NUR 170 Exam 1 V2 | NUR 170 Medical-Surgical Nursing | Actual Q&A
with Rationale (NUR 170 Exam 1) | Galen
1. A 72-year-old female patient is admitted with a diagnosis of dehydration and heart failure.
The nurse notes a serum sodium level of 152 mEq/L. Which nursing intervention is the
priority for this patient?
A. Encourage increased water intake and monitor for neurological changes.
B. Restrict fluid intake to 1,000 mL per 24 hours.
C. Administer a 3% hypertonic saline infusion as ordered.
D. Administer salt tablets to balance the electrolyte levels.
Answer: A
Rationale: The patient is experiencing hypernatremia, which is a serum sodium level
greater than 145 mEq/L. The priority is to replace free water to dilute the sodium
concentration while monitoring for neurological changes like confusion or seizures.
Hypertonic saline would worsen the condition, and fluid restriction is contraindicated for
dehydration-induced hypernatremia.
2. A postoperative patient is being monitored in the PACU after an abdominal surgery. The
nurse observes that the patient’s blood pressure has dropped from 126/82 mmHg to 94/60
mmHg, and the heart rate has increased from 80 bpm to 115 bpm. What should the nurse do
first?
A. Increase the IV fluid rate and notify the surgeon immediately.
B. Administer the prescribed PRN pain medication.
C. Place the patient in a high-Fowler’s position to assist breathing.
D. Document the findings and recheck the vitals in 15 minutes.
Answer: A
Rationale: Tachycardia and hypotension in a postoperative patient are classic signs of
hypovolemic shock, likely due to hemorrhage. The nurse must prioritize fluid resuscitation
to maintain organ perfusion and alert the surgical team for intervention. Waiting 15
minutes to recheck vitals could lead to further clinical deterioration.
3. A 55-year-old male patient with a history of COPD presents with the following ABG results:
pH 7.31, PaCO2 55 mmHg, and HCO3 28 mEq/L. How should the nurse interpret these results?
A. Uncompensated Metabolic Acidosis
B. Fully Compensated Respiratory Alkalosis
,C. Uncompensated Respiratory Acidosis
D. Partially Compensated Respiratory Acidosis
Answer: D
Rationale: The pH is below 7.35, indicating acidosis, and the PaCO2 is elevated above 45
mmHg, indicating a respiratory cause. The HCO3 is also elevated above 26 mEq/L, which
shows the kidneys are attempting to compensate. Because the pH has not yet returned to
the normal range, the condition is partially compensated.
4. A patient is scheduled for an elective cholecystectomy. During the preoperative
assessment, the patient states, ‘I am not really sure what the surgeon is going to do during
the procedure.’ Which action is most appropriate for the nurse?
A. Explain the surgical procedure in detail to the patient.
B. Notify the surgeon that the patient requires further clarification.
C. Ask the patient to sign the consent form anyway.
D. Tell the patient that everything will be fine and it is a common surgery.
Answer: B
Rationale: The nurse’s role in informed consent is to witness the signature and ensure the
patient is competent. If the patient expresses a lack of understanding regarding the
procedure, the nurse must notify the surgeon to provide the necessary education. It is
outside the nurse’s scope of practice to provide the initial detailed surgical explanation.
5. The nurse is caring for a patient who has just returned from a thyroidectomy. The patient
reports tingling in the fingers and around the mouth. Which medication should the nurse
have readily available?
A. Potassium Chloride
B. Sodium Bicarbonate
C. Magnesium Sulfate
D. Calcium Gluconate
Answer: D
Rationale: Tingling in the extremities and circumoral area are early signs of hypocalcemia,
which can occur if the parathyroid glands are accidentally damaged or removed during
thyroid surgery. Calcium gluconate is the emergency treatment to prevent tetany and
laryngospasm. Monitoring for Chvostek’s and Trousseau’s signs is also a critical nursing
assessment in this scenario.
, 6. A patient with Stage IV lung cancer is receiving palliative care. The patient’s family asks the
nurse what the primary goal of palliative care is. What is the nurse’s best response?
A. Palliative care aims to improve the quality of life through symptom management.
B. Palliative care is only provided when the patient has less than 6 months to live.
C. Palliative care focuses on curing the underlying disease.
D. Palliative care requires the patient to stop all active treatments like chemotherapy.
Answer: A
Rationale: Palliative care focuses on relief from symptoms and the stress of a serious
illness, regardless of the diagnosis. Unlike hospice, it can be provided alongside curative
treatments at any stage of a disease. The main objective is to enhance the quality of life for
both the patient and the family.
7. The nurse is assessing a patient with a pressure injury on the sacrum. The wound bed is
covered with yellow slough, and the depth cannot be determined. How should the nurse
stage this injury?
A. Stage III
B. Stage IV
C. Deep Tissue Pressure Injury
D. Unstageable
Answer: D
Rationale: A pressure injury is classified as unstageable when the true depth of the wound
is obscured by slough or eschar. Until enough slough or eschar is removed to expose the
base of the wound, the stage cannot be determined. Once the base is visible, it is usually
classified as a Stage III or Stage IV injury.
8. A nurse is caring for a patient who sustained full-thickness burns to 40% of their body 4
hours ago. Which finding would indicate that the patient is entering the distributive shock
phase of a burn injury?
