NUR 170 Exam 4: Med Surg - Galen College of Nursing
Updated and Latest Questions and Correct Answers with
Rationale
1. A nurse is evaluating a client’s glycosylated hemoglobin (HbA1c) level of 8.5%. Which interpretation by
the nurse is correct?
A. The client has been compliant with their diabetic diet over the last 2 weeks.
B. The client requires an immediate dose of fast-acting insulin.
C. The client’s blood glucose has been poorly controlled over the last 3 months.
D. The result is within the normal therapeutic range for a diabetic patient.
Correct Answer: C
Rationale: The HbA1c test measures the average blood glucose concentration over the past 120 days. A
level of 8.5% indicates that the client’s blood sugar has been consistently elevated above the
recommended range. This diagnostic tool is more reliable than a single finger-stick glucose reading for
long-term monitoring. Therapeutic goals for most diabetic patients are usually set below 7.0%. The nurse
should use this data to discuss lifestyle modifications or medication adjustments with the provider.
2. The nurse is caring for a postoperative client who suddenly reports a ‘popping’ sensation at the
abdominal incision site. Upon inspection, the nurse notes internal organs are protruding through the
wound. What is the priority action?
A. Attempt to push the organs back into the abdominal cavity gently.
B. Apply a dry sterile dressing and call the surgeon immediately.
C. Cover the protruding organs with sterile dressings soaked in normal saline.
D. Place the client in a high-Fowler’s position to reduce pressure.
,Correct Answer: C
Rationale: Wound evisceration is a medical emergency that requires immediate nursing intervention.
The nurse must cover the exposed abdominal contents with sterile, saline-soaked gauze to prevent tissue
desiccation and infection. The client should be placed in a low-Fowler’s position with the knees flexed to
reduce abdominal wall tension. The nurse must stay with the client while another staff member notifies
the surgical team. Under no circumstances should the nurse attempt to re-insert the protruding organs
manually.
3. A client presents with a serum potassium level of 6.5 mEq/L. Which electrocardiogram (EKG) change is
the nurse most likely to observe?
A. Tall, peaked T waves
B. Prominent U waves
C. ST-segment depression
D. Shortened PR interval
Correct Answer: A
Rationale: Hyperkalemia is a critical electrolyte imbalance that can lead to fatal cardiac dysrhythmias.
Tall, peaked T waves are one of the earliest signs of elevated potassium on an EKG. As levels increase
further, the nurse may see a widened QRS complex or loss of P waves. Correcting the potassium level is
essential to prevent progress into ventricular fibrillation. The nurse should prioritize cardiac monitoring
for any client with a potassium level above the normal range.
4. Which clinical manifestation should the nurse expect when assessing a client with hypocalcemia?
A. Constipation and kidney stones
B. Hyporeflexia and muscle weakness
, C. Positive Trousseau’s sign
D. Shortened QT interval on EKG
Correct Answer: C
Rationale: Hypocalcemia increases neuromuscular excitability, leading to muscle twitching and spasms.
A positive Trousseau’s sign occurs when a carpal spasm is induced by inflating a blood pressure cuff. This
indicates a high risk for tetany and potential airway obstruction due to laryngeal spasms. The nurse must
monitor the client’s calcium levels and assess for numbness or tingling in the extremities. Emergency
equipment like a tracheostomy tray should be available if severe symptoms develop.
5. A client is admitted with a suspected thyroid storm. Which vital sign assessment finding requires the most
immediate intervention?
A. Blood pressure of 145/90 mmHg
B. Respiratory rate of 22 breaths per minute
C. Temperature of 104.5 degrees F (40.3 C)
D. Heart rate of 98 beats per minute
Correct Answer: C
Rationale: Thyroid storm is an extreme state of hyperthyroidism characterized by hyperpyrexia and
cardiovascular collapse. A temperature of 104.5 degrees F is a critical finding that can lead to seizures
and death. Management focuses on cooling the client and administering antithyroid medications like
propylthiouracil. The nurse should also expect to give beta-blockers to manage the associated
tachycardia. This condition is a life-threatening emergency that necessitates rapid stabilization in an
intensive care setting.
