NU 155 EXAM 3 /NU 155 MEDICAL SURGICAL
NURSING I EXAM 3 WITH ACTUAL CORRECT
QUESTIONS AND VERIFIED DETAILED
ANSWERS| CURRENTLY TESTING VERSION |
ALREADY GRADED A+|NEWEST|EXPERT
VERIFIED FOR GUARANTEED PASS 2026/2027
The nurse is caring for a patient who underwent a transfemoral cardiac catheterization
with coronary angiography earlier in the day. The patient denies pain and no longer
requires bed rest. The groin is soft with no palpable hematoma. Which postprocedure
care is most important for the patient at this time?
Obtain vital signs every 15 minutes.
Assist the patient with ambulation.
Administer pain medications as ordered.
Encourage increased fluid intake.
Encourage increased fluid intake.
Rationale: The procedure uses a large volume of dye, which can be harmful to the
kidneys. Increasing fluid intake is the priority focus for care at this time after
hemostasis is obtained. Keeping the patient hydrated increases the rate of urine
flow, dilutes the urine, and helps prevent kidney damage as the contrast is
excreted. The patient denies pain. Vital signs are taken every 15 minutes for the
first hour and are checked progressively less frequently unless there is evidence of
bleeding or instability. The patient can now ambulate, but ambulation is a lesser
priority than flushing out the hypertonic dye.
During the acute phase following a myocardial infarction (MI), the nurse anticipates that
the patient may require a temporary pacemaker in which situation(s)? (Select all that
apply.)
The patient’s systolic BP drops to 60.
The patient’s heart rate remains above 120 beats per minute.
The patient experiences complete heart block.
The patient experiences worsening anginal pain.
1|Page
,The patient’s pulse rate remains below 40 beats per minute.
The patient experiences complete heart block.
The patient's pulse rate remains below 40 beats per minute.
The nurse is caring for a patient with a compression dressing. Which action indicates
appropriate wound care?
The nurse dons a face mask before applying a compression dressing.
The nurse changes the compression dressing daily.
The nurse places a compression dressing over the wound dressing.
The nurse uses an alcohol-based cleanser before applying the compression dressing.
The nurse places a compression dressing over the wound dressing.
Rationale: Compression therapy options include compression stockings, elastic
tubular support bandages, intermittent compression devices, a paste bandage
such as Unna boot, or placement of two to four layers of compression dressings to
the affected area. Venous return is accomplished as the patient moves his leg and
achieves pressure on the calf muscles. Compression dressings can be placed over
wound dressings. The dressings help to reduce ulcer pain, keep the wound moist,
and assist debridement. The dressing is changed from every 2 to 3 days to every
few weeks depending on the type of dressing applied. An alcohol-based cleanser
would be drying and harsh. Compression dressings do not necessitate use of a face
mask.
The nurse is caring for assigned clients. Which of the following laboratory value results
would be necessary for the nurse to report to the primary healthcare provider (PHCP)?
Serum sodium level of 137 mEq/L
Blood glucose level of 105mg/dL
Serum calcium level of 11.2 mEq/L
Serum potassium level of 4.2 mEq/L
Serum calcium level of 11.2 mEq/L
2|Page
,The nurse is providing care for a client who has serum potassium level of 6.0mEq/L. The
nurse should assess for which of the following manifestations? (Select all that apply.)
dysrhythmias (premature ventricular contractions)
hypoactive bowel sounds
seizures
confusion
dysrhythmias (premature ventricular contractions)
The nurse is providing care for a client who has a diagnosis of hyponatremia. Which of
the following would be an expected finding?
- muscle weakness
- decreased deep tendon reflexes
- seizures
- coma
- confusion
- hyperactive bowel sounds
- anorexia
- nausea, vomiting
The nurse is reviewing a student nurse's charting and notes that the student has
documented absent bowel sounds. The nurse reminds the student that in order to
document absent bowel sounds, one must auscultate each quadrant at what period of
time?
30 seconds
1 minute
2 minutes
5 minutes
5 minutes
Rationale: The criterion for the documentation of absent bowel sounds is that each
quadrant is auscultated for 5 minutes.
3|Page
, The nurse is reviewing the laboratory results of an assigned patient. The serum bilirubin
is 2.8 mg/dL. The nurse anticipates that the patient's urine will display which finding?
Dark color
Low specific gravity
Very scant amount
Foul odor
Dark color
Low specific gravity
Rationale: Normal serum bilirubin is 0.1 to 1.2 mg/dL. Jaundice is present at
readings above 2.5 mg/dL. The patient who is jaundiced will have dark, tea-colored
urine. Specific gravity refers to the concentration of the urine. The amount and odor
of urine will not be directly influenced by the bilirubin level.
When assessing a patient's bowel sounds, nurse auscultates loud bowel sounds in
each quadrant every 3 seconds. The nurse understands that these findings could
indicate that the patient is experiencing which condition?
Diarrhea
Paralytic ileus
Vomiting
Constipation
Diarrhea
Rationale: Loud, rapid bowel sounds are indicative of hypermobility, which could
result in diarrhea. Absent bowel sounds are associated with paralytic ileus. Normal
bowel sounds present as soft gurgles and clicks every 5 to 15 seconds. Hypoactive
bowel sounds indicate decreased motility and could indicate that the patient is
constipated.
A patient who had gastric bypass surgery 5 weeks ago calls the office to report feelings
of nausea, sweating, and diarrhea shortly after eating meals. What response by the
nurse is most appropriate?
