NUR 155 Exam 2, 3 and 4
Combined | Questions and
Answers | 2026 Update | 100%
Correct – Galen College.
Course
NUR 155
QUESTION 1
A client has fluid volume overload. Which interventions should the nurse anticipate? Select all
that apply.
A. Encourage unrestricted oral fluids
B. Restrict sodium intake
C. Monitor daily weight
D. Monitor intake and output
E. Encourage high-sodium foods
Correct Answer: B, C, D
Rationale: Sodium restriction can decrease fluid retention. Daily weights are one of the most
sensitive indicators of fluid gain or loss, while intake and output help evaluate fluid balance.
Unrestricted fluids and high-sodium foods can worsen fluid overload.
QUESTION 2
A client has a serum potassium level of 2.8 mEq/L. Which assessment finding should the nurse
expect?
A. Muscle weakness
B. Bounding pulses
C. Hyperactive reflexes
D. Severe hypertension
Correct Answer: A. Muscle weakness
Rationale: Hypokalemia can cause muscle weakness, fatigue, muscle cramps, decreased
gastrointestinal motility, and potentially dangerous cardiac dysrhythmias.
,QUESTION 3
Which food should the nurse recommend to a client who needs to increase dietary potassium?
A. White rice
B. Applesauce
C. Baked potato
D. White bread
Correct Answer: C. Baked potato
Rationale: Potatoes are potassium-rich foods. Other potassium-containing foods include
bananas, oranges, tomatoes, spinach, beans, and avocados.
QUESTION 4
A client has a serum sodium level of 124 mEq/L. Which finding is most concerning?
A. Dry lips
B. Mild thirst
C. Confusion and decreased level of consciousness
D. Increased appetite
Correct Answer: C. Confusion and decreased level of consciousness
Rationale: Significant hyponatremia can cause cerebral edema and neurological manifestations,
including headache, confusion, seizures, and decreased consciousness. Neurological changes
require prompt attention.
QUESTION 5
The nurse is teaching a client about increasing dietary fiber to prevent constipation. Which food
is the best choice?
A. White bread
B. Bran cereal
C. Processed cheese
D. Eggs
Correct Answer: B. Bran cereal
Rationale: Bran cereal is high in dietary fiber. Adequate fiber combined with sufficient fluid
intake and physical activity promotes normal bowel elimination.
,QUESTION 6
A client reports constipation. Which nursing intervention should generally be encouraged first
when appropriate?
A. Encourage activity and adequate fluid/fiber intake
B. Administer an antidiarrheal medication
C. Restrict all oral fluids
D. Keep the client on strict bed rest
Correct Answer: A. Encourage activity and adequate fluid/fiber intake
Rationale: Lifestyle measures such as adequate fluids, dietary fiber, and activity can improve
bowel motility and are commonly appropriate initial measures when there are no
contraindications.
QUESTION 7
A nurse is caring for a client with urinary retention. Which assessment finding is most consistent
with the condition?
A. Inability to completely empty the bladder
B. Continuous watery diarrhea
C. Absent bowel sounds
D. Excessive salivation
Correct Answer: A. Inability to completely empty the bladder
Rationale: Urinary retention occurs when the bladder cannot empty adequately. The client may
report hesitancy, weak stream, incomplete emptying, frequency, or bladder discomfort.
QUESTION 8
Which instruction is appropriate when teaching a client about collecting a clean-catch urine
specimen?
A. Collect the first urine that appears without cleansing
B. Cleanse the urinary opening and collect the midstream portion
C. Touch the inside of the specimen container
D. Collect urine from the toilet
, Correct Answer: B. Cleanse the urinary opening and collect the midstream portion
Rationale: Cleansing and collecting midstream urine reduces contamination from organisms
normally present around the urethral opening.
QUESTION 9
The nurse is assessing a pressure injury. The wound has full-thickness skin loss, and adipose
tissue is visible. Bone, tendon, and muscle are not exposed. How should the injury be classified?
A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
Correct Answer: C. Stage 3
Rationale: Stage 3 pressure injury involves full-thickness skin loss with visible adipose tissue and
granulation tissue. Deeper structures such as fascia, muscle, tendon, cartilage, or bone are not
exposed.
QUESTION 10
Which nursing intervention best helps prevent shear when repositioning a client?
A. Drag the client across the bed
B. Use a lift device or draw sheet when appropriate
C. Raise the head of the bed as high as possible during repositioning
D. Pull the client by the arms
Correct Answer: B. Use a lift device or draw sheet when appropriate
Rationale: Shearing occurs when skin remains stationary while underlying tissues move. Using
appropriate lifting/repositioning equipment reduces friction and shear.
QUESTION 11
A wound is described as having healthy red granulation tissue. Which action is most
appropriate?
