,NUR 242 Exam 1 | Med-Surg Concepts (2026/2027) PDF
| Nursing | Galen College
1. Which of the following best describes the primary purpose of the nursing
process in medical-surgical nursing?
A) To diagnose and treat medical diseases independently
B) To provide a systematic framework for delivering individualized patient care
C) To prescribe medications and treatments without provider orders
D) To replace the need for clinical judgment in nursing practice
Correct Answer: To provide a systematic framework for delivering individualized
patient care
Rationale: The nursing process is a systematic, five-step framework
(assessment, diagnosis, planning, implementation, evaluation) that guides
nurses in delivering holistic, patient-centered care. It promotes clinical
reasoning and individualized interventions rather than rigid standardization. It
does not diagnose medical diseases, prescribe treatments independently, or
replace clinical judgment.
2. What is the primary function of the assessment phase in the nursing process?
A) To establish patient goals and expected outcomes
B) To systematically collect and analyze patient data
C) To implement nursing interventions based on evidence
D) To evaluate the effectiveness of nursing care
,Correct Answer: To systematically collect and analyze patient data
Rationale: The assessment phase is the first step of the nursing process,
involving the systematic collection of subjective and objective data through
history taking, physical examination, and diagnostic testing. This data forms the
foundation for identifying patient problems and planning care. Goal setting
occurs during planning, implementation involves carrying out interventions, and
evaluation determines whether outcomes were met.
3. According to the NCSBN Clinical Judgment Measurement Model, which layer
immediately follows "Analyze Cues"?
A) Take Actions
B) Recognize Cues
C) Prioritize Hypotheses
D) Evaluate Outcomes
Correct Answer: Prioritize Hypotheses
Rationale: The NCSBN CJMM consists of six layers: Recognize Cues, Analyze
Cues, Prioritize Hypotheses, Generate Solutions, Take Actions, and Evaluate
Outcomes. After analyzing cues, the nurse prioritizes hypotheses to determine
which patient problems are most urgent. Taking actions and evaluating
outcomes occur later in the model.
4. A nurse is caring for a client who is 24 hours postoperative from abdominal
surgery. Which finding requires immediate intervention?
, A) A temperature of 37.8 degrees Celsius
B) A heart rate of 96 beats per minute
C) A urinary output of 20 mL per hour
D) A blood pressure of 118/76 mmHg
Correct Answer: A urinary output of 20 mL per hour
Rationale: Urinary output below 30 mL per hour indicates inadequate renal
perfusion and may signal hypovolemia, shock, or urinary tract obstruction.
Immediate intervention is required to prevent acute kidney injury. A low-grade
temperature and mild tachycardia are common postoperative findings. A blood
pressure of 118/76 mmHg is within normal limits.
5. Which term refers to the movement of a body part toward the midline of the
body?
A) Abduction
B) Flexion
C) Adduction
D) Extension
Correct Answer: Adduction
Rationale: Adduction is the movement of a limb toward the midline of the body.
Abduction is movement away from the midline. Flexion decreases the angle
| Nursing | Galen College
1. Which of the following best describes the primary purpose of the nursing
process in medical-surgical nursing?
A) To diagnose and treat medical diseases independently
B) To provide a systematic framework for delivering individualized patient care
C) To prescribe medications and treatments without provider orders
D) To replace the need for clinical judgment in nursing practice
Correct Answer: To provide a systematic framework for delivering individualized
patient care
Rationale: The nursing process is a systematic, five-step framework
(assessment, diagnosis, planning, implementation, evaluation) that guides
nurses in delivering holistic, patient-centered care. It promotes clinical
reasoning and individualized interventions rather than rigid standardization. It
does not diagnose medical diseases, prescribe treatments independently, or
replace clinical judgment.
2. What is the primary function of the assessment phase in the nursing process?
A) To establish patient goals and expected outcomes
B) To systematically collect and analyze patient data
C) To implement nursing interventions based on evidence
D) To evaluate the effectiveness of nursing care
,Correct Answer: To systematically collect and analyze patient data
Rationale: The assessment phase is the first step of the nursing process,
involving the systematic collection of subjective and objective data through
history taking, physical examination, and diagnostic testing. This data forms the
foundation for identifying patient problems and planning care. Goal setting
occurs during planning, implementation involves carrying out interventions, and
evaluation determines whether outcomes were met.
3. According to the NCSBN Clinical Judgment Measurement Model, which layer
immediately follows "Analyze Cues"?
A) Take Actions
B) Recognize Cues
C) Prioritize Hypotheses
D) Evaluate Outcomes
Correct Answer: Prioritize Hypotheses
Rationale: The NCSBN CJMM consists of six layers: Recognize Cues, Analyze
Cues, Prioritize Hypotheses, Generate Solutions, Take Actions, and Evaluate
Outcomes. After analyzing cues, the nurse prioritizes hypotheses to determine
which patient problems are most urgent. Taking actions and evaluating
outcomes occur later in the model.
4. A nurse is caring for a client who is 24 hours postoperative from abdominal
surgery. Which finding requires immediate intervention?
, A) A temperature of 37.8 degrees Celsius
B) A heart rate of 96 beats per minute
C) A urinary output of 20 mL per hour
D) A blood pressure of 118/76 mmHg
Correct Answer: A urinary output of 20 mL per hour
Rationale: Urinary output below 30 mL per hour indicates inadequate renal
perfusion and may signal hypovolemia, shock, or urinary tract obstruction.
Immediate intervention is required to prevent acute kidney injury. A low-grade
temperature and mild tachycardia are common postoperative findings. A blood
pressure of 118/76 mmHg is within normal limits.
5. Which term refers to the movement of a body part toward the midline of the
body?
A) Abduction
B) Flexion
C) Adduction
D) Extension
Correct Answer: Adduction
Rationale: Adduction is the movement of a limb toward the midline of the body.
Abduction is movement away from the midline. Flexion decreases the angle
