NUR 155 Exam 3 – StRoNg aND BRaND NEW PRacticE
QUEStioNS & aNSWERS (aDDED WitH SUFFiciENt aND WELL
ExPLaiNED RatioNaLES)2026 RELEaSE
1.
A nurse is caring for a client admitted with worsening congestive heart failure. Which assessment
finding indicates the highest priority need for immediate intervention?
A. The patient reports increasing fatigue when walking short distances and requires frequent rest
periods after mild activity.
B. The patient has bilateral lower-extremity edema graded as +1 and states shoes fit tighter than
usual over the last week.
C. The patient has crackles throughout both lung fields, severe shortness of breath at rest, and
oxygen saturation decreased to 88% despite oxygen therapy.
D. The patient reports sleeping with two pillows at night because lying flat causes mild
discomfort.
Correct Answer: C
Rationale:
Diffuse crackles, dyspnea, and low oxygen saturation suggest pulmonary edema causing
impaired oxygen exchange. This threatens airway and breathing and requires urgent intervention.
2.
A patient receiving long-term warfarin therapy asks the nurse which dietary changes should be
considered while taking the medication. Which response is most appropriate?
A. “You should significantly increase foods rich in vitamin K, including spinach, broccoli, and
kale, to improve medication effectiveness.”
B. “Foods high in vitamin K should remain consistent or be limited because sudden increases
may reduce warfarin’s anticoagulant effect.”
C. “Consuming grapefruit juice daily helps increase the therapeutic action of warfarin and
prevents clot formation.”
D. “Milk products improve absorption of warfarin, so dairy intake should increase substantially.”
Correct Answer: B
,Rationale:
Vitamin K antagonizes warfarin. Patients should maintain a consistent intake rather than abrupt
increases.
3.
Following abdominal surgery, which assessment finding most strongly suggests internal
hemorrhage?
A. Patient reports mild incision pain rated 4/10 and requests additional pain medication after
repositioning.
B. Blood pressure decreased to 86/50 mmHg, heart rate increased to 128 bpm, and skin appears
cool and clammy.
C. Temperature increased slightly to 99°F six hours after surgery with stable vital signs.
D. Urinary output averages 40–50 mL/hr with adequate fluid intake.
Correct Answer: B
Rationale:
Hypotension, tachycardia, and cool clammy skin indicate hypovolemic shock from possible
bleeding.
4.
The nurse reviews laboratory findings before administering morning medications. Which result
requires immediate notification of the healthcare provider?
A. Sodium level of 138 mEq/L in a patient receiving IV fluids after dehydration treatment.
B. Potassium level of 6.2 mEq/L in a patient with chronic kidney disease complaining of muscle
weakness.
C. Hemoglobin level of 13 g/dL in a patient recovering from pneumonia.
D. Calcium level of 9 mg/dL in an adult admitted for observation.
Correct Answer: B
Rationale:
Severe hyperkalemia increases risk of life-threatening arrhythmias.
5.
,A diabetic patient suddenly becomes sweaty, confused, shaky, and complains of dizziness. Which
nursing action should occur first?
A. Administer prescribed rapid-acting insulin because symptoms indicate uncontrolled
hyperglycemia.
B. Assess blood glucose immediately before implementing further interventions or treatment
measures.
C. Encourage ambulation to stimulate circulation and improve metabolic activity.
D. Restrict oral intake until laboratory studies confirm the underlying problem.
Correct Answer: B
Rationale:
Symptoms suggest hypoglycemia. Verify blood glucose before intervention.
6.
Which hospitalized patient has the greatest risk for developing pressure injuries?
A. A 24-year-old patient recovering from appendectomy who ambulates independently several
times daily.
B. An elderly bedridden patient with poor nutritional status, urinary incontinence, and limited
mobility.
C. A middle-aged patient receiving oral antibiotics for respiratory infection.
D. A patient with arm fracture who performs independent repositioning.
Correct Answer: B
Rationale:
Immobility, malnutrition, and moisture increase pressure injury risk.
7.
The RN delegates tasks to an experienced UAP. Which task should remain with the RN?
A. Obtaining blood pressure measurements from stable patients on a medical unit.
B. Recording oral temperatures and pulse rates during morning rounds.
C. Assisting a patient with hygiene after orthopedic surgery.
D. Evaluating abnormal vital signs and determining necessary nursing interventions.
Correct Answer: D
, Rationale:
Assessment and evaluation require nursing judgment and cannot be delegated.
8.
A nurse teaches a patient with COPD about pursed-lip breathing. Which patient statement
indicates proper understanding?
A. “I should inhale rapidly through my mouth and hold my breath before exhaling.”
B. “I will inhale slowly through my nose and exhale longer through pursed lips to help keep
airways open.”
C. “Breathing exercises should stop whenever I become short of breath.”
D. “I should breathe quickly to increase oxygen delivery.”
Correct Answer: B
Rationale:
Pursed-lip breathing decreases air trapping and improves ventilation.
9.
A patient arrives in the emergency department with sudden facial drooping and slurred speech.
Which assessment is highest priority?
A. Obtain detailed nutritional history and dietary habits over previous months.
B. Assess neurological status including level of consciousness, speech, and motor function
immediately.
C. Evaluate family support system before initiating interventions.
D. Ask about previous hospital admissions unrelated to neurological problems.
Correct Answer: B
Rationale:
Rapid neurological evaluation is essential for stroke management.
10.
Which nursing action maintains sterile technique during wound care?
