Comprehensive Questions & Answers
Review for Galen College NU 170
(Maternal-Child) and NUR 170
(Medical-Surgical) Nursing Exams
A nurse is preparing a sterile field. Which actions contaminate the sterile
field? (Select all that apply)
A) A cotton ball dampened with sterile normal saline is placed on the
field.
B) A contaminated instrument touches the outer edge of the sterile
field.
C) A sterile instrument is dropped onto the near side of the sterile
field.
D) The nurse turns to address the client’s question concerning the
procedure.
E) The procedure is postponed for 30 minutes to accommodate the
client.
F) A liquid is poured into a sterile container from a distance of 25 cm.
Answer: A, D, E, F
Rationale: Any object that is not sterile (including cotton balls that
are not individually wrapped sterile) contaminates the field. Turning
away from the field breaks sterility because the nurse cannot
guarantee that the field remained in sight and unexposed. A sterile
field should be prepared immediately before use; postponing for 30
minutes increases contamination risk. Liquids should be poured from
, a height of no more than 4-6 inches (10-15 cm) to avoid splashing
and contamination.
A nurse is assessing a client who is non-verbal and grimacing after
abdominal surgery. Which action should the nurse take first to determine
the client’s pain level?
A) Administer the prescribed PRN opioid analgesic immediately.
B) Use an alternative method, such as the FLACC or PAINAD scale, to
determine the pain level.
C) Wait until the client is fully awake and able to verbalize a number
on the 0-10 scale.
D) Document that the client is experiencing severe pain based on
facial expressions.
Answer: B. Use an alternative method, such as the FLACC or PAINAD
scale, to determine the pain level.
Rationale: When a client cannot self-report pain using a standard
numerical scale, the nurse must use a validated behavioral assessment
tool to ensure objective and accurate data collection before
intervening.
Which document serves as the legal authority defining the scope of
practice for a registered nurse in their specific state?
A) Hospital Policies and Procedures Manual.
B) American Nurses Association (ANA) Code of Ethics.
C) Nurse Practice Act.
D) The Joint Commission (TJC) Safety Standards.
Answer: C. Nurse Practice Act.
Rationale: The Nurse Practice Act is the specific state law that governs
nursing practice, defines the scope of nursing, and establishes
requirements for licensure to protect the public.
,A nurse is assessing a client following surgery. Which finding is expected in
a client experiencing acute pain?
A) Decreased heart rate
B) Decreased blood pressure
C) Increased heart rate and blood pressure
D) Hypothermia
Answer: C. Increased heart rate and blood pressure
Rationale: Acute pain triggers the sympathetic nervous system,
leading to an increase in heart rate and blood pressure.
A client asks the nurse for a copy of their medical record. The nurse knows
that this right is part of which regulation?
A) The Patient Self-Determination Act
B) HIPAA
C) The Uniform Anatomical Gift Act
D) The Americans with Disabilities Act
Answer: B. HIPAA
Rationale: The Health Insurance Portability and Accountability Act
(HIPAA) gives clients the right to access and obtain a copy of their
medical records.
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?
A) The patient will feel better by discharge.
B) The patient will ambulate in the hall.
C) The patient will feed self at all mealtimes today without reports of
shortness of breath.
, D) The patient will have decreased pain.
Answer: C. The patient will feed self at all mealtimes today without
reports of shortness of breath.
Rationale: A SMART outcome is Specific, Measurable, Attainable,
Realistic, and Timely. This option includes a specific action (feed self),
a measurable criterion (without reports of shortness of breath), and a
time frame (at all mealtimes today).
A nurse is teaching about play stages. Which type of play is most common
in a 2-year-old?
A) Cooperative play
B) Parallel play
C) Associative play
D) Solitary play
Answer: B. Parallel play
Rationale: At 2 years of age, toddlers engage mainly in parallel play,
where they play alongside other children but do not directly interact.
This reflects their developmental stage where social interaction is
emerging but not fully established. Cooperative and associative play
develop later during preschool years.
A nurse assesses the weight of a 1-year-old born at 7 pounds, 8 ounces.
What is the expected weight?
