Galen College NUR 170 Exam 2 (pdf) | 2026/2027 | Med-Surg Q&A |
Medical-Surgical Nursing
1. A nurse is assessing a patient after a thoracentesis. Which finding
warrants immediate action?
A) The patient rates pain as 5/10 at the site of the procedure
B) A small amount of drainage from the site is noted
C) Pulse oximetry is 93% on 2 L of oxygen
D) Breath sounds are diminished on the side of the procedure
Correct Answer: Breath sounds are diminished on the side of the procedure
Rationale: Diminished or absent breath sounds on the side of a thoracentesis
may indicate a re-accumulation of fluid or a pneumothorax, a serious
complication. The other findings are expected or near normal. Pulse oximetry
of 93% may be acceptable, especially in patients with underlying lung
disease.
2. A patient with a new tracheostomy is being seen in the clinic. What finding
best indicates that goals for the nursing diagnosis of impaired self-esteem
are being met?
A) The patient demonstrates a good understanding of stoma care
B) The patient has joined a book club that meets at the library
C) Family members take turns assisting with stoma care
D) Skin around the stoma is intact without signs of infection
Correct Answer: The patient has joined a book club that meets at the library
Rationale: Joining a book club that meets outside the home indicates the
patient is willing to go out in public and socialize, which is the best evidence
,of improved self-esteem. Understanding stoma care and intact skin are
positive outcomes but relate to physical health, not self-esteem.
3. A patient with a stroke is being evaluated for fibrinolytic therapy. What
information from the patient or family is most important for the nurse to
obtain?
A) Loss of bladder control
B) Other medical conditions
C) Progression of symptoms
D) Time of symptom onset
Correct Answer: Time of symptom onset
Rationale: The time limit for initiating fibrinolytic therapy for a stroke is 4.5
hours, so the exact time of symptom onset is the most critical piece of
information. This determines whether the patient is a candidate for this time-
sensitive therapy.
4. A nurse is seeing patients in the ophthalmology clinic. Which patient
should the nurse see first?
A) Patient with intraocular pressure reading of 24 mm Hg
B) Patient who has had cataract surgery and has worsening vision
C) Patient whose red reflex is absent on ophthalmologic examination
D) Patient with a tearing, reddened eye with exudate
Correct Answer: Patient who has had cataract surgery and has worsening
vision
Rationale: After cataract surgery, worsening vision indicates a potential
complication such as infection or retinal detachment and requires immediate
,attention. An intraocular pressure of 24 mm Hg is slightly elevated but not
emergent.
5. A nurse is delegating care for a client with Parkinson disease to an
unlicensed assistive personnel (UAP). Which statement would the nurse
include when delegating this client's care?
A) "Allow the client to be as independent as possible with activities."
B) "Assist the client with frequent and meticulous oral care."
C) "Assess the client's ability to eat and swallow before each meal."
D) "Schedule appointments early in the morning to ensure rest in the
afternoon."
Correct Answer: "Allow the client to be as independent as possible with
activities."
Rationale: Clients with Parkinson disease should be encouraged to be as
independent as possible, allowing them extra time to complete activities.
Assessment of swallowing is a nursing responsibility that cannot be
delegated to a UAP.
6. A patient with heart failure is prescribed furosemide. Which laboratory
value should the nurse monitor most closely?
A) Sodium
B) Potassium
C) Calcium
D) Magnesium
Correct Answer: Potassium
, Rationale: Furosemide is a loop diuretic that can cause hypokalemia (low
potassium). Monitoring potassium is essential to prevent cardiac
arrhythmias. Sodium and calcium are less directly affected.
7. A patient reports chest pain radiating to the left arm. What is the nurse's
priority action?
A) Obtain vital signs
B) Administer nitroglycerin
C) Place the patient on a cardiac monitor
D) Assess pain characteristics
Correct Answer: Place the patient on a cardiac monitor
Rationale: Immediate cardiac monitoring is critical in suspected myocardial
infarction to detect life-threatening arrhythmias. Pain assessment and
nitroglycerin follow per protocol, but monitoring is the priority to ensure
patient safety.
8. Which symptom indicates left-sided heart failure?
A) Peripheral edema
B) Pulmonary congestion
C) Hepatomegaly
D) Jugular vein distention
Correct Answer: Pulmonary congestion
Rationale: Left-sided heart failure leads to fluid backing up into the lungs,
causing pulmonary congestion, dyspnea, and crackles. Peripheral edema,
hepatomegaly, and jugular vein distention are signs of right-sided heart
failure.
