NUR 170 Exam 1: Med Surg - Galen College of Nursing
Updated and Latest Questions and Correct Answers with
Rationale
1. A nurse is collecting data from a client and records the statement, “I feel short of breath when I walk to
the bathroom.” Which type of data is this?
A. Subjective data
B. Objective data
C. Secondary data
D. Inferred data
Correct Answer: A
Rationale: Subjective data consists of information that only the patient can perceive and describe to the
nurse. This includes the patient’s feelings, symptoms, or perceptions regarding their health status.
Objective data, conversely, involves measurable or observable signs such as blood pressure or lung
sounds. In this case, the feeling of shortness of breath is the patient’s personal experience. Identifying
subjective data accurately allows the nurse to build a comprehensive plan of care based on the patient’s
concerns.
2. A client is admitted with a serum sodium level of 128 mEq/L. Which clinical manifestation should the
nurse expect to observe?
A. Bounding pulse and hypertension
B. Dry mucous membranes and thirst
C. Muscle twitches and hyperreflexia
D. Confusion and lethargy
,Correct Answer: D
Rationale: Hyponatremia occurs when the serum sodium level falls below the normal range of 135 to
145 mEq/L. Low sodium levels cause water to move into the cells, leading to cerebral edema and
neurological symptoms. The nurse should anticipate signs such as confusion, headache, and decreased
level of consciousness in these patients. Other options like thirst or dry membranes are more indicative
of hypernatremia or dehydration. Monitoring safety is the primary nursing priority for a client with
significant electrolyte imbalances.
3. Which of the following interventions is a priority for a post-operative patient to prevent the development
of atelectasis?
A. Encouraging the use of an incentive spirometer
B. Administering prophylactic antibiotics
C. Maintaining a strict bed rest protocol
D. Restricting fluid intake to 1000 mL per day
Correct Answer: A
Rationale: The use of an incentive spirometer is critical for promoting deep breathing and lung
expansion after surgery. This device helps keep the alveoli open and prevents the collapse of lung tissue
known as atelectasis. Encouraging early ambulation and frequent repositioning also supports optimal
respiratory function in the post-operative period. Antibiotics do not prevent atelectasis, although they
may treat a secondary pneumonia. Nurses must educate patients on the proper technique of using the
spirometer to ensure maximum clinical benefit.
4. A nurse is caring for a client with a wound that has a small amount of yellow drainage and visible pink
tissue. How should the nurse document the tissue type?
A. Slough
, B. Eschar
C. Exudate
D. Granulation tissue
Correct Answer: D
Rationale: Granulation tissue is identified by its pinkish-red, moist, and granular appearance indicating
healthy healing. It consists of new blood vessels and connective tissue that fill the wound bed during the
proliferative phase. Slough appears as yellow or white stringy substance, while eschar is black or brown
necrotic tissue. Exudate is a general term for the fluid or drainage that comes from the wound. Proper
identification of wound bed characteristics is essential for selecting appropriate dressings and
monitoring progress.
5. When applying the nursing process, which action does the nurse perform during the ‘Evaluation’ phase?
A. Setting priorities for patient care
B. Determining if the patient’s goals were met
C. Performing a physical assessment
D. Implementing a new nursing intervention
Correct Answer: B
Rationale: The evaluation phase involves comparing the patient’s current health status against the
predefined goals and outcomes. This step helps the nurse determine if the nursing interventions were
effective or if the care plan needs revision. If the goals were not met, the nurse must analyze the factors
that hindered progress and adjust the plan accordingly. Assessment is the first step, while planning
involves setting priorities and goals. This systematic process ensures that patient care remains dynamic
and evidence-based throughout the hospital stay.
Updated and Latest Questions and Correct Answers with
Rationale
1. A nurse is collecting data from a client and records the statement, “I feel short of breath when I walk to
the bathroom.” Which type of data is this?
A. Subjective data
B. Objective data
C. Secondary data
D. Inferred data
Correct Answer: A
Rationale: Subjective data consists of information that only the patient can perceive and describe to the
nurse. This includes the patient’s feelings, symptoms, or perceptions regarding their health status.
Objective data, conversely, involves measurable or observable signs such as blood pressure or lung
sounds. In this case, the feeling of shortness of breath is the patient’s personal experience. Identifying
subjective data accurately allows the nurse to build a comprehensive plan of care based on the patient’s
concerns.
2. A client is admitted with a serum sodium level of 128 mEq/L. Which clinical manifestation should the
nurse expect to observe?
A. Bounding pulse and hypertension
B. Dry mucous membranes and thirst
C. Muscle twitches and hyperreflexia
D. Confusion and lethargy
,Correct Answer: D
Rationale: Hyponatremia occurs when the serum sodium level falls below the normal range of 135 to
145 mEq/L. Low sodium levels cause water to move into the cells, leading to cerebral edema and
neurological symptoms. The nurse should anticipate signs such as confusion, headache, and decreased
level of consciousness in these patients. Other options like thirst or dry membranes are more indicative
of hypernatremia or dehydration. Monitoring safety is the primary nursing priority for a client with
significant electrolyte imbalances.
3. Which of the following interventions is a priority for a post-operative patient to prevent the development
of atelectasis?
A. Encouraging the use of an incentive spirometer
B. Administering prophylactic antibiotics
C. Maintaining a strict bed rest protocol
D. Restricting fluid intake to 1000 mL per day
Correct Answer: A
Rationale: The use of an incentive spirometer is critical for promoting deep breathing and lung
expansion after surgery. This device helps keep the alveoli open and prevents the collapse of lung tissue
known as atelectasis. Encouraging early ambulation and frequent repositioning also supports optimal
respiratory function in the post-operative period. Antibiotics do not prevent atelectasis, although they
may treat a secondary pneumonia. Nurses must educate patients on the proper technique of using the
spirometer to ensure maximum clinical benefit.
4. A nurse is caring for a client with a wound that has a small amount of yellow drainage and visible pink
tissue. How should the nurse document the tissue type?
A. Slough
, B. Eschar
C. Exudate
D. Granulation tissue
Correct Answer: D
Rationale: Granulation tissue is identified by its pinkish-red, moist, and granular appearance indicating
healthy healing. It consists of new blood vessels and connective tissue that fill the wound bed during the
proliferative phase. Slough appears as yellow or white stringy substance, while eschar is black or brown
necrotic tissue. Exudate is a general term for the fluid or drainage that comes from the wound. Proper
identification of wound bed characteristics is essential for selecting appropriate dressings and
monitoring progress.
5. When applying the nursing process, which action does the nurse perform during the ‘Evaluation’ phase?
A. Setting priorities for patient care
B. Determining if the patient’s goals were met
C. Performing a physical assessment
D. Implementing a new nursing intervention
Correct Answer: B
Rationale: The evaluation phase involves comparing the patient’s current health status against the
predefined goals and outcomes. This step helps the nurse determine if the nursing interventions were
effective or if the care plan needs revision. If the goals were not met, the nurse must analyze the factors
that hindered progress and adjust the plan accordingly. Assessment is the first step, while planning
involves setting priorities and goals. This systematic process ensures that patient care remains dynamic
and evidence-based throughout the hospital stay.