A. Increased urinary output and hypertension.
B. Decreased heart rate and clear lung sounds.
C. Elevated hematocrit and decreased blood pressure.
D. Normal capillary refill and warm extremities.
Answer: C
Rationale: In the early phase of a major burn, fluid shifts from the intravascular to the
interstitial space, causing hypovolemia. This results in hemoconcentration (elevated
with Rationale (NUR 170 Exam 1) | Galen
1. A 72-year-old female patient is admitted with a diagnosis of dehydration and heart failure.
The nurse notes a serum sodium level of 152 mEq/L. Which nursing intervention is the
priority for this patient?
A. Encourage increased water intake and monitor for neurological changes.
B. Restrict fluid intake to 1,000 mL per 24 hours.
C. Administer a 3% hypertonic saline infusion as ordered.
D. Administer salt tablets to balance the electrolyte levels.
Answer: A
Rationale: The patient is experiencing hypernatremia, which is a serum sodium level
greater than 145 mEq/L. The priority is to replace free water to dilute the sodium
concentration while monitoring for neurological changes like confusion or seizures.
Hypertonic saline would worsen the condition, and fluid restriction is contraindicated for
dehydration-induced hypernatremia.
2. A postoperative patient is being monitored in the PACU after an abdominal surgery. The
nurse observes that the patient’s blood pressure has dropped from 126/82 mmHg to 94/60
mmHg, and the heart rate has increased from 80 bpm to 115 bpm. What should the nurse do
first?
A. Increase the IV fluid rate and notify the surgeon immediately.
B. Administer the prescribed PRN pain medication.
C. Place the patient in a high-Fowler’s position to assist breathing.
D. Document the findings and recheck the vitals in 15 minutes.
Answer: A
Rationale: Tachycardia and hypotension in a postoperative patient are classic signs of
hypovolemic shock, likely due to hemorrhage. The nurse must prioritize fluid resuscitation
to maintain organ perfusion and alert the surgical team for intervention. Waiting 15
minutes to recheck vitals could lead to further clinical deterioration.
3. A 55-year-old male patient with a history of COPD presents with the following ABG results:
pH 7.31, PaCO2 55 mmHg, and HCO3 28 mEq/L. How should the nurse interpret these results?
A. Uncompensated Metabolic Acidosis
B. Fully Compensated Respiratory Alkalosis
,C. Uncompensated Respiratory Acidosis
D. Partially Compensated Respiratory Acidosis
Answer: D
Rationale: The pH is below 7.35, indicating acidosis, and the PaCO2 is elevated above 45
mmHg, indicating a respiratory cause. The HCO3 is also elevated above 26 mEq/L, which
shows the kidneys are attempting to compensate. Because the pH has not yet returned to
the normal range, the condition is partially compensated.
4. A patient is scheduled for an elective cholecystectomy. During the preoperative
assessment, the patient states, ‘I am not really sure what the surgeon is going to do during
the procedure.’ Which action is most appropriate for the nurse?
A. Explain the surgical procedure in detail to the patient.
B. Notify the surgeon that the patient requires further clarification.
C. Ask the patient to sign the consent form anyway.
D. Tell the patient that everything will be fine and it is a common surgery.
Answer: B
Rationale: The nurse’s role in informed consent is to witness the signature and ensure the
patient is competent. If the patient expresses a lack of understanding regarding the
procedure, the nurse must notify the surgeon to provide the necessary education. It is
outside the nurse’s scope of practice to provide the initial detailed surgical explanation.
5. The nurse is caring for a patient who has just returned from a thyroidectomy. The patient
reports tingling in the fingers and around the mouth. Which medication should the nurse
have readily available?
A. Potassium Chloride
B. Sodium Bicarbonate
C. Magnesium Sulfate
D. Calcium Gluconate
Answer: D
Rationale: Tingling in the extremities and circumoral area are early signs of hypocalcemia,
which can occur if the parathyroid glands are accidentally damaged or removed during
thyroid surgery. Calcium gluconate is the emergency treatment to prevent tetany and
laryngospasm. Monitoring for Chvostek’s and Trousseau’s signs is also a critical nursing
assessment in this scenario.
, 6. A patient with Stage IV lung cancer is receiving palliative care. The patient’s family asks the
nurse what the primary goal of palliative care is. What is the nurse’s best response?
A. Palliative care aims to improve the quality of life through symptom management.
B. Palliative care is only provided when the patient has less than 6 months to live.
C. Palliative care focuses on curing the underlying disease.
D. Palliative care requires the patient to stop all active treatments like chemotherapy.
Answer: A
Rationale: Palliative care focuses on relief from symptoms and the stress of a serious
illness, regardless of the diagnosis. Unlike hospice, it can be provided alongside curative
treatments at any stage of a disease. The main objective is to enhance the quality of life for
both the patient and the family.
7. The nurse is assessing a patient with a pressure injury on the sacrum. The wound bed is
covered with yellow slough, and the depth cannot be determined. How should the nurse
stage this injury?
A. Stage III
B. Stage IV
C. Deep Tissue Pressure Injury
D. Unstageable
Answer: D
Rationale: A pressure injury is classified as unstageable when the true depth of the wound
is obscured by slough or eschar. Until enough slough or eschar is removed to expose the
base of the wound, the stage cannot be determined. Once the base is visible, it is usually
classified as a Stage III or Stage IV injury.
8. A nurse is caring for a patient who sustained full-thickness burns to 40% of their body 4
hours ago. Which finding would indicate that the patient is entering the distributive shock
phase of a burn injury?
A. Increased urinary output and hypertension.
B. Decreased heart rate and clear lung sounds.
C. Elevated hematocrit and decreased blood pressure.
D. Normal capillary refill and warm extremities.
Answer: C
Rationale: In the early phase of a major burn, fluid shifts from the intravascular to the
interstitial space, causing hypovolemia. This results in hemoconcentration (elevated
