NUR 265 Exam 1 Medical-Surgical
Nursing (2026-2027) PDF Nursing Galen
College
Fundamentals & Clinical Judgment
1. A nurse is assessing a client who reports sudden shortness of breath. Which assessment
should the nurse perform first?
A. Pain level
B. Airway and breathing
C. Dietary history
D. Sleep pattern
Answer: B
Rationale: Airway and breathing are immediate priorities because impaired oxygenation can
rapidly become life-threatening.
2. Which finding requires the most immediate intervention?
A. Temperature of 37.5°C
B. Heart rate of 88/min
C. Respiratory rate of 30/min with cyanosis
D. Blood pressure of 128/76 mmHg
Answer: C
Rationale: Tachypnea with cyanosis indicates impaired oxygenation and requires immediate
assessment.
3. Which finding is considered subjective data?
A. Blood pressure of 150/90 mmHg
B. Temperature of 38.5°C
C. Client reports severe nausea
D. Oxygen saturation of 91%
Answer: C
Rationale: Subjective data are symptoms reported by the client.
,4. A nurse is caring for four clients. Which client should be assessed first?
A. Client requesting assistance with bathing
B. Client with new-onset confusion and oxygen saturation of 86%
C. Client waiting for discharge instructions
D. Client reporting mild chronic back pain
Answer: B
Rationale: Hypoxemia accompanied by acute confusion may indicate serious respiratory
compromise.
5. Which nursing action best demonstrates clinical judgment?
A. Following every routine task in the same order
B. Recognizing a change in condition and determining the appropriate response
C. Completing documentation at the end of the shift
D. Waiting for another nurse to identify abnormalities
Answer: B
Rationale: Clinical judgment involves recognizing cues, interpreting findings, prioritizing
problems, and responding appropriately.
6. Which action is most effective for preventing healthcare-associated infections?
A. Wearing a mask for every client
B. Using sterile gloves for all procedures
C. Performing appropriate hand hygiene
D. Limiting visitors
Answer: C
Rationale: Proper hand hygiene is a fundamental measure for preventing transmission of
microorganisms.
7. A client is at risk for falling. Which intervention is appropriate?
A. Keep the bed in the highest position
B. Place frequently used items within reach
C. Encourage the client to walk without assistance
D. Keep the room dark at night
,Answer: B
Rationale: Keeping needed items and the call light within reach reduces unnecessary attempts
to get out of bed.
8. Which client statement indicates correct understanding of incentive spirometer use?
A. “I will breathe rapidly into the device.”
B. “I will use it only when I feel short of breath.”
C. “I will inhale slowly and deeply through the mouthpiece.”
D. “I should exhale forcefully into the device.”
Answer: C
Rationale: Slow, deep inhalation through an incentive spirometer promotes lung expansion.
9. Which position generally promotes lung expansion in a client experiencing dyspnea?
A. Supine
B. Trendelenburg
C. High-Fowler's
D. Prone
Answer: C
Rationale: High-Fowler's positioning facilitates chest expansion and can improve ventilation.
10. A nurse receives a report about a client with a new change in mental status. What is the
priority?
A. Document the finding later
B. Assess the client immediately
C. Ask the family to monitor the client
D. Wait for the next scheduled vital signs
Answer: B
Rationale: An acute mental-status change can indicate hypoxia, infection, metabolic
abnormalities, stroke, or another emergency.
Fluid & Electrolyte Balance
, 11. Which finding is most consistent with dehydration?
A. Peripheral edema
B. Moist mucous membranes
C. Poor skin turgor and concentrated urine
D. Bounding pulse
Answer: C
Rationale: Fluid deficit commonly causes dry mucous membranes, decreased urine output,
concentrated urine, and poor skin turgor.
12. Which finding suggests fluid volume excess?
A. Flat neck veins
B. Crackles in the lungs
C. Dry tongue
D. Decreased body weight
Answer: B
Rationale: Pulmonary crackles can occur when excess fluid accumulates in the lungs.
13. Which assessment is particularly useful for monitoring changes in fluid balance?
A. Daily body weight
B. Hair color
C. Pupil size
D. Visual acuity
Answer: A
Rationale: Daily weight is a sensitive indicator of changes in overall fluid balance.
14. A client has a serum potassium level of 2.8 mEq/L. Which finding should the nurse
anticipate?
