NUR 170 Med Surg Exam 2 V1 and V2 | Questions and
Answers | 2026 Updates | Galen College of Nursing
QUESTION 1
The home health nurse is assigned to visit these clients when a change in agency staffing requires that one
of the clients be rescheduled for a visit on the following day. Which client will be best to reschedule?
A. A client with emphysema who has been on home oxygen for a month and has SpO2 levels of 91% to
93%
B. A client with new-onset diabetes requiring insulin teaching
C. A client with a new tracheostomy requiring suctioning
D. A client with a postoperative wound infection requiring IV antibiotics
Correct Answer: A. A client with emphysema who has been on home oxygen for a month and has SpO2
levels of 91% to 93%
Expert Rationale: The client with emphysema who has been stable on home oxygen with SpO2 levels of
91-93% is the most stable and can safely be rescheduled . The client has established care and is not
showing acute deterioration. The other clients have acute needs: new-onset diabetes requiring immediate
teaching (B), a new tracheostomy requiring frequent suctioning (C), and a wound infection requiring IV
antibiotics (D) are higher acuity and should not be rescheduled.
QUESTION 2
A client is admitted to the unit with which of the following conditions that requires the nurse to prioritize
neurological assessment?
A. Pneumonia
B. Stroke (brain attack)
C. Gastroenteritis
D. Cellulitis
,Correct Answer: B. Stroke (brain attack)
Expert Rationale: A client admitted with a stroke requires immediate and ongoing neurological
assessment to monitor for changes in level of consciousness, motor function, and other neurological
deficits . Neurological assessment is the priority for stroke patients. Pneumonia (A), gastroenteritis (C),
and cellulitis (D) require assessment but neurological status is not the primary focus.
QUESTION 3
A charge nurse is reviewing outcome statements written by a novice nurse. The nurse is using the SMART
approach. Which patient outcome statement will the charge nurse identify as appropriate to the new
nurse?
A. The patient will feel better by tomorrow
B. The patient will feed self at all mealtimes today without reports of shortness of breath
C. The patient will be happy with their care
D. The patient will walk when they are ready
Correct Answer: B. The patient will feed self at all mealtimes today without reports of shortness of breath
Expert Rationale: SMART outcomes are Specific, Measurable, Attainable, Realistic, and Timely . Option
B includes a specific action (feed self), measurement (without shortness of breath), timing (today), and is
realistic. Options A, C, and D are too vague and not measurable. Outcome statements must be measurable
to evaluate effectiveness.
QUESTION 4
Which of the following patients would the nurse identify as being highest risk for stroke?
A. A 27-year-old heavy cocaine user
B. A 30-year-old who drinks a beer a day
C. A 40-year-old who uses seasonal antihistamines
,D. A 65-year-old who is active and on no medications
Correct Answer: A. A 27-year-old heavy cocaine user
Expert Rationale: Cocaine use is a significant risk factor for stroke, even in young individuals, due to
vasoconstriction and increased blood pressure . While age is a risk factor, the heavy cocaine use presents
a more immediate and severe risk. Moderate alcohol consumption (B), antihistamine use (C), and being
active with no medications (D) are not primary stroke risk factors.
QUESTION 5
A nurse assesses a client who has a history of migraines. Which clinical manifestation would the nurse
identify as an aura?
A. Vertigo
B. Visual disturbances
C. Lethargy
D. Numbness of the face
Correct Answer: B. Visual disturbances
Expert Rationale: Visual disturbances (sparkles, zig-zags, halos, scotoma) are the most common aura
symptoms in migraine headaches, occurring in about 20% of cases . Vertigo (A), lethargy (C), and facial
numbness (D) can occur but are not classic aura manifestations. Aura is a sensory disturbance that
precedes the headache phase.
QUESTION 6
What does the acronym POUND stand for in migraine assessment?
A. Pulsatile, One day duration, Unilateral, Nausea, Disabling
B. Painful, Ongoing, Unrelenting, Nausea, Dizziness
C. Pounding, Ocular, Unilateral, Neck pain, Dizziness
, D. Pulsatile, Occipital, Unilateral, Nausea, Drowsiness
Correct Answer: A. Pulsatile, One day duration, Unilateral, Nausea, Disabling
Expert Rationale: The POUND acronym for migraines includes: Pulsatile quality, One day duration (4-72
hours), Unilateral location, Nausea/vomiting, and Disabling intensity . This is a useful clinical tool for
identifying migraine headaches. Migraines are supraorbital or retroorbital, last 4-72 hours, pain worsens
with movement, and include N/V, photophobia, and tingly scalp.
QUESTION 7
A patient experiencing a migraine headache reports throbbing pain lasting 6 hours. The nurse notes the
pain is unilateral and the patient reports nausea. Based on the POUND acronym, which finding is NOT
part of the migraine criteria?
A. Pulsatile quality
B. One day duration
C. Unilateral location
D. Nausea and vomiting
Correct Answer: B. One day duration
Expert Rationale: The POUND acronym for migraines includes: Pulsatile quality, One day duration (4-72
hours is correct, not 1 day), Unilateral location, Nausea/vomiting, Disabling intensity . While 1 day (24
hours) could fit within the 4-72 hour range, the classic description is "duration of 4-72 hours," making
"one day" an incomplete representation.
QUESTION 8
Which statement about migraine triggers is accurate?