A) 14 pounds
B) 21 pounds
C) 28 pounds
D) 35 pounds
Answer: B. 21 pounds
Rationale: By 1 year of age, most infants' weight triples their birth
Review for Galen College NU 170
(Maternal-Child) and NUR 170
(Medical-Surgical) Nursing Exams
A nurse is preparing a sterile field. Which actions contaminate the sterile
field? (Select all that apply)
A) A cotton ball dampened with sterile normal saline is placed on the
field.
B) A contaminated instrument touches the outer edge of the sterile
field.
C) A sterile instrument is dropped onto the near side of the sterile
field.
D) The nurse turns to address the client’s question concerning the
procedure.
E) The procedure is postponed for 30 minutes to accommodate the
client.
F) A liquid is poured into a sterile container from a distance of 25 cm.
Answer: A, D, E, F
Rationale: Any object that is not sterile (including cotton balls that
are not individually wrapped sterile) contaminates the field. Turning
away from the field breaks sterility because the nurse cannot
guarantee that the field remained in sight and unexposed. A sterile
field should be prepared immediately before use; postponing for 30
minutes increases contamination risk. Liquids should be poured from
, a height of no more than 4-6 inches (10-15 cm) to avoid splashing
and contamination.
A nurse is assessing a client who is non-verbal and grimacing after
abdominal surgery. Which action should the nurse take first to determine
the client’s pain level?
A) Administer the prescribed PRN opioid analgesic immediately.
B) Use an alternative method, such as the FLACC or PAINAD scale, to
determine the pain level.
C) Wait until the client is fully awake and able to verbalize a number
on the 0-10 scale.
D) Document that the client is experiencing severe pain based on
facial expressions.
Answer: B. Use an alternative method, such as the FLACC or PAINAD
scale, to determine the pain level.
Rationale: When a client cannot self-report pain using a standard
numerical scale, the nurse must use a validated behavioral assessment
tool to ensure objective and accurate data collection before
intervening.
Which document serves as the legal authority defining the scope of
practice for a registered nurse in their specific state?
A) Hospital Policies and Procedures Manual.
B) American Nurses Association (ANA) Code of Ethics.
C) Nurse Practice Act.
D) The Joint Commission (TJC) Safety Standards.
Answer: C. Nurse Practice Act.
Rationale: The Nurse Practice Act is the specific state law that governs
nursing practice, defines the scope of nursing, and establishes
requirements for licensure to protect the public.
,A nurse is assessing a client following surgery. Which finding is expected in
a client experiencing acute pain?
A) Decreased heart rate
B) Decreased blood pressure
C) Increased heart rate and blood pressure
D) Hypothermia
Answer: C. Increased heart rate and blood pressure
Rationale: Acute pain triggers the sympathetic nervous system,
leading to an increase in heart rate and blood pressure.
A client asks the nurse for a copy of their medical record. The nurse knows
that this right is part of which regulation?
A) The Patient Self-Determination Act
B) HIPAA
C) The Uniform Anatomical Gift Act
D) The Americans with Disabilities Act
Answer: B. HIPAA
Rationale: The Health Insurance Portability and Accountability Act
(HIPAA) gives clients the right to access and obtain a copy of their
medical records.
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?
A) The patient will feel better by discharge.
B) The patient will ambulate in the hall.
C) The patient will feed self at all mealtimes today without reports of
shortness of breath.
, D) The patient will have decreased pain.
Answer: C. The patient will feed self at all mealtimes today without
reports of shortness of breath.
Rationale: A SMART outcome is Specific, Measurable, Attainable,
Realistic, and Timely. This option includes a specific action (feed self),
a measurable criterion (without reports of shortness of breath), and a
time frame (at all mealtimes today).
A nurse is teaching about play stages. Which type of play is most common
in a 2-year-old?
A) Cooperative play
B) Parallel play
C) Associative play
D) Solitary play
Answer: B. Parallel play
Rationale: At 2 years of age, toddlers engage mainly in parallel play,
where they play alongside other children but do not directly interact.
This reflects their developmental stage where social interaction is
emerging but not fully established. Cooperative and associative play
develop later during preschool years.
A nurse assesses the weight of a 1-year-old born at 7 pounds, 8 ounces.
What is the expected weight?
A) 14 pounds
B) 21 pounds
C) 28 pounds
D) 35 pounds
Answer: B. 21 pounds
Rationale: By 1 year of age, most infants' weight triples their birth
