NUR 155 Exam 3 V2 | NUR 155
Foundations of Nursing | Q&A with
Rationale (NUR155 Exam 3) | Galen
College of Nursing
1. A nurse is caring for a patient who is post-operative day 2 and reports sudden shortness of
breath. What should be the nurse’s first action?
A. Raise the head of the bed to High-Fowler’s position.
B. Auscultate the patient’s lung sounds.
C. Administer the prescribed PRN morphine for pain.
D. Notify the physician immediately.
Answer: A
Rationale: Raising the head of the bed is the immediate priority intervention to facilitate
chest expansion and improve gas exchange. This action uses gravity to move the abdominal
organs away from the diaphragm, allowing for better lung volume. Following this
intervention, the nurse should assess the patient and then notify the healthcare provider if
the condition persists.
2. When assessing a patient’s surgical incision, the nurse notes a thick, yellow-green
discharge. How should the nurse document this finding?
A. Serous drainage
,B. Sanguineous drainage
C. Purulent drainage
D. Serosanguineous drainage
Answer: C
Rationale: Purulent drainage is thick and consists of white blood cells, dead tissue debris,
and bacteria, indicating a potential infection. Serous drainage is clear and watery, while
sanguineous is bright red blood. Serosanguineous drainage is a pale, red, watery mixture of
clear and red fluid.
3. A patient with a history of chronic obstructive pulmonary disease (COPD) is receiving
oxygen. Which delivery method is most precise for specific oxygen concentrations?
A. Venturi mask
B. Simple face mask
C. Nasal cannula
D. Non-rebreather mask
Answer: A
Rationale: The Venturi mask is designed to deliver a specific and precise concentration of
oxygen by utilizing different sized adapters. This is particularly important for patients with
COPD who may rely on a hypoxic drive to breathe. Other delivery methods like the nasal
,cannula or simple mask provide more variable concentrations depending on the patient’s
respiratory rate.
4. Which electrolyte imbalance is a patient at risk for if they are experiencing excessive
vomiting and diarrhea?
A. Hyperkalemia
B. Hypercalcemia
C. Hypokalemia
D. Hypocalcemia
Answer: C
Rationale: Potassium is primarily lost through gastrointestinal fluids; therefore, vomiting
and diarrhea are common causes of hypokalemia. Low potassium levels can lead to cardiac
dysrhythmias and muscle weakness. The nurse must monitor serum electrolyte levels and
assess for signs of electrolyte depletion in these patients.
5. A nurse is preparing to administer a tube feeding via a nasogastric (NG) tube. What is the
most reliable method to confirm correct tube placement before feeding?
A. Aspirating gastric contents and checking the pH level.
B. Injecting air and listening for a ‘whoosh’ over the stomach.
C. Checking the measurement markings on the tube.
D. Reviewing the results of a recent chest X-ray.
, Answer: D
Rationale: Radiographic verification via X-ray is the gold standard and most reliable
method for confirming NG tube placement. While pH testing and measuring the tube are
helpful bedside checks, they are not as definitive as an X-ray. Auscultation is no longer
recommended as a primary method due to its inaccuracy in distinguishing between gastric
and pulmonary placement.
6. A patient is experiencing acute pain following abdominal surgery. The nurse understands
that according to the Gate Control Theory, which intervention might help reduce pain?
A. Administering high-dose opioids.
B. Encouraging the patient to sleep through the pain.
C. Restricting the patient’s movement entirely.
D. Providing a back massage or tactile stimulation.
Answer: D
Rationale: The Gate Control Theory suggests that non-painful sensory input, such as
massage or heat, can ‘close the gate’ to painful stimuli traveling to the brain. By stimulating
large-diameter nerve fibers, the transmission of pain impulses via small-diameter fibers is
inhibited. This provides a physiological basis for the effectiveness of non-pharmacological
pain management techniques.
Foundations of Nursing | Q&A with
Rationale (NUR155 Exam 3) | Galen
College of Nursing
1. A nurse is caring for a patient who is post-operative day 2 and reports sudden shortness of
breath. What should be the nurse’s first action?
A. Raise the head of the bed to High-Fowler’s position.
B. Auscultate the patient’s lung sounds.
C. Administer the prescribed PRN morphine for pain.
D. Notify the physician immediately.
Answer: A
Rationale: Raising the head of the bed is the immediate priority intervention to facilitate
chest expansion and improve gas exchange. This action uses gravity to move the abdominal
organs away from the diaphragm, allowing for better lung volume. Following this
intervention, the nurse should assess the patient and then notify the healthcare provider if
the condition persists.
2. When assessing a patient’s surgical incision, the nurse notes a thick, yellow-green
discharge. How should the nurse document this finding?
A. Serous drainage
,B. Sanguineous drainage
C. Purulent drainage
D. Serosanguineous drainage
Answer: C
Rationale: Purulent drainage is thick and consists of white blood cells, dead tissue debris,
and bacteria, indicating a potential infection. Serous drainage is clear and watery, while
sanguineous is bright red blood. Serosanguineous drainage is a pale, red, watery mixture of
clear and red fluid.
3. A patient with a history of chronic obstructive pulmonary disease (COPD) is receiving
oxygen. Which delivery method is most precise for specific oxygen concentrations?
A. Venturi mask
B. Simple face mask
C. Nasal cannula
D. Non-rebreather mask
Answer: A
Rationale: The Venturi mask is designed to deliver a specific and precise concentration of
oxygen by utilizing different sized adapters. This is particularly important for patients with
COPD who may rely on a hypoxic drive to breathe. Other delivery methods like the nasal
,cannula or simple mask provide more variable concentrations depending on the patient’s
respiratory rate.
4. Which electrolyte imbalance is a patient at risk for if they are experiencing excessive
vomiting and diarrhea?
A. Hyperkalemia
B. Hypercalcemia
C. Hypokalemia
D. Hypocalcemia
Answer: C
Rationale: Potassium is primarily lost through gastrointestinal fluids; therefore, vomiting
and diarrhea are common causes of hypokalemia. Low potassium levels can lead to cardiac
dysrhythmias and muscle weakness. The nurse must monitor serum electrolyte levels and
assess for signs of electrolyte depletion in these patients.
5. A nurse is preparing to administer a tube feeding via a nasogastric (NG) tube. What is the
most reliable method to confirm correct tube placement before feeding?
A. Aspirating gastric contents and checking the pH level.
B. Injecting air and listening for a ‘whoosh’ over the stomach.
C. Checking the measurement markings on the tube.
D. Reviewing the results of a recent chest X-ray.
, Answer: D
Rationale: Radiographic verification via X-ray is the gold standard and most reliable
method for confirming NG tube placement. While pH testing and measuring the tube are
helpful bedside checks, they are not as definitive as an X-ray. Auscultation is no longer
recommended as a primary method due to its inaccuracy in distinguishing between gastric
and pulmonary placement.
6. A patient is experiencing acute pain following abdominal surgery. The nurse understands
that according to the Gate Control Theory, which intervention might help reduce pain?
A. Administering high-dose opioids.
B. Encouraging the patient to sleep through the pain.
C. Restricting the patient’s movement entirely.
D. Providing a back massage or tactile stimulation.
Answer: D
Rationale: The Gate Control Theory suggests that non-painful sensory input, such as
massage or heat, can ‘close the gate’ to painful stimuli traveling to the brain. By stimulating
large-diameter nerve fibers, the transmission of pain impulses via small-diameter fibers is
inhibited. This provides a physiological basis for the effectiveness of non-pharmacological
pain management techniques.
