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NUR 265 EXAM 1 MEDICAL-SURGICAL NURSING EXAM QUESTIONS 2026 EXAM LATEST
VERSION SOLVED QUESTIONS & ANSWERS VERIFIED 100 %
NUR 265 Exam 1 Medical-Surgical Nursing — 250 Questions
SECTION 1: NURSING PROCESS & CLINICAL JUDGMENT (Q1–Q25)
1. A nurse is caring for a client who has just been admitted to the medical-surgical
unit with complaints of severe abdominal pain. Which action should the nurse take
first?
A. Administer the prescribed pain medication immediately
B. Complete a comprehensive pain assessment including location, quality, and severity
C. Document the client's complaint in the electronic health record
D. Notify the provider of the client's admission
Correct Answer: B
Rationale: Assessment is the first step of the nursing process and must precede any
intervention. The nurse must collect comprehensive data about the pain before
administering medication or notifying the provider. Documentation follows assessment
and intervention.
2. A nurse is developing a plan of care for a client who has impaired mobility. Which
outcome statement is written correctly according to SMART criteria?
A. "Client will feel better by tomorrow."
B. "Client will ambulate 50 feet with a walker by the end of the shift."
C. "Client should improve mobility soon."
D. "Client will be able to move without difficulty."
Correct Answer: B
Rationale: A correctly written goal is specific, measurable, attainable, realistic, and
time-bound. "Ambulate 50 feet with a walker by the end of the shift" meets all SMART
criteria. The other options are vague and not measurable.
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3. A nurse is reviewing a client's medical record and notes the following data: blood
pressure 142/88 mm Hg, heart rate 96 beats/min, and client states "I feel anxious."
Which of these findings is subjective data?
A. Blood pressure 142/88 mm Hg
B. Heart rate 96 beats/min
C. Client states "I feel anxious"
D. All of the above are subjective
Correct Answer: C
Rationale: Subjective data includes the client's verbal descriptions of their condition,
such as feelings, perceptions, and concerns. Blood pressure and heart rate are
objective, measurable findings. The client's statement about feeling anxious is
subjective.
4. A nurse is caring for a client who has a new diagnosis of diabetes mellitus. The
client states, "I don't know how I'm going to give myself shots every day." Which
nursing diagnosis is most appropriate?
A. Impaired Skin Integrity
B. Anxiety related to new diagnosis
C. Deficient Knowledge regarding insulin administration
D. Risk for Infection
Correct Answer: C
Rationale: The client's statement indicates a lack of understanding about how to
administer insulin injections. Deficient Knowledge is the most appropriate nursing
diagnosis. Anxiety may also be present, but the primary problem is knowledge deficit.
5. A nurse is evaluating the effectiveness of a client's care plan. Which action best
demonstrates the evaluation phase of the nursing process?
A. Administering pain medication as prescribed
B. Collecting a urine specimen for analysis
C. Determining whether the client's pain level has decreased after intervention
D. Documenting the client's vital signs
Correct Answer: C
Rationale: Evaluation involves determining whether the client's goals and outcomes
have been achieved. Comparing the client's pain level before and after intervention
demonstrates evaluation. Administering medication is implementation, collecting
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specimens is assessment, and documenting vital signs is a component of assessment
or implementation.
6. A nurse is prioritizing care for four clients at the beginning of a shift. Which client
should the nurse assess first?
A. A client who is scheduled for discharge and needs teaching
B. A client who reports new onset of chest pain and shortness of breath
C. A client who is requesting pain medication for chronic back pain
D. A client who needs assistance with ambulation to the bathroom
Correct Answer: B
Rationale: Using the ABC priority framework, new-onset chest pain and shortness of
breath indicate potential airway, breathing, or circulation compromise and must be
assessed first. Discharge teaching, chronic pain management, and ambulation
assistance are important but not immediately life-threatening.
7. A nurse is assessing a client who has been admitted with dehydration. Which
finding is an early indicator of fluid volume deficit?
A. Dry mucous membranes
B. Decreased urine output
C. Thirst
D. Sunken eyes
Correct Answer: C
Rationale: Thirst is the earliest indicator of dehydration. Dry mucous membranes,
decreased urine output, and sunken eyes are later signs of fluid volume deficit. Early
recognition allows prompt intervention.
