NU 155 EXAM 4 /NU 155 MEDICAL SURGICAL
NURSING I EXAM 4 WITH ACTUAL CORRECT
QUESTIONS AND VERIFIED DETAILED
ANSWERS| CURRENTLY TESTING VERSION |
ALREADY GRADED A+|NEWEST|EXPERT
VERIFIED FOR GUARANTEED PASS 2026/2027
1. A nurse is caring for a client who has developed acute respiratory distress. Which
assessment finding requires the nurse to intervene first?
A. Respiratory rate of 24/min
B. Oxygen saturation of 88%
C. Mild anxiety
D. Productive cough
Answer: B. Oxygen saturation of 88%
Rationale: An oxygen saturation of 88% indicates hypoxemia and represents an
immediate airway/breathing concern. The nurse should prioritize oxygenation
using the ABC framework. Anxiety and an increased respiratory rate may
accompany respiratory distress, but significant hypoxemia requires immediate
attention.
2. A client is receiving an opioid analgesic after surgery. Which finding is most
concerning?
A. Pain rating of 4/10
B. Respiratory rate of 8/min
C. Heart rate of 92/min
D. Mild nausea
,Answer: B. Respiratory rate of 8/min
Rationale: Opioids can cause respiratory depression. A respiratory rate of 8/min is
dangerously low and requires immediate assessment and intervention. The nurse
should assess level of consciousness, respiratory status, oxygenation, and follow
the prescribed protocol for opioid-induced respiratory depression.
3. Which intervention is most appropriate when administering medication to an older
adult who is at increased risk for adverse drug effects?
A. Administer all medications simultaneously
B. Use the highest effective dose
C. Monitor closely for adverse effects
D. Encourage the client to discontinue medications when feeling better
Answer: C. Monitor closely for adverse effects
Rationale: Older adults may have altered renal and hepatic function, changes in
body composition, and increased sensitivity to medications. These factors can
increase the risk of drug accumulation and adverse effects. Close monitoring is
essential.
4. A nurse is teaching a client about infection prevention. Which client statement
indicates correct understanding?
A. “I only need to wash my hands when they look dirty.”
B. “Hand hygiene should be performed before and after patient contact.”
C. “Gloves eliminate the need for hand hygiene.”
D. “Antibiotics prevent all infections.”
Answer: B. “Hand hygiene should be performed before and after patient contact.”
Rationale: Hand hygiene is one of the most effective methods of preventing
transmission of infection. Gloves do not replace hand hygiene because
,contamination can occur during glove removal or from contact with contaminated
surfaces.
5. A client suddenly becomes confused and restless. Which assessment should the
nurse perform first?
A. Assess oxygenation
B. Ask about family history
C. Determine the client's dietary preferences
D. Review the client's childhood illnesses
Answer: A. Assess oxygenation
Rationale: Acute confusion and restlessness can be early manifestations of
hypoxia. Because oxygenation is an immediate physiologic priority, the nurse
should assess respiratory status and oxygen saturation first.
6. A nurse is preparing to administer a medication. Which action best prevents
medication errors?
A. Rely on memory for frequently administered medications
B. Compare the medication with the medication administration record
C. Ask another client whether the medication is familiar
D. Skip identification if the nurse knows the client
Answer: B. Compare the medication with the medication administration record
Rationale: Medication safety requires verification of the medication order/MAR and
the rights of medication administration. Client identification should also be
confirmed using approved identifiers.
7. A client reports dizziness when getting out of bed. What should the nurse do first?
, A. Encourage the client to walk independently
B. Assist the client back to a safe position
C. Tell the client that dizziness is expected
D. Restrict all oral fluids
Answer: B. Assist the client back to a safe position
Rationale: Safety is the immediate priority. Dizziness may indicate orthostatic
hypotension and places the client at risk for falling. The nurse should prevent
injury, assess vital signs, and determine the cause.
8. Which finding is most consistent with dehydration?
A. Bounding pulse
B. Moist mucous membranes
C. Concentrated urine
D. Peripheral edema
Answer: C. Concentrated urine
Rationale: Dehydration commonly causes concentrated urine, dry mucous
membranes, thirst, decreased urine output, tachycardia, and potentially
hypotension. Edema is associated with excess fluid rather than dehydration.
9. A nurse is teaching a client about antibiotics. Which statement indicates a need for
further teaching?
A. “I should take the medication as prescribed.”
B. “I should not share my antibiotics with someone else.”
C. “I can stop taking the antibiotic once I feel completely better.”
D. “I should report serious adverse reactions.”
Answer: C. “I can stop taking the antibiotic once I feel completely better.”
