NUR 170 Final Exam: Med Surg - Galen College of Nursing
Updated and Latest Questions and Correct Answers with
Rationale
1. A post-operative patient shows signs of tachycardia, hypotension, and a urine output of less than 30
mL/hr. Which action should the nurse prioritize first?
A. Initiate intravenous fluid resuscitation
B. Administer prescribed analgesic for pain
C. Place the patient in a high-Fowler’s position
D. Perform a complete head-to-toe assessment
Correct Answer: A
Rationale: The patient is exhibiting classic clinical signs of hypovolemic shock requiring immediate
intervention. Administering IV fluids is the priority to restore circulating volume and stabilize blood
pressure. Failure to restore volume quickly can lead to permanent renal damage or organ failure.
Monitoring of heart rate and blood pressure helps evaluate the effectiveness of the fluid bolus. Rapid
stabilization is the core focus of emergency medical-surgical nursing care.
2. A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) receiving oxygen.
Which finding requires immediate intervention?
A. Oxygen flow rate set at 6 liters per minute via nasal cannula
B. A respiratory rate of 18 breaths per minute
C. Oxygen saturation level of 91% on room air
D. Expectoration of clear, thin mucoid sputum
Correct Answer: A
,Rationale: High concentrations of oxygen can suppress the hypoxic drive in patients with chronic COPD.
A flow rate of 6 liters is typically too high and can lead to carbon dioxide retention. Most COPD patients
have a target oxygen saturation range between 88 percent and 92 percent. The nurse must adjust the
flow to maintain the lowest effective dose for the patient. Protecting the respiratory drive is essential for
preventing respiratory arrest in these patients.
3. Which laboratory test is considered the most specific diagnostic marker for a patient suspected of having
congestive heart failure?
A. B-type Natriuretic Peptide (BNP)
B. Serum Troponin I and T
C. Creatine Kinase-MB (CK-MB)
D. Serum Potassium levels
Correct Answer: A
Rationale: BNP is a hormone secreted by the heart ventricles in response to excessive stretching and
volume overload. It serves as a highly specific biomarker to differentiate heart failure from other causes
of shortness of breath. Elevated BNP levels correlate directly with the severity of the patient’s heart
failure symptoms. Troponin and CK-MB are primarily markers for myocardial infarction rather than
congestive failure. Understanding laboratory values is crucial for accurate disease management in the
adult population.
4. A patient with type 1 diabetes mellitus is found confused, diaphoretic, and tremulous. What is the nurse’s
first action?
A. Administer 10 units of regular insulin subcutaneously
B. Provide 15 grams of simple carbohydrates by mouth
,C. Obtain a stat venous blood sample for glucose testing
D. Encourage the patient to drink 500 mL of plain water
Correct Answer: B
Rationale: Confused and diaphoretic states are primary indicators of hypoglycemia which require rapid
reversal to prevent seizures. The 15-15 rule involves giving 15 grams of fast-acting carbs and rechecking
levels in 15 minutes. Insulin would worsen the condition by further lowering the patient’s blood sugar
levels significantly. Immediate treatment should not be delayed by waiting for a laboratory blood draw
confirmation. Safety protocols mandate addressing the low glucose immediately to protect neurological
function.
5. A patient who underwent a total hip replacement 48 hours ago reports sudden onset of shortness of
breath and chest pain. What is the priority nursing suspicion?
A. Myocardial infarction
B. Pneumonia
C. Atelectasis
D. Pulmonary embolism
Correct Answer: D
Rationale: Post-operative patients are at a high risk for developing deep vein thrombosis and
subsequent pulmonary embolism. Sudden dyspnea and chest pain are the classic presenting symptoms of
a clot in the lung. Early mobilization and anticoagulation are standard evidence-based practices to
prevent this specific life-threatening complication. The nurse must stabilize the patient with oxygen and
notify the physician immediately for imaging. Pulmonary embolism management is a critical competency
in medical-surgical nursing care.
, 6. Which electrolyte abnormality is the nurse most concerned about for a patient in acute renal failure?
A. Hypokalemia
B. Hypercalcemia
C. Hyperkalemia
D. Hyponatremia
Correct Answer: C
Rationale: The kidneys are responsible for excreting potassium, so failure leads to dangerous
accumulations in the blood. Hyperkalemia can cause lethal cardiac arrhythmias such as ventricular
fibrillation or cardiac standstill. Monitoring the EKG for peaked T-waves is a priority assessment for these
specific patients. Dietary restrictions and medical management like Kayexalate or insulin are used to
lower levels. Electrolyte balance is a fundamental aspect of managing patients with compromised renal
function.
7. A patient is prescribed Lisinopril for hypertension. Which side effect should the nurse instruct the patient
to report immediately?
A. A metallic taste in the mouth
B. Mild dizziness upon standing
C. Increased urinary frequency
D. Dry, persistent cough
Correct Answer: D
Rationale: Lisinopril is an ACE inhibitor that can cause a build-up of bradykinin in the lungs. This often
leads to a dry, non-productive cough that can be distressing for the patient. While not life-threatening, it
often requires a change in medication to an Angiotensin II Receptor Blocker. The nurse must educate the
Updated and Latest Questions and Correct Answers with
Rationale
1. A post-operative patient shows signs of tachycardia, hypotension, and a urine output of less than 30
mL/hr. Which action should the nurse prioritize first?
