodium and fluid intake, which can
exacerbate edema and cardiovascular strain . Fluid restrictions and sodium restrictions are
essential components of therapy. Patient education on reading sodium content in foods helps
ensure ongoing adherence. Encouraging increased fluid intake is contraindicated in fluid
overload.
10. The client who was started on total parenteral nutrition (TPN) yesterday has the
following morning lab results. Which result indicates the greatest urgency for the nurse's
collaboration with the physician?
A) Potassium of 3.5 mEq/L
B) Serum glucose of 328 mg/dL
C) BUN of 60 mg/dL
D) Prealbumin of 15 mg/dL
Correct Answer: Serum glucose of 328 mg/dL
Rationale: Hyperglycemia (serum glucose 328) is a common and serious complication of TPN
requiring immediate intervention . Potassium of 3.5 is at the normal lower limit, BUN of 60 is
elevated but less urgent, and prealbumin 15 is suboptimal but not immediately urgent.
11. A patient who has a colostomy is complaining about having excess gas. The nurse asks
the patient what has been eaten in the past 48 hours. Which food would the nurse suspect
is causing the excessive gas?