NURSING I EXAM 4 WITH ACTUAL CORRECT
QUESTIONS AND VERIFIED DETAILED
ANSWERS| CURRENTLY TESTING VERSION |
ALREADY GRADED A+|NEWEST|EXPERT
VERIFIED FOR GUARANTEED PASS 2026/2027
1. A nurse is caring for a client who has developed acute respiratory distress. Which
assessment finding requires the nurse to intervene first?
A. Respiratory rate of 24/min
B. Oxygen saturation of 88%
C. Mild anxiety
D. Productive cough
Answer: B. Oxygen saturation of 88%
Rationale: An oxygen saturation of 88% indicates hypoxemia and represents an
immediate airway/breathing concern. The nurse should prioritize oxygenation
using the ABC framework. Anxiety and an increased respiratory rate may
accompany respiratory distress, but significant hypoxemia requires immediate
attention.
2. A client is receiving an opioid analgesic after surgery. Which finding is most
concerning?
A. Pain rating of 4/10
B. Respiratory rate of 8/min
C. Heart rate of 92/min
D. Mild nausea
,Answer: B. Respiratory rate of 8/min
Rationale: Opioids can cause respiratory depression. A respiratory rate of 8/min is
dangerously low and requires immediate assessment and intervention. The nurse
should assess level of consciousness, respiratory status, oxygenation, and follow
the prescribed protocol for opioid-induced respiratory depression.
3. Which intervention is most appropriate when administering medication to an older
adult who is at increased risk for adverse drug effects?
A. Administer all medications simultaneously
B. Use the highest effective dose
C. Monitor closely for adverse effects
D. Encourage the client to discontinue medications when feeling better
Answer: C. Monitor closely for adverse effects
Rationale: Older adults may have altered renal and hepatic function, changes in
body composition, and increased sensitivity to medications. These factors can
increase the risk of drug accumulation and adverse effects. Close monitoring is
essential.
4. A nurse is teaching a client about infection prevention. Which client statement
indicates correct understanding?
A. “I only need to wash my hands when they look dirty.”
B. “Hand hygiene should be performed before and after patient contact.”
C. “Gloves eliminate the need for hand hygiene.”
D. “Antibiotics prevent all infections.”
Answer: B. “Hand hygiene should be performed before and after patient contact.”
Rationale: Hand hygiene is one of the most effective methods of preventing
transmission of infection. Gloves do not replace hand hygiene because
,contamination can occur during glove removal or from contact with contaminated
surfaces.
5. A client suddenly becomes confused and restless. Which assessment should the
nurse perform first?
A. Assess oxygenation
B. Ask about family history
C. Determine the client's dietary preferences
D. Review the client's childhood illnesses
Answer: A. Assess oxygenation
Rationale: Acute confusion and restlessness can be early manifestations of
hypoxia. Because oxygenation is an immediate physiologic priority, the nurse
should assess respiratory status and oxygen saturation first.
6. A nurse is preparing to administer a medication. Which action best prevents
medication errors?
A. Rely on memory for frequently administered medications
B. Compare the medication with the medication administration record
C. Ask another client whether the medication is familiar
D. Skip identification if the nurse knows the client
Answer: B. Compare the medication with the medication administration record
Rationale: Medication safety requires verification of the medication order/MAR and
the rights of medication administration. Client identification should also be
confirmed using approved identifiers.
7. A client reports dizziness when getting out of bed. What should the nurse do first?
, A. Encourage the client to walk independently
B. Assist the client back to a safe position
C. Tell the client that dizziness is expected
D. Restrict all oral fluids
Answer: B. Assist the client back to a safe position
Rationale: Safety is the immediate priority. Dizziness may indicate orthostatic
hypotension and places the client at risk for falling. The nurse should prevent
injury, assess vital signs, and determine the cause.
8. Which finding is most consistent with dehydration?
A. Bounding pulse
B. Moist mucous membranes
C. Concentrated urine
D. Peripheral edema
Answer: C. Concentrated urine
Rationale: Dehydration commonly causes concentrated urine, dry mucous
membranes, thirst, decreased urine output, tachycardia, and potentially
hypotension. Edema is associated with excess fluid rather than dehydration.
9. A nurse is teaching a client about antibiotics. Which statement indicates a need for
further teaching?
A. “I should take the medication as prescribed.”
B. “I should not share my antibiotics with someone else.”
C. “I can stop taking the antibiotic once I feel completely better.”
D. “I should report serious adverse reactions.”
Answer: C. “I can stop taking the antibiotic once I feel completely better.”