8. A nurse is teaching a client about the purpose of the nursing process. Which
statement by the client indicates understanding?
A. "The nursing process helps ensure my care is organized and consistent."
B. "The nursing process is a one-time assessment that never changes."
C. "The nursing process only considers my physical needs."
D. "The nursing process replaces the need for medical treatment."
Correct Answer: A
Rationale: The nursing process provides a systematic, patient-centered framework for
delivering holistic care. It is dynamic and continuous, considers physical, emotional,
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and social needs, and works in collaboration with medical treatment, not as a
replacement.
9. A nurse is caring for a client who has been placed on seizure precautions. Which
action demonstrates the implementation phase of the nursing process?
A. Documenting the client's seizure history
B. Placing padding on the side rails of the bed
C. Determining whether the client has had any seizures
D. Planning when to administer antiseizure medication
Correct Answer: B
Rationale: Implementation involves carrying out the planned interventions. Placing
padding on the side rails is an action that implements the seizure precaution plan.
Assessment involves collecting data, planning involves developing goals and
interventions, and evaluation involves determining outcomes.
10. A nurse is using the SBAR communication tool to report a change in a client's
condition to the provider. Which information should the nurse include in the "A"
(Assessment) component?
A. The client's name, room number, and medical diagnosis
B. The nurse's clinical impression of the situation
C. The client's vital signs and current medications
D. The nurse's recommendation for what should be done
Correct Answer: B
Rationale: In SBAR, "A" stands for Assessment—the nurse's clinical impression or
conclusion about the situation. Situation includes identifying information, Background
includes vital signs and medications, and Recommendation is the nurse's suggestion.
11. A nurse is reviewing a client's laboratory results and notes a potassium level of
5.8 mEq/L. Which action should the nurse take first?
A. Document the finding and reassess in 4 hours
B. Obtain a 12-lead ECG and notify the provider
C. Administer sodium polystyrene sulfonate orally
D. Restrict dietary potassium intake
Correct Answer: B
Rationale: Hyperkalemia can cause life-threatening cardiac dysrhythmias. The first
NUR 265 EXAM 1 MEDICAL-SURGICAL NURSING EXAM QUESTIONS 2026 EXAM LATEST
VERSION SOLVED QUESTIONS & ANSWERS VERIFIED 100 %
NUR 265 Exam 1 Medical-Surgical Nursing — 250 Questions
SECTION 1: NURSING PROCESS & CLINICAL JUDGMENT (Q1–Q25)
1. A nurse is caring for a client who has just been admitted to the medical-surgical
unit with complaints of severe abdominal pain. Which action should the nurse take
first?
A. Administer the prescribed pain medication immediately
B. Complete a comprehensive pain assessment including location, quality, and severity
C. Document the client's complaint in the electronic health record
D. Notify the provider of the client's admission
Correct Answer: B
Rationale: Assessment is the first step of the nursing process and must precede any
intervention. The nurse must collect comprehensive data about the pain before
administering medication or notifying the provider. Documentation follows assessment
and intervention.
2. A nurse is developing a plan of care for a client who has impaired mobility. Which
outcome statement is written correctly according to SMART criteria?
A. "Client will feel better by tomorrow."
B. "Client will ambulate 50 feet with a walker by the end of the shift."
C. "Client should improve mobility soon."
D. "Client will be able to move without difficulty."
Correct Answer: B
Rationale: A correctly written goal is specific, measurable, attainable, realistic, and
time-bound. "Ambulate 50 feet with a walker by the end of the shift" meets all SMART
criteria. The other options are vague and not measurable.
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3. A nurse is reviewing a client's medical record and notes the following data: blood
pressure 142/88 mm Hg, heart rate 96 beats/min, and client states "I feel anxious."
Which of these findings is subjective data?
A. Blood pressure 142/88 mm Hg
B. Heart rate 96 beats/min
C. Client states "I feel anxious"
D. All of the above are subjective
Correct Answer: C
Rationale: Subjective data includes the client's verbal descriptions of their condition,
such as feelings, perceptions, and concerns. Blood pressure and heart rate are
objective, measurable findings. The client's statement about feeling anxious is
subjective.
