(2026/2027) PDF | Nursing | Galen College
1. The nurse is prioritizing care after a change-of-shift
report. Which patient should be seen FIRST?
A. A 45-year-old with COPD and SpO2 of 89% on 2L
NC.
B. A 30-year-old who had an ERCP 30 minutes ago and
reports difficulty swallowing.
C. A 60-year-old post-hip replacement requesting pain
medication.
D. A 50-year-old with a potassium level of 3.2.
Answer: B.
Rationale: Difficulty swallowing post-ERCP suggests the
gag reflex has not returned, placing the patient at
immediate risk for aspiration (airway compromise). ABCs
override stable hypoxia, pain, or electrolyte imbalance.
2. A nurse in the ED is triaging after a factory explosion.
Which client requires priority treatment?
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,A. A client with a simple arm laceration.
B. A client with second-degree burns to the face and soot
around the mouth.
C. A client with a fractured femur and a pedal pulse
present.
D. A client with tinnitus and a perforated eardrum.
Answer: B.
Rationale: Soot around the mouth and facial burns
indicate potential inhalation injury and airway
compromise, which is the highest priority in triage (ABCs).
3. The nurse is assessing a client with acute pancreatitis.
Which finding requires immediate intervention?
A. Pain rated 6/10.
B. Serum amylase 300 U/L.
C. Pain on deep inspiration.
D. Lipase 250 U/L.
Answer: C.
Rationale: Pain on deep inspiration may indicate pleural
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,effusion or ARDS, signaling respiratory deterioration. This
takes priority over expected lab findings of pancreatitis.
4. A client with full-thickness burns to 50% of TBSA has a
temperature of 104.2°F (40.1°C). What should the nurse
do?
A. Administer Acetaminophen as ordered.
B. Increase the room temperature.
C. Notify the primary health care provider immediately.
D. Re-assess the temperature in 30 minutes.
Answer: C.
Rationale: This hyperthermia is indicative of sepsis or a
severe infection, which is life-threatening in a burn patient.
This is an urgent clinical finding requiring immediate
notification.
5. On a mother-baby unit, which client should the nurse
assess INITIALLY?
A. A neonate, 4 hours old, with a heart rate of 95 BPM.
B. A mother with a spinal headache requesting medication.
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, C. A 24-hour-old newborn who has not voided.
D. A mother requesting discharge teaching.
Answer: A.
Rationale: Normal newborn HR is 120-160 BPM. A rate
of 95 BPM indicates bradycardia, often a sign of
hypoxia or distress in an infant, requiring immediate
assessment.
6. The charge nurse must assign a room for a client with a
fever of unknown origin. Which room assignment is best?
A. A semi-private room with a client with pneumonia.
B. A private room with negative pressure airflow.
C. A private room with standard airflow.
D. A semi-private room with an immunocompromised
patient.
Answer: C.
Rationale: Fever of unknown origin requires a private
room (to rule out communicable diseases), but negative
pressure is specifically for airborne illnesses (TB, Measles).
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