A. Initiate intravenous fluid resuscitation
B. Administer prescribed analgesic for pain
C. Place the patient in a high-Fowler’s position
D. Perform a complete head-to-toe assessment
Correct Answer: A
Rationale: The patient is exhibiting classic clinical signs of hypovolemic shock requiring immediate
intervention. Administering IV fluids is the priority to restore circulating volume and stabilize blood
pressure. Failure to restore volume quickly can lead to permanent renal damage or organ failure.
Monitoring of heart rate and blood pressure helps evaluate the effectiveness of the fluid bolus. Rapid
stabilization is the core focus of emergency medical-surgical nursing care.
2. A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) receiving oxygen.
Which finding requires immediate intervention?
A. Oxygen flow rate set at 6 liters per minute via nasal cannula
B. A respiratory rate of 18 breaths per minute
C. Oxygen saturation level of 91% on room air
D. Expectoration of clear, thin mucoid sputum
Correct Answer: A
,Rationale: High concentrations of oxygen can suppress the hypoxic drive in patients with chronic COPD.
A flow rate of 6 liters is typically too high and can lead to carbon dioxide retention. Most COPD patients
have a target oxygen saturation range between 88 percent and 92 percent. The nurse must adjust the
flow to maintain the lowest effective dose for the patient. Protecting the respiratory drive is essential for
preventing respiratory arrest in these patients.
3. Which laboratory test is considered the most specific diagnostic marker for a patient suspected of having
congestive heart failure?
A. B-type Natriuretic Peptide (BNP)
B. Serum Troponin I and T
C. Creatine Kinase-MB (CK-MB)
D. Serum Potassium levels
Correct Answer: A
Rationale: BNP is a hormone secreted by the heart ventricles in response to excessive stretching and
volume overload. It serves as a highly specific biomarker to differentiate heart failure from other causes
of shortness of breath. Elevated BNP levels correlate directly with the severity of the patient’s heart
failure symptoms. Troponin and CK-MB are primarily markers for myocardial infarction rather than
congestive failure. Understanding laboratory values is crucial for accurate disease management in the
adult population.
4. A patient with type 1 diabetes mellitus is found confused, diaphoretic, and tremulous. What is the nurse’s
first action?
A. Administer 10 units of regular insulin subcutaneously
B. Provide 15 grams of simple carbohydrates by mouth
,C. Obtain a stat venous blood sample for glucose testing
D. Encourage the patient to drink 500 mL of plain water
Correct Answer: B
Rationale: Confused and diaphoretic states are primary indicators of hypoglycemia which require rapid
reversal to prevent seizures. The 15-15 rule involves giving 15 grams of fast-acting carbs and rechecking
levels in 15 minutes. Insulin would worsen the condition by further lowering the patient’s blood sugar
levels significantly. Immediate treatment should not be delayed by waiting for a laboratory blood draw
confirmation. Safety protocols mandate addressing the low glucose immediately to protect neurological
function.
5. A patient who underwent a total hip replacement 48 hours ago reports sudden onset of shortness of
breath and chest pain. What is the priority nursing suspicion?
A. Myocardial infarction
B. Pneumonia
C. Atelectasis
D. Pulmonary embolism
Correct Answer: D
Rationale: Post-operative patients are at a high risk for developing deep vein thrombosis and
subsequent pulmonary embolism. Sudden dyspnea and chest pain are the classic presenting symptoms of
a clot in the lung. Early mobilization and anticoagulation are standard evidence-based practices to
prevent this specific life-threatening complication. The nurse must stabilize the patient with oxygen and
notify the physician immediately for imaging. Pulmonary embolism management is a critical competency
in medical-surgical nursing care.
, 6. Which electrolyte abnormality is the nurse most concerned about for a patient in acute renal failure?
A. Hypokalemia
B. Hypercalcemia
C. Hyperkalemia
D. Hyponatremia
Correct Answer: C
Rationale: The kidneys are responsible for excreting potassium, so failure leads to dangerous
accumulations in the blood. Hyperkalemia can cause lethal cardiac arrhythmias such as ventricular
fibrillation or cardiac standstill. Monitoring the EKG for peaked T-waves is a priority assessment for these
specific patients. Dietary restrictions and medical management like Kayexalate or insulin are used to
lower levels. Electrolyte balance is a fundamental aspect of managing patients with compromised renal
function.
7. A patient is prescribed Lisinopril for hypertension. Which side effect should the nurse instruct the patient
to report immediately?
A. A metallic taste in the mouth
B. Mild dizziness upon standing
C. Increased urinary frequency
D. Dry, persistent cough
Correct Answer: D
Rationale: Lisinopril is an ACE inhibitor that can cause a build-up of bradykinin in the lungs. This often
leads to a dry, non-productive cough that can be distressing for the patient. While not life-threatening, it
often requires a change in medication to an Angiotensin II Receptor Blocker. The nurse must educate the