A. Muscle weakness
B. Bounding pulse
C. Increased deep tendon reflexes
D. Severe hypertension
Nursing (2026-2027) PDF Nursing Galen
College
Fundamentals & Clinical Judgment
1. A nurse is assessing a client who reports sudden shortness of breath. Which assessment
should the nurse perform first?
A. Pain level
B. Airway and breathing
C. Dietary history
D. Sleep pattern
Answer: B
Rationale: Airway and breathing are immediate priorities because impaired oxygenation can
rapidly become life-threatening.
2. Which finding requires the most immediate intervention?
A. Temperature of 37.5°C
B. Heart rate of 88/min
C. Respiratory rate of 30/min with cyanosis
D. Blood pressure of 128/76 mmHg
Answer: C
Rationale: Tachypnea with cyanosis indicates impaired oxygenation and requires immediate
assessment.
3. Which finding is considered subjective data?
A. Blood pressure of 150/90 mmHg
B. Temperature of 38.5°C
C. Client reports severe nausea
D. Oxygen saturation of 91%
Answer: C
Rationale: Subjective data are symptoms reported by the client.
,4. A nurse is caring for four clients. Which client should be assessed first?
A. Client requesting assistance with bathing
B. Client with new-onset confusion and oxygen saturation of 86%
C. Client waiting for discharge instructions
D. Client reporting mild chronic back pain
Answer: B
Rationale: Hypoxemia accompanied by acute confusion may indicate serious respiratory
compromise.
5. Which nursing action best demonstrates clinical judgment?
A. Following every routine task in the same order
B. Recognizing a change in condition and determining the appropriate response
C. Completing documentation at the end of the shift
D. Waiting for another nurse to identify abnormalities
Answer: B
Rationale: Clinical judgment involves recognizing cues, interpreting findings, prioritizing
problems, and responding appropriately.
6. Which action is most effective for preventing healthcare-associated infections?
A. Wearing a mask for every client
B. Using sterile gloves for all procedures
C. Performing appropriate hand hygiene
D. Limiting visitors
Answer: C
Rationale: Proper hand hygiene is a fundamental measure for preventing transmission of
microorganisms.
7. A client is at risk for falling. Which intervention is appropriate?
A. Keep the bed in the highest position
B. Place frequently used items within reach
C. Encourage the client to walk without assistance
D. Keep the room dark at night
,Answer: B
Rationale: Keeping needed items and the call light within reach reduces unnecessary attempts
to get out of bed.
8. Which client statement indicates correct understanding of incentive spirometer use?
A. “I will breathe rapidly into the device.”
B. “I will use it only when I feel short of breath.”
C. “I will inhale slowly and deeply through the mouthpiece.”
D. “I should exhale forcefully into the device.”
Answer: C
Rationale: Slow, deep inhalation through an incentive spirometer promotes lung expansion.
9. Which position generally promotes lung expansion in a client experiencing dyspnea?
A. Supine
B. Trendelenburg
C. High-Fowler's
D. Prone
Answer: C
Rationale: High-Fowler's positioning facilitates chest expansion and can improve ventilation.
10. A nurse receives a report about a client with a new change in mental status. What is the
priority?
A. Document the finding later
B. Assess the client immediately
C. Ask the family to monitor the client
D. Wait for the next scheduled vital signs
Answer: B
Rationale: An acute mental-status change can indicate hypoxia, infection, metabolic
abnormalities, stroke, or another emergency.
Fluid & Electrolyte Balance
, 11. Which finding is most consistent with dehydration?
A. Peripheral edema
B. Moist mucous membranes
C. Poor skin turgor and concentrated urine
D. Bounding pulse
Answer: C
Rationale: Fluid deficit commonly causes dry mucous membranes, decreased urine output,
concentrated urine, and poor skin turgor.
12. Which finding suggests fluid volume excess?
A. Flat neck veins
B. Crackles in the lungs
C. Dry tongue
D. Decreased body weight
Answer: B
Rationale: Pulmonary crackles can occur when excess fluid accumulates in the lungs.
13. Which assessment is particularly useful for monitoring changes in fluid balance?
A. Daily body weight
B. Hair color
C. Pupil size
D. Visual acuity
Answer: A
Rationale: Daily weight is a sensitive indicator of changes in overall fluid balance.
14. A client has a serum potassium level of 2.8 mEq/L. Which finding should the nurse
anticipate?
A. Muscle weakness
B. Bounding pulse
C. Increased deep tendon reflexes
D. Severe hypertension
