,NUR 170 Exam 1 | Concepts of Med-Surg Nursing
(2026/2027) PDF | Galen
1. A nurse is preparing to administer a blood transfusion. Which action should
the nurse take first?
A) Verify the blood product with a second nurse at the bedside
B) Obtain the client's baseline vital signs
C) Prime the tubing with 0.9 percent normal saline
D) Begin the transfusion at a slow rate
Correct Answer: Obtain the client's baseline vital signs
Rationale: Baseline vital signs must be obtained before initiating a blood
transfusion to provide a comparison for detecting transfusion reactions. While
verification with a second nurse is required, the nurse must first assess the
client's current status. Priming the tubing with normal saline is appropriate, but
baseline assessment is the priority.
2. What is the primary function of albumin in the vascular space?
A) To carry oxygen to tissues
B) To maintain oncotic pressure and hold fluid in the vascular space
C) To fight infection as part of the immune system
D) To clot blood during hemorrhage
,Correct Answer: To maintain oncotic pressure and hold fluid in the vascular
space
Rationale: Albumin is a plasma protein that exerts oncotic pressure, which
draws fluid into the capillaries and maintains intravascular volume. Low
albumin levels lead to edema as fluid leaks into interstitial spaces. Hemoglobin
carries oxygen, white blood cells fight infection, and platelets and clotting
factors facilitate hemostasis.
3. A client with renal failure is at risk for which electrolyte imbalance?
A) Hypercalcemia
B) Hyperkalemia
C) Hypokalemia
D) Hypophosphatemia
Correct Answer: Hyperkalemia
Rationale: The kidneys are responsible for excreting potassium. In renal failure,
potassium retention leads to hyperkalemia, which can cause cardiac
dysrhythmias and cardiac arrest. Calcium and phosphate imbalances also occur
in renal failure, but hyperkalemia is the most immediately life-threatening.
Hypokalemia is more common with diuretic use or gastrointestinal losses.
4. What is the most important nursing action to prevent central line-associated
bloodstream infections?
, A) Changing the dressing every 24 hours
B) Performing hand hygiene and using sterile technique during insertion and
care
C) Flushing the line with heparin daily
D) Administering prophylactic antibiotics
Correct Answer: Performing hand hygiene and using sterile technique during
insertion and care
Rationale: Central line-associated bloodstream infections are best prevented
through strict adherence to hand hygiene and sterile technique during insertion
and maintenance of the central line. Daily dressing changes are not required
unless the dressing is soiled or loose. Heparin flushing prevents occlusion, not
infection. Prophylactic antibiotics are not routinely recommended.
5. The nurse is assessing a client who is scheduled for surgery and has been NPO
since midnight. The client reports feeling weak and dizzy. Which action should
the nurse take first?
A) Administer a prescribed antiemetic
B) Obtain a blood glucose reading
C) Encourage the client to sip clear liquids
D) Reposition the client to a supine position
Correct Answer: Obtain a blood glucose reading
(2026/2027) PDF | Galen
1. A nurse is preparing to administer a blood transfusion. Which action should
the nurse take first?
A) Verify the blood product with a second nurse at the bedside
B) Obtain the client's baseline vital signs
C) Prime the tubing with 0.9 percent normal saline
D) Begin the transfusion at a slow rate
Correct Answer: Obtain the client's baseline vital signs
Rationale: Baseline vital signs must be obtained before initiating a blood
transfusion to provide a comparison for detecting transfusion reactions. While
verification with a second nurse is required, the nurse must first assess the
client's current status. Priming the tubing with normal saline is appropriate, but
baseline assessment is the priority.
2. What is the primary function of albumin in the vascular space?
A) To carry oxygen to tissues
B) To maintain oncotic pressure and hold fluid in the vascular space
C) To fight infection as part of the immune system
D) To clot blood during hemorrhage
,Correct Answer: To maintain oncotic pressure and hold fluid in the vascular
space
Rationale: Albumin is a plasma protein that exerts oncotic pressure, which
draws fluid into the capillaries and maintains intravascular volume. Low
albumin levels lead to edema as fluid leaks into interstitial spaces. Hemoglobin
carries oxygen, white blood cells fight infection, and platelets and clotting
factors facilitate hemostasis.
3. A client with renal failure is at risk for which electrolyte imbalance?
A) Hypercalcemia
B) Hyperkalemia
C) Hypokalemia
D) Hypophosphatemia
Correct Answer: Hyperkalemia
Rationale: The kidneys are responsible for excreting potassium. In renal failure,
potassium retention leads to hyperkalemia, which can cause cardiac
dysrhythmias and cardiac arrest. Calcium and phosphate imbalances also occur
in renal failure, but hyperkalemia is the most immediately life-threatening.
Hypokalemia is more common with diuretic use or gastrointestinal losses.
4. What is the most important nursing action to prevent central line-associated
bloodstream infections?
, A) Changing the dressing every 24 hours
B) Performing hand hygiene and using sterile technique during insertion and
care
C) Flushing the line with heparin daily
D) Administering prophylactic antibiotics
Correct Answer: Performing hand hygiene and using sterile technique during
insertion and care
Rationale: Central line-associated bloodstream infections are best prevented
through strict adherence to hand hygiene and sterile technique during insertion
and maintenance of the central line. Daily dressing changes are not required
unless the dressing is soiled or loose. Heparin flushing prevents occlusion, not
infection. Prophylactic antibiotics are not routinely recommended.
5. The nurse is assessing a client who is scheduled for surgery and has been NPO
since midnight. The client reports feeling weak and dizzy. Which action should
the nurse take first?
A) Administer a prescribed antiemetic
B) Obtain a blood glucose reading
C) Encourage the client to sip clear liquids
D) Reposition the client to a supine position
Correct Answer: Obtain a blood glucose reading