A. Holding sterile supplies below waist level while organizing equipment.
B. Reaching across the sterile field to retrieve additional materials.
QUEStioNS & aNSWERS (aDDED WitH SUFFiciENt aND WELL
ExPLaiNED RatioNaLES)2026 RELEaSE
1.
A nurse is caring for a client admitted with worsening congestive heart failure. Which assessment
finding indicates the highest priority need for immediate intervention?
A. The patient reports increasing fatigue when walking short distances and requires frequent rest
periods after mild activity.
B. The patient has bilateral lower-extremity edema graded as +1 and states shoes fit tighter than
usual over the last week.
C. The patient has crackles throughout both lung fields, severe shortness of breath at rest, and
oxygen saturation decreased to 88% despite oxygen therapy.
D. The patient reports sleeping with two pillows at night because lying flat causes mild
discomfort.
Correct Answer: C
Rationale:
Diffuse crackles, dyspnea, and low oxygen saturation suggest pulmonary edema causing
impaired oxygen exchange. This threatens airway and breathing and requires urgent intervention.
2.
A patient receiving long-term warfarin therapy asks the nurse which dietary changes should be
considered while taking the medication. Which response is most appropriate?
A. “You should significantly increase foods rich in vitamin K, including spinach, broccoli, and
kale, to improve medication effectiveness.”
B. “Foods high in vitamin K should remain consistent or be limited because sudden increases
may reduce warfarin’s anticoagulant effect.”
C. “Consuming grapefruit juice daily helps increase the therapeutic action of warfarin and
prevents clot formation.”
D. “Milk products improve absorption of warfarin, so dairy intake should increase substantially.”
Correct Answer: B
,Rationale:
Vitamin K antagonizes warfarin. Patients should maintain a consistent intake rather than abrupt
increases.
3.
Following abdominal surgery, which assessment finding most strongly suggests internal
hemorrhage?
A. Patient reports mild incision pain rated 4/10 and requests additional pain medication after
repositioning.
B. Blood pressure decreased to 86/50 mmHg, heart rate increased to 128 bpm, and skin appears
cool and clammy.
C. Temperature increased slightly to 99°F six hours after surgery with stable vital signs.
D. Urinary output averages 40–50 mL/hr with adequate fluid intake.
Correct Answer: B
Rationale:
Hypotension, tachycardia, and cool clammy skin indicate hypovolemic shock from possible
bleeding.
4.
The nurse reviews laboratory findings before administering morning medications. Which result
requires immediate notification of the healthcare provider?
A. Sodium level of 138 mEq/L in a patient receiving IV fluids after dehydration treatment.
B. Potassium level of 6.2 mEq/L in a patient with chronic kidney disease complaining of muscle
weakness.
C. Hemoglobin level of 13 g/dL in a patient recovering from pneumonia.
D. Calcium level of 9 mg/dL in an adult admitted for observation.
Correct Answer: B
Rationale:
Severe hyperkalemia increases risk of life-threatening arrhythmias.
5.
,A diabetic patient suddenly becomes sweaty, confused, shaky, and complains of dizziness. Which
nursing action should occur first?
A. Administer prescribed rapid-acting insulin because symptoms indicate uncontrolled
hyperglycemia.
B. Assess blood glucose immediately before implementing further interventions or treatment
measures.
C. Encourage ambulation to stimulate circulation and improve metabolic activity.
D. Restrict oral intake until laboratory studies confirm the underlying problem.
Correct Answer: B
Rationale:
Symptoms suggest hypoglycemia. Verify blood glucose before intervention.
6.
Which hospitalized patient has the greatest risk for developing pressure injuries?
A. A 24-year-old patient recovering from appendectomy who ambulates independently several
times daily.
B. An elderly bedridden patient with poor nutritional status, urinary incontinence, and limited
mobility.
C. A middle-aged patient receiving oral antibiotics for respiratory infection.
D. A patient with arm fracture who performs independent repositioning.
Correct Answer: B
Rationale:
Immobility, malnutrition, and moisture increase pressure injury risk.
7.
The RN delegates tasks to an experienced UAP. Which task should remain with the RN?
A. Obtaining blood pressure measurements from stable patients on a medical unit.
B. Recording oral temperatures and pulse rates during morning rounds.
C. Assisting a patient with hygiene after orthopedic surgery.
D. Evaluating abnormal vital signs and determining necessary nursing interventions.
Correct Answer: D
, Rationale:
Assessment and evaluation require nursing judgment and cannot be delegated.
8.
A nurse teaches a patient with COPD about pursed-lip breathing. Which patient statement
indicates proper understanding?
A. “I should inhale rapidly through my mouth and hold my breath before exhaling.”
B. “I will inhale slowly through my nose and exhale longer through pursed lips to help keep
airways open.”
C. “Breathing exercises should stop whenever I become short of breath.”
D. “I should breathe quickly to increase oxygen delivery.”
Correct Answer: B
Rationale:
Pursed-lip breathing decreases air trapping and improves ventilation.
9.
A patient arrives in the emergency department with sudden facial drooping and slurred speech.
Which assessment is highest priority?
A. Obtain detailed nutritional history and dietary habits over previous months.
B. Assess neurological status including level of consciousness, speech, and motor function
immediately.
C. Evaluate family support system before initiating interventions.
D. Ask about previous hospital admissions unrelated to neurological problems.
Correct Answer: B
Rationale:
Rapid neurological evaluation is essential for stroke management.
10.
Which nursing action maintains sterile technique during wound care?
A. Holding sterile supplies below waist level while organizing equipment.
B. Reaching across the sterile field to retrieve additional materials.