4. A nurse is caring for a client who has a new diagnosis of diabetes mellitus. The
client states, "I don't know how I'm going to give myself shots every day." Which
nursing diagnosis is most appropriate?
A. Impaired Skin Integrity
B. Anxiety related to new diagnosis
C. Deficient Knowledge regarding insulin administration
D. Risk for Infection
Correct Answer: C
Rationale: The client's statement indicates a lack of understanding about how to
administer insulin injections. Deficient Knowledge is the most appropriate nursing
diagnosis. Anxiety may also be present, but the primary problem is knowledge deficit.
5. A nurse is evaluating the effectiveness of a client's care plan. Which action best
demonstrates the evaluation phase of the nursing process?
A. Administering pain medication as prescribed
B. Collecting a urine specimen for analysis
C. Determining whether the client's pain level has decreased after intervention
D. Documenting the client's vital signs
Correct Answer: C
Rationale: Evaluation involves determining whether the client's goals and outcomes
have been achieved. Comparing the client's pain level before and after intervention
demonstrates evaluation. Administering medication is implementation, collecting
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specimens is assessment, and documenting vital signs is a component of assessment
or implementation.
6. A nurse is prioritizing care for four clients at the beginning of a shift. Which client
should the nurse assess first?
A. A client who is scheduled for discharge and needs teaching
B. A client who reports new onset of chest pain and shortness of breath
C. A client who is requesting pain medication for chronic back pain
D. A client who needs assistance with ambulation to the bathroom
Correct Answer: B
Rationale: Using the ABC priority framework, new-onset chest pain and shortness of
breath indicate potential airway, breathing, or circulation compromise and must be
assessed first. Discharge teaching, chronic pain management, and ambulation
assistance are important but not immediately life-threatening.
7. A nurse is assessing a client who has been admitted with dehydration. Which
finding is an early indicator of fluid volume deficit?
A. Dry mucous membranes
B. Decreased urine output
C. Thirst
D. Sunken eyes
Correct Answer: C
Rationale: Thirst is the earliest indicator of dehydration. Dry mucous membranes,
decreased urine output, and sunken eyes are later signs of fluid volume deficit. Early
recognition allows prompt intervention.
8. A nurse is teaching a client about the purpose of the nursing process. Which
statement by the client indicates understanding?
A. "The nursing process helps ensure my care is organized and consistent."
B. "The nursing process is a one-time assessment that never changes."
C. "The nursing process only considers my physical needs."
D. "The nursing process replaces the need for medical treatment."
Correct Answer: A
Rationale: The nursing process provides a systematic, patient-centered framework for
delivering holistic care. It is dynamic and continuous, considers physical, emotional,
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and social needs, and works in collaboration with medical treatment, not as a
replacement.
9. A nurse is caring for a client who has been placed on seizure precautions. Which
action demonstrates the implementation phase of the nursing process?
A. Documenting the client's seizure history
B. Placing padding on the side rails of the bed
C. Determining whether the client has had any seizures
D. Planning when to administer antiseizure medication
Correct Answer: B
Rationale: Implementation involves carrying out the planned interventions. Placing
padding on the side rails is an action that implements the seizure precaution plan.
Assessment involves collecting data, planning involves developing goals and
interventions, and evaluation involves determining outcomes.
10. A nurse is using the SBAR communication tool to report a change in a client's
condition to the provider. Which information should the nurse include in the "A"
(Assessment) component?
A. The client's name, room number, and medical diagnosis
B. The nurse's clinical impression of the situation
C. The client's vital signs and current medications
D. The nurse's recommendation for what should be done
Correct Answer: B
Rationale: In SBAR, "A" stands for Assessment—the nurse's clinical impression or
conclusion about the situation. Situation includes identifying information, Background
includes vital signs and medications, and Recommendation is the nurse's suggestion.
11. A nurse is reviewing a client's laboratory results and notes a potassium level of
5.8 mEq/L. Which action should the nurse take first?
A. Document the finding and reassess in 4 hours
B. Obtain a 12-lead ECG and notify the provider
C. Administer sodium polystyrene sulfonate orally
D. Restrict dietary potassium intake
Correct Answer: B
Rationale: Hyperkalemia can cause life-threatening cardiac dysrhythmias. The first