A. Tyramine is found in fresh fruits and vegetables
B. Dehydration is a known trigger
Answers | 2026 Updates | Galen College of Nursing
QUESTION 1
The home health nurse is assigned to visit these clients when a change in agency staffing requires that one
of the clients be rescheduled for a visit on the following day. Which client will be best to reschedule?
A. A client with emphysema who has been on home oxygen for a month and has SpO2 levels of 91% to
93%
B. A client with new-onset diabetes requiring insulin teaching
C. A client with a new tracheostomy requiring suctioning
D. A client with a postoperative wound infection requiring IV antibiotics
Correct Answer: A. A client with emphysema who has been on home oxygen for a month and has SpO2
levels of 91% to 93%
Expert Rationale: The client with emphysema who has been stable on home oxygen with SpO2 levels of
91-93% is the most stable and can safely be rescheduled . The client has established care and is not
showing acute deterioration. The other clients have acute needs: new-onset diabetes requiring immediate
teaching (B), a new tracheostomy requiring frequent suctioning (C), and a wound infection requiring IV
antibiotics (D) are higher acuity and should not be rescheduled.
QUESTION 2
A client is admitted to the unit with which of the following conditions that requires the nurse to prioritize
neurological assessment?
A. Pneumonia
B. Stroke (brain attack)
C. Gastroenteritis
D. Cellulitis
,Correct Answer: B. Stroke (brain attack)
Expert Rationale: A client admitted with a stroke requires immediate and ongoing neurological
assessment to monitor for changes in level of consciousness, motor function, and other neurological
deficits . Neurological assessment is the priority for stroke patients. Pneumonia (A), gastroenteritis (C),
and cellulitis (D) require assessment but neurological status is not the primary focus.
QUESTION 3
A charge nurse is reviewing outcome statements written by a novice nurse. The nurse is using the SMART
approach. Which patient outcome statement will the charge nurse identify as appropriate to the new
nurse?
A. The patient will feel better by tomorrow
B. The patient will feed self at all mealtimes today without reports of shortness of breath
C. The patient will be happy with their care
D. The patient will walk when they are ready
Correct Answer: B. The patient will feed self at all mealtimes today without reports of shortness of breath
Expert Rationale: SMART outcomes are Specific, Measurable, Attainable, Realistic, and Timely . Option
B includes a specific action (feed self), measurement (without shortness of breath), timing (today), and is
realistic. Options A, C, and D are too vague and not measurable. Outcome statements must be measurable
to evaluate effectiveness.
QUESTION 4
Which of the following patients would the nurse identify as being highest risk for stroke?
A. A 27-year-old heavy cocaine user
B. A 30-year-old who drinks a beer a day
C. A 40-year-old who uses seasonal antihistamines
,D. A 65-year-old who is active and on no medications
Correct Answer: A. A 27-year-old heavy cocaine user
Expert Rationale: Cocaine use is a significant risk factor for stroke, even in young individuals, due to
vasoconstriction and increased blood pressure . While age is a risk factor, the heavy cocaine use presents
a more immediate and severe risk. Moderate alcohol consumption (B), antihistamine use (C), and being
active with no medications (D) are not primary stroke risk factors.
QUESTION 5
A nurse assesses a client who has a history of migraines. Which clinical manifestation would the nurse
identify as an aura?
A. Vertigo
B. Visual disturbances
C. Lethargy
D. Numbness of the face
Correct Answer: B. Visual disturbances
Expert Rationale: Visual disturbances (sparkles, zig-zags, halos, scotoma) are the most common aura
symptoms in migraine headaches, occurring in about 20% of cases . Vertigo (A), lethargy (C), and facial
numbness (D) can occur but are not classic aura manifestations. Aura is a sensory disturbance that
precedes the headache phase.
QUESTION 6
What does the acronym POUND stand for in migraine assessment?
A. Pulsatile, One day duration, Unilateral, Nausea, Disabling
B. Painful, Ongoing, Unrelenting, Nausea, Dizziness
C. Pounding, Ocular, Unilateral, Neck pain, Dizziness
, D. Pulsatile, Occipital, Unilateral, Nausea, Drowsiness
Correct Answer: A. Pulsatile, One day duration, Unilateral, Nausea, Disabling
Expert Rationale: The POUND acronym for migraines includes: Pulsatile quality, One day duration (4-72
hours), Unilateral location, Nausea/vomiting, and Disabling intensity . This is a useful clinical tool for
identifying migraine headaches. Migraines are supraorbital or retroorbital, last 4-72 hours, pain worsens
with movement, and include N/V, photophobia, and tingly scalp.
QUESTION 7
A patient experiencing a migraine headache reports throbbing pain lasting 6 hours. The nurse notes the
pain is unilateral and the patient reports nausea. Based on the POUND acronym, which finding is NOT
part of the migraine criteria?
A. Pulsatile quality
B. One day duration
C. Unilateral location
D. Nausea and vomiting
Correct Answer: B. One day duration
Expert Rationale: The POUND acronym for migraines includes: Pulsatile quality, One day duration (4-72
hours is correct, not 1 day), Unilateral location, Nausea/vomiting, Disabling intensity . While 1 day (24
hours) could fit within the 4-72 hour range, the classic description is "duration of 4-72 hours," making
"one day" an incomplete representation.
QUESTION 8
Which statement about migraine triggers is accurate?
A. Tyramine is found in fresh fruits and vegetables
B. Dehydration is a known trigger