4|Page
NURSING I EXAM 3 WITH ACTUAL CORRECT
QUESTIONS AND VERIFIED DETAILED
ANSWERS| CURRENTLY TESTING VERSION |
ALREADY GRADED A+|NEWEST|EXPERT
VERIFIED FOR GUARANTEED PASS 2026/2027
The nurse is caring for a patient who underwent a transfemoral cardiac catheterization
with coronary angiography earlier in the day. The patient denies pain and no longer
requires bed rest. The groin is soft with no palpable hematoma. Which postprocedure
care is most important for the patient at this time?
Obtain vital signs every 15 minutes.
Assist the patient with ambulation.
Administer pain medications as ordered.
Encourage increased fluid intake.
Encourage increased fluid intake.
Rationale: The procedure uses a large volume of dye, which can be harmful to the
kidneys. Increasing fluid intake is the priority focus for care at this time after
hemostasis is obtained. Keeping the patient hydrated increases the rate of urine
flow, dilutes the urine, and helps prevent kidney damage as the contrast is
excreted. The patient denies pain. Vital signs are taken every 15 minutes for the
first hour and are checked progressively less frequently unless there is evidence of
bleeding or instability. The patient can now ambulate, but ambulation is a lesser
priority than flushing out the hypertonic dye.
During the acute phase following a myocardial infarction (MI), the nurse anticipates that
the patient may require a temporary pacemaker in which situation(s)? (Select all that
apply.)
The patient’s systolic BP drops to 60.
The patient’s heart rate remains above 120 beats per minute.
The patient experiences complete heart block.
The patient experiences worsening anginal pain.
1|Page
,The patient’s pulse rate remains below 40 beats per minute.
The patient experiences complete heart block.
The patient's pulse rate remains below 40 beats per minute.
The nurse is caring for a patient with a compression dressing. Which action indicates
appropriate wound care?
The nurse dons a face mask before applying a compression dressing.
The nurse changes the compression dressing daily.
The nurse places a compression dressing over the wound dressing.
The nurse uses an alcohol-based cleanser before applying the compression dressing.
The nurse places a compression dressing over the wound dressing.
Rationale: Compression therapy options include compression stockings, elastic
tubular support bandages, intermittent compression devices, a paste bandage
such as Unna boot, or placement of two to four layers of compression dressings to
the affected area. Venous return is accomplished as the patient moves his leg and
achieves pressure on the calf muscles. Compression dressings can be placed over
wound dressings. The dressings help to reduce ulcer pain, keep the wound moist,
and assist debridement. The dressing is changed from every 2 to 3 days to every
few weeks depending on the type of dressing applied. An alcohol-based cleanser
would be drying and harsh. Compression dressings do not necessitate use of a face
mask.
The nurse is caring for assigned clients. Which of the following laboratory value results
would be necessary for the nurse to report to the primary healthcare provider (PHCP)?
Serum sodium level of 137 mEq/L
Blood glucose level of 105mg/dL
Serum calcium level of 11.2 mEq/L
Serum potassium level of 4.2 mEq/L
Serum calcium level of 11.2 mEq/L
2|Page
,The nurse is providing care for a client who has serum potassium level of 6.0mEq/L. The
nurse should assess for which of the following manifestations? (Select all that apply.)
dysrhythmias (premature ventricular contractions)
hypoactive bowel sounds
seizures
confusion
dysrhythmias (premature ventricular contractions)
The nurse is providing care for a client who has a diagnosis of hyponatremia. Which of
the following would be an expected finding?
- muscle weakness
- decreased deep tendon reflexes
- seizures
- coma
- confusion
- hyperactive bowel sounds
- anorexia
- nausea, vomiting
The nurse is reviewing a student nurse's charting and notes that the student has
documented absent bowel sounds. The nurse reminds the student that in order to
document absent bowel sounds, one must auscultate each quadrant at what period of
time?
30 seconds
1 minute
2 minutes
5 minutes
5 minutes
Rationale: The criterion for the documentation of absent bowel sounds is that each
quadrant is auscultated for 5 minutes.
3|Page
, The nurse is reviewing the laboratory results of an assigned patient. The serum bilirubin
is 2.8 mg/dL. The nurse anticipates that the patient's urine will display which finding?
Dark color
Low specific gravity
Very scant amount
Foul odor
Dark color
Low specific gravity
Rationale: Normal serum bilirubin is 0.1 to 1.2 mg/dL. Jaundice is present at
readings above 2.5 mg/dL. The patient who is jaundiced will have dark, tea-colored
urine. Specific gravity refers to the concentration of the urine. The amount and odor
of urine will not be directly influenced by the bilirubin level.
When assessing a patient's bowel sounds, nurse auscultates loud bowel sounds in
each quadrant every 3 seconds. The nurse understands that these findings could
indicate that the patient is experiencing which condition?
Diarrhea
Paralytic ileus
Vomiting
Constipation
Diarrhea
Rationale: Loud, rapid bowel sounds are indicative of hypermobility, which could
result in diarrhea. Absent bowel sounds are associated with paralytic ileus. Normal
bowel sounds present as soft gurgles and clicks every 5 to 15 seconds. Hypoactive
bowel sounds indicate decreased motility and could indicate that the patient is
constipated.
A patient who had gastric bypass surgery 5 weeks ago calls the office to report feelings
of nausea, sweating, and diarrhea shortly after eating meals. What response by the
nurse is most appropriate?
4|Page