Medical-Surgical Nursing
1. A nurse is assessing a patient after a thoracentesis. Which finding
warrants immediate action?
A) The patient rates pain as 5/10 at the site of the procedure
B) A small amount of drainage from the site is noted
C) Pulse oximetry is 93% on 2 L of oxygen
D) Breath sounds are diminished on the side of the procedure
Correct Answer: Breath sounds are diminished on the side of the procedure
Rationale: Diminished or absent breath sounds on the side of a thoracentesis
may indicate a re-accumulation of fluid or a pneumothorax, a serious
complication. The other findings are expected or near normal. Pulse oximetry
of 93% may be acceptable, especially in patients with underlying lung
disease.
2. A patient with a new tracheostomy is being seen in the clinic. What finding
best indicates that goals for the nursing diagnosis of impaired self-esteem
are being met?
A) The patient demonstrates a good understanding of stoma care
B) The patient has joined a book club that meets at the library
C) Family members take turns assisting with stoma care
D) Skin around the stoma is intact without signs of infection
Correct Answer: The patient has joined a book club that meets at the library
Rationale: Joining a book club that meets outside the home indicates the
patient is willing to go out in public and socialize, which is the best evidence
,of improved self-esteem. Understanding stoma care and intact skin are
positive outcomes but relate to physical health, not self-esteem.
3. A patient with a stroke is being evaluated for fibrinolytic therapy. What
information from the patient or family is most important for the nurse to
obtain?
A) Loss of bladder control
B) Other medical conditions
C) Progression of symptoms
D) Time of symptom onset
Correct Answer: Time of symptom onset
Rationale: The time limit for initiating fibrinolytic therapy for a stroke is 4.5
hours, so the exact time of symptom onset is the most critical piece of
information. This determines whether the patient is a candidate for this time-
sensitive therapy.
4. A nurse is seeing patients in the ophthalmology clinic. Which patient
should the nurse see first?
A) Patient with intraocular pressure reading of 24 mm Hg
B) Patient who has had cataract surgery and has worsening vision
C) Patient whose red reflex is absent on ophthalmologic examination
D) Patient with a tearing, reddened eye with exudate
Correct Answer: Patient who has had cataract surgery and has worsening
vision
Rationale: After cataract surgery, worsening vision indicates a potential
complication such as infection or retinal detachment and requires immediate
,attention. An intraocular pressure of 24 mm Hg is slightly elevated but not
emergent.
5. A nurse is delegating care for a client with Parkinson disease to an
unlicensed assistive personnel (UAP). Which statement would the nurse
include when delegating this client's care?
A) "Allow the client to be as independent as possible with activities."
B) "Assist the client with frequent and meticulous oral care."
C) "Assess the client's ability to eat and swallow before each meal."
D) "Schedule appointments early in the morning to ensure rest in the
afternoon."
Correct Answer: "Allow the client to be as independent as possible with
activities."
Rationale: Clients with Parkinson disease should be encouraged to be as
independent as possible, allowing them extra time to complete activities.
Assessment of swallowing is a nursing responsibility that cannot be
delegated to a UAP.
6. A patient with heart failure is prescribed furosemide. Which laboratory
value should the nurse monitor most closely?
A) Sodium
B) Potassium
C) Calcium
D) Magnesium
Correct Answer: Potassium
, Rationale: Furosemide is a loop diuretic that can cause hypokalemia (low
potassium). Monitoring potassium is essential to prevent cardiac
arrhythmias. Sodium and calcium are less directly affected.
7. A patient reports chest pain radiating to the left arm. What is the nurse's
priority action?
A) Obtain vital signs
B) Administer nitroglycerin
C) Place the patient on a cardiac monitor
D) Assess pain characteristics
Correct Answer: Place the patient on a cardiac monitor
Rationale: Immediate cardiac monitoring is critical in suspected myocardial
infarction to detect life-threatening arrhythmias. Pain assessment and
nitroglycerin follow per protocol, but monitoring is the priority to ensure
patient safety.
8. Which symptom indicates left-sided heart failure?
A) Peripheral edema
B) Pulmonary congestion
C) Hepatomegaly
D) Jugular vein distention
Correct Answer: Pulmonary congestion
Rationale: Left-sided heart failure leads to fluid backing up into the lungs,
causing pulmonary congestion, dyspnea, and crackles. Peripheral edema,
hepatomegaly, and jugular vein distention are signs of right-sided heart
failure.
