NUR 155 Exam 3 V1 | NUR 155
Foundations of Nursing | Q&A with
Rationale (NUR155 Exam 3) | Galen
College of Nursing
1. A nurse is caring for a client who is post-operative and reports difficulty voiding. Which
initial action should the nurse take to promote urination?
A. Perform a straight catheterization immediately.
B. Assist the client to a normal standing or sitting position.
C. Increase the client’s intravenous fluid rate.
D. Administer a prescribed diuretic to stimulate the kidneys.
Answer: B
Rationale: Assisting a client to their normal voiding position uses gravity to help the
bladder empty more efficiently. This is a non-invasive nursing intervention that should be
attempted before considering invasive procedures like catheterization. The nurse should
also provide privacy and run water to further stimulate the urge to void.
2. When teaching a client about incentive spirometry, which instruction should the nurse
prioritize to ensure effective lung expansion?
A. Exhale forcefully into the device until the piston reaches the top.
B. Inhale slowly and deeply through the mouthpiece to raise the piston.
,C. Use the device once every eight hours while awake.
D. Hold your breath for at least 30 seconds after inhalation.
Answer: B
Rationale: Incentive spirometry is designed to promote deep breathing and prevent
atelectasis by encouraging slow, sustained inspiration. The client should be taught to seal
their lips around the mouthpiece and inhale until the target volume is reached. This
practice helps to open collapsed alveoli and improve overall gas exchange in the post-
operative period.
3. A nurse is assessing a client with a history of obstructive sleep apnea (OSA). Which clinical
manifestation should the nurse expect to observe?
A. Excessive daytime sleepiness and morning headaches.
B. Increased alertness during the daytime hours.
C. Bradypnea and deep respirations during sleep.
D. Heightened concentration and cognitive performance.
Answer: A
Rationale: Obstructive sleep apnea is characterized by repetitive pauses in breathing
during sleep, which leads to fragmented sleep patterns. Consequently, clients often
experience excessive daytime sleepiness and may suffer from morning headaches due to
carbon dioxide retention. Long-term untreated OSA can also lead to cardiovascular
complications like hypertension.
,4. Which documentation entry by the nurse best reflects objective data regarding a client’s
pain level?
A. ‘The client seems to be in a lot of pain today.’
B. ‘Client states, ’My leg is throbbing like a heartbeat.’’
C. ‘The client is uncooperative during the physical assessment.’
D. ‘Client is grimacing and guarding the right lower quadrant.’
Answer: D
Rationale: Objective data consists of observable and measurable signs, such as grimacing,
guarding, or physiological changes in vital signs. Stating the client ‘seems’ to be in pain is a
subjective interpretation and is not precise documentation. The nurse should focus on
reporting specific behaviors that indicate the presence and intensity of pain.
5. A client is scheduled for an elective surgery. Who is primarily responsible for obtaining the
informed consent and explaining the risks and benefits of the procedure?
A. The registered nurse assigned to the client.
B. The surgeon performing the procedure.
C. The surgical technician in the operating room.
D. The hospital’s risk management officer.
Answer: B
, Rationale: It is the legal and professional responsibility of the surgeon to explain the
procedure, risks, benefits, and alternatives to the client. The nurse’s role in the consent
process is typically limited to witnessing the client’s signature and ensuring the client
understands their rights. If the nurse discovers the client does not understand the surgery,
the nurse must notify the surgeon immediately.
6. The nurse is caring for an older adult client with sensory overload in the Intensive Care
Unit. Which intervention should the nurse implement?
A. Keep the overhead lights on to ensure safety.
B. Cluster nursing care activities to provide longer rest periods.
C. Provide a television for constant background noise.
D. Encourage frequent visits from large groups of family members.
Answer: B
Rationale: Sensory overload occurs when a client receives more sensory stimuli than their
brain can process, often leading to confusion and agitation. Clustering care helps minimize
frequent interruptions and reduces the overall level of stimulation in the environment. The
nurse should also dim lights and reduce noise levels whenever possible to facilitate rest.
7. A nurse is preparing to administer a cleansing enema. In which position should the nurse
place the client?