Updated and Latest Questions and Correct Answers with
Rationale
1. A nurse is evaluating a client’s glycosylated hemoglobin (HbA1c) level of 8.5%. Which interpretation by
the nurse is correct?
A. The client has been compliant with their diabetic diet over the last 2 weeks.
B. The client requires an immediate dose of fast-acting insulin.
C. The client’s blood glucose has been poorly controlled over the last 3 months.
D. The result is within the normal therapeutic range for a diabetic patient.
Correct Answer: C
Rationale: The HbA1c test measures the average blood glucose concentration over the past 120 days. A
level of 8.5% indicates that the client’s blood sugar has been consistently elevated above the
recommended range. This diagnostic tool is more reliable than a single finger-stick glucose reading for
long-term monitoring. Therapeutic goals for most diabetic patients are usually set below 7.0%. The nurse
should use this data to discuss lifestyle modifications or medication adjustments with the provider.
2. The nurse is caring for a postoperative client who suddenly reports a ‘popping’ sensation at the
abdominal incision site. Upon inspection, the nurse notes internal organs are protruding through the
wound. What is the priority action?
A. Attempt to push the organs back into the abdominal cavity gently.
B. Apply a dry sterile dressing and call the surgeon immediately.
C. Cover the protruding organs with sterile dressings soaked in normal saline.
D. Place the client in a high-Fowler’s position to reduce pressure.
,Correct Answer: C
Rationale: Wound evisceration is a medical emergency that requires immediate nursing intervention.
The nurse must cover the exposed abdominal contents with sterile, saline-soaked gauze to prevent tissue
desiccation and infection. The client should be placed in a low-Fowler’s position with the knees flexed to
reduce abdominal wall tension. The nurse must stay with the client while another staff member notifies
the surgical team. Under no circumstances should the nurse attempt to re-insert the protruding organs
manually.
3. A client presents with a serum potassium level of 6.5 mEq/L. Which electrocardiogram (EKG) change is
the nurse most likely to observe?
A. Tall, peaked T waves
B. Prominent U waves
C. ST-segment depression
D. Shortened PR interval
Correct Answer: A
Rationale: Hyperkalemia is a critical electrolyte imbalance that can lead to fatal cardiac dysrhythmias.
Tall, peaked T waves are one of the earliest signs of elevated potassium on an EKG. As levels increase
further, the nurse may see a widened QRS complex or loss of P waves. Correcting the potassium level is
essential to prevent progress into ventricular fibrillation. The nurse should prioritize cardiac monitoring
for any client with a potassium level above the normal range.
4. Which clinical manifestation should the nurse expect when assessing a client with hypocalcemia?
A. Constipation and kidney stones
B. Hyporeflexia and muscle weakness
, C. Positive Trousseau’s sign
D. Shortened QT interval on EKG
Correct Answer: C
Rationale: Hypocalcemia increases neuromuscular excitability, leading to muscle twitching and spasms.
A positive Trousseau’s sign occurs when a carpal spasm is induced by inflating a blood pressure cuff. This
indicates a high risk for tetany and potential airway obstruction due to laryngeal spasms. The nurse must
monitor the client’s calcium levels and assess for numbness or tingling in the extremities. Emergency
equipment like a tracheostomy tray should be available if severe symptoms develop.
5. A client is admitted with a suspected thyroid storm. Which vital sign assessment finding requires the most
immediate intervention?
A. Blood pressure of 145/90 mmHg
B. Respiratory rate of 22 breaths per minute
C. Temperature of 104.5 degrees F (40.3 C)
D. Heart rate of 98 beats per minute
Correct Answer: C
Rationale: Thyroid storm is an extreme state of hyperthyroidism characterized by hyperpyrexia and
cardiovascular collapse. A temperature of 104.5 degrees F is a critical finding that can lead to seizures
and death. Management focuses on cooling the client and administering antithyroid medications like
propylthiouracil. The nurse should also expect to give beta-blockers to manage the associated
tachycardia. This condition is a life-threatening emergency that necessitates rapid stabilization in an
intensive care setting.