Combined | Questions and
Answers | 2026 Update | 100%
Correct – Galen College.
Course
NUR 155
QUESTION 1
A client has fluid volume overload. Which interventions should the nurse anticipate? Select all
that apply.
A. Encourage unrestricted oral fluids
B. Restrict sodium intake
C. Monitor daily weight
D. Monitor intake and output
E. Encourage high-sodium foods
Correct Answer: B, C, D
Rationale: Sodium restriction can decrease fluid retention. Daily weights are one of the most
sensitive indicators of fluid gain or loss, while intake and output help evaluate fluid balance.
Unrestricted fluids and high-sodium foods can worsen fluid overload.
QUESTION 2
A client has a serum potassium level of 2.8 mEq/L. Which assessment finding should the nurse
expect?
A. Muscle weakness
B. Bounding pulses
C. Hyperactive reflexes
D. Severe hypertension
Correct Answer: A. Muscle weakness
Rationale: Hypokalemia can cause muscle weakness, fatigue, muscle cramps, decreased
gastrointestinal motility, and potentially dangerous cardiac dysrhythmias.
,QUESTION 3
Which food should the nurse recommend to a client who needs to increase dietary potassium?
A. White rice
B. Applesauce
C. Baked potato
D. White bread
Correct Answer: C. Baked potato
Rationale: Potatoes are potassium-rich foods. Other potassium-containing foods include
bananas, oranges, tomatoes, spinach, beans, and avocados.
QUESTION 4
A client has a serum sodium level of 124 mEq/L. Which finding is most concerning?
A. Dry lips
B. Mild thirst
C. Confusion and decreased level of consciousness
D. Increased appetite
Correct Answer: C. Confusion and decreased level of consciousness
Rationale: Significant hyponatremia can cause cerebral edema and neurological manifestations,
including headache, confusion, seizures, and decreased consciousness. Neurological changes
require prompt attention.
QUESTION 5
The nurse is teaching a client about increasing dietary fiber to prevent constipation. Which food
is the best choice?
A. White bread
B. Bran cereal
C. Processed cheese
D. Eggs
Correct Answer: B. Bran cereal
Rationale: Bran cereal is high in dietary fiber. Adequate fiber combined with sufficient fluid
intake and physical activity promotes normal bowel elimination.
,QUESTION 6
A client reports constipation. Which nursing intervention should generally be encouraged first
when appropriate?
A. Encourage activity and adequate fluid/fiber intake
B. Administer an antidiarrheal medication
C. Restrict all oral fluids
D. Keep the client on strict bed rest
Correct Answer: A. Encourage activity and adequate fluid/fiber intake
Rationale: Lifestyle measures such as adequate fluids, dietary fiber, and activity can improve
bowel motility and are commonly appropriate initial measures when there are no
contraindications.
QUESTION 7
A nurse is caring for a client with urinary retention. Which assessment finding is most consistent
with the condition?
A. Inability to completely empty the bladder
B. Continuous watery diarrhea
C. Absent bowel sounds
D. Excessive salivation
Correct Answer: A. Inability to completely empty the bladder
Rationale: Urinary retention occurs when the bladder cannot empty adequately. The client may
report hesitancy, weak stream, incomplete emptying, frequency, or bladder discomfort.
QUESTION 8
Which instruction is appropriate when teaching a client about collecting a clean-catch urine
specimen?
A. Collect the first urine that appears without cleansing
B. Cleanse the urinary opening and collect the midstream portion
C. Touch the inside of the specimen container
D. Collect urine from the toilet
, Correct Answer: B. Cleanse the urinary opening and collect the midstream portion
Rationale: Cleansing and collecting midstream urine reduces contamination from organisms
normally present around the urethral opening.
QUESTION 9
The nurse is assessing a pressure injury. The wound has full-thickness skin loss, and adipose
tissue is visible. Bone, tendon, and muscle are not exposed. How should the injury be classified?
A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
Correct Answer: C. Stage 3
Rationale: Stage 3 pressure injury involves full-thickness skin loss with visible adipose tissue and
granulation tissue. Deeper structures such as fascia, muscle, tendon, cartilage, or bone are not
exposed.
QUESTION 10
Which nursing intervention best helps prevent shear when repositioning a client?
A. Drag the client across the bed
B. Use a lift device or draw sheet when appropriate
C. Raise the head of the bed as high as possible during repositioning
D. Pull the client by the arms
Correct Answer: B. Use a lift device or draw sheet when appropriate
Rationale: Shearing occurs when skin remains stationary while underlying tissues move. Using
appropriate lifting/repositioning equipment reduces friction and shear.
QUESTION 11
A wound is described as having healthy red granulation tissue. Which action is most
appropriate?