A. Supine position with the head of the bed flat.
B. Prone position with a pillow under the abdomen.
Foundations of Nursing | Q&A with
Rationale (NUR155 Exam 3) | Galen
College of Nursing
1. A nurse is caring for a client who is post-operative and reports difficulty voiding. Which
initial action should the nurse take to promote urination?
A. Perform a straight catheterization immediately.
B. Assist the client to a normal standing or sitting position.
C. Increase the client’s intravenous fluid rate.
D. Administer a prescribed diuretic to stimulate the kidneys.
Answer: B
Rationale: Assisting a client to their normal voiding position uses gravity to help the
bladder empty more efficiently. This is a non-invasive nursing intervention that should be
attempted before considering invasive procedures like catheterization. The nurse should
also provide privacy and run water to further stimulate the urge to void.
2. When teaching a client about incentive spirometry, which instruction should the nurse
prioritize to ensure effective lung expansion?
A. Exhale forcefully into the device until the piston reaches the top.
B. Inhale slowly and deeply through the mouthpiece to raise the piston.
,C. Use the device once every eight hours while awake.
D. Hold your breath for at least 30 seconds after inhalation.
Answer: B
Rationale: Incentive spirometry is designed to promote deep breathing and prevent
atelectasis by encouraging slow, sustained inspiration. The client should be taught to seal
their lips around the mouthpiece and inhale until the target volume is reached. This
practice helps to open collapsed alveoli and improve overall gas exchange in the post-
operative period.
3. A nurse is assessing a client with a history of obstructive sleep apnea (OSA). Which clinical
manifestation should the nurse expect to observe?
A. Excessive daytime sleepiness and morning headaches.
B. Increased alertness during the daytime hours.
C. Bradypnea and deep respirations during sleep.
D. Heightened concentration and cognitive performance.
Answer: A
Rationale: Obstructive sleep apnea is characterized by repetitive pauses in breathing
during sleep, which leads to fragmented sleep patterns. Consequently, clients often
experience excessive daytime sleepiness and may suffer from morning headaches due to
carbon dioxide retention. Long-term untreated OSA can also lead to cardiovascular
complications like hypertension.
,4. Which documentation entry by the nurse best reflects objective data regarding a client’s
pain level?
A. ‘The client seems to be in a lot of pain today.’
B. ‘Client states, ’My leg is throbbing like a heartbeat.’’
C. ‘The client is uncooperative during the physical assessment.’
D. ‘Client is grimacing and guarding the right lower quadrant.’
Answer: D
Rationale: Objective data consists of observable and measurable signs, such as grimacing,
guarding, or physiological changes in vital signs. Stating the client ‘seems’ to be in pain is a
subjective interpretation and is not precise documentation. The nurse should focus on
reporting specific behaviors that indicate the presence and intensity of pain.
5. A client is scheduled for an elective surgery. Who is primarily responsible for obtaining the
informed consent and explaining the risks and benefits of the procedure?
A. The registered nurse assigned to the client.
B. The surgeon performing the procedure.
C. The surgical technician in the operating room.
D. The hospital’s risk management officer.
Answer: B
, Rationale: It is the legal and professional responsibility of the surgeon to explain the
procedure, risks, benefits, and alternatives to the client. The nurse’s role in the consent
process is typically limited to witnessing the client’s signature and ensuring the client
understands their rights. If the nurse discovers the client does not understand the surgery,
the nurse must notify the surgeon immediately.
6. The nurse is caring for an older adult client with sensory overload in the Intensive Care
Unit. Which intervention should the nurse implement?
A. Keep the overhead lights on to ensure safety.
B. Cluster nursing care activities to provide longer rest periods.
C. Provide a television for constant background noise.
D. Encourage frequent visits from large groups of family members.
Answer: B
Rationale: Sensory overload occurs when a client receives more sensory stimuli than their
brain can process, often leading to confusion and agitation. Clustering care helps minimize
frequent interruptions and reduces the overall level of stimulation in the environment. The
nurse should also dim lights and reduce noise levels whenever possible to facilitate rest.
7. A nurse is preparing to administer a cleansing enema. In which position should the nurse
place the client?
A. Supine position with the head of the bed flat.
B. Prone position with a pillow under the abdomen.
