NUR 265 Exam 1: Nur Med Surg - Galen College of Nursing
Updated and Latest Questions and Correct Answers with
Rationale
1. A nurse is caring for a patient whose laboratory results show a serum potassium level of 3.0 mEq/L.
Which action should the nurse take first?
A. Administer a potassium supplement orally as ordered.
B. Notify the provider and request an electrocardiogram (ECG).
C. Assess the patient’s deep tendon reflexes.
D. Document the finding as a normal result for the patient.
Correct Answer: B
Rationale: Hypokalemia is a critical electrolyte imbalance that can lead to life-threatening cardiac
dysrhythmias. The nurse must first ensure the heart’s electrical activity is monitored via an ECG to
identify dangerous changes. While oral supplements may be given later, the priority is assessing for
immediate cardiac risk. Other signs like muscle weakness or decreased reflexes are secondary to cardiac
stability. Always remember that ‘potassium’ and ‘heart’ are linked in nursing priorities.
2. A patient with a history of heart failure presents with jugular venous distention, peripheral edema, and a
weight gain of 5 lbs in two days. Which fluid imbalance does the nurse suspect?
A. Fluid volume deficit
B. Isotonic dehydration
C. Hypovolemic shock
D. Fluid volume excess
Correct Answer: D
,Rationale: Fluid volume excess occurs when the body retains sodium and water in the extracellular
compartment. Clinical signs include rapid weight gain, edema, and distended neck veins due to increased
intravascular pressure. The nurse must recognize that weight changes are the most reliable indicator of
fluid status in heart failure. Diuretics are commonly prescribed to manage this condition and reduce the
workload on the heart. Assessment of lung sounds for crackles is also vital to detect pulmonary
congestion.
3. Which precaution should the nurse implement for a patient admitted with a confirmed Clostridium
difficile (C. diff) infection?
A. Contact precautions
B. Droplet precautions
C. Airborne precautions
D. Standard precautions only
Correct Answer: A
Rationale: Contact precautions are required for organisms spread by direct or indirect contact, such as C.
diff. The nurse must wear gloves and a gown when entering the room to prevent cross-contamination.
Hand hygiene must be performed with soap and water because alcohol-based rubs do not kill C. diff
spores. Dedicated equipment should be used for the patient to minimize the spread of the infection.
Environmental cleaning with bleach-based solutions is also necessary for this specific pathogen.
4. A nurse is monitoring a patient receiving 3% sodium chloride intravenously. Which assessment finding
requires immediate intervention?
A. Increased urine output
B. Improved level of consciousness
, C. Crackles in the lung bases
D. Sodium level of 136 mEq/L
Correct Answer: C
Rationale: Hypertonic solutions like 3% sodium chloride pull fluid from the cells into the vascular space.
This rapid shift increases the risk of pulmonary edema and fluid volume overload in the patient. Crackles
in the lungs are an early sign that the heart cannot handle the increased fluid volume. The nurse must
stop the infusion and notify the provider immediately to prevent respiratory distress. Monitoring
neurological status is also crucial because hypertonic fluids can cause cerebral shrinkage.
5. When assessing a patient for Trousseau’s sign, which technique should the nurse use?
A. Tap the facial nerve in front of the ear.
B. Inflate a blood pressure cuff on the upper arm for several minutes.
C. Assess for hyperactive deep tendon reflexes.
D. Palpate the patient’s calf for tenderness and warmth.
Correct Answer: B
Rationale: Trousseau’s sign is a clinical indicator of hypocalcemia that involves carpal spasm induced by
ischemia. The nurse inflates a blood pressure cuff above the systolic pressure to trigger the spasm. This
occurs because low calcium levels increase neuromuscular irritability and excitability. Chvostek’s sign,
which involves tapping the facial nerve, is another assessment for the same condition. Identifying these
signs early helps prevent complications like tetany or seizures.
6. A patient is admitted with a diagnosis of dehydration. Which laboratory result is the nurse most likely to
find?
A. Decreased serum sodium
Updated and Latest Questions and Correct Answers with
Rationale
1. A nurse is caring for a patient whose laboratory results show a serum potassium level of 3.0 mEq/L.
Which action should the nurse take first?
A. Administer a potassium supplement orally as ordered.
B. Notify the provider and request an electrocardiogram (ECG).
C. Assess the patient’s deep tendon reflexes.
D. Document the finding as a normal result for the patient.
Correct Answer: B
Rationale: Hypokalemia is a critical electrolyte imbalance that can lead to life-threatening cardiac
dysrhythmias. The nurse must first ensure the heart’s electrical activity is monitored via an ECG to
identify dangerous changes. While oral supplements may be given later, the priority is assessing for
immediate cardiac risk. Other signs like muscle weakness or decreased reflexes are secondary to cardiac
stability. Always remember that ‘potassium’ and ‘heart’ are linked in nursing priorities.
2. A patient with a history of heart failure presents with jugular venous distention, peripheral edema, and a
weight gain of 5 lbs in two days. Which fluid imbalance does the nurse suspect?
A. Fluid volume deficit
B. Isotonic dehydration
C. Hypovolemic shock
D. Fluid volume excess
Correct Answer: D
,Rationale: Fluid volume excess occurs when the body retains sodium and water in the extracellular
compartment. Clinical signs include rapid weight gain, edema, and distended neck veins due to increased
intravascular pressure. The nurse must recognize that weight changes are the most reliable indicator of
fluid status in heart failure. Diuretics are commonly prescribed to manage this condition and reduce the
workload on the heart. Assessment of lung sounds for crackles is also vital to detect pulmonary
congestion.
3. Which precaution should the nurse implement for a patient admitted with a confirmed Clostridium
difficile (C. diff) infection?
A. Contact precautions
B. Droplet precautions
C. Airborne precautions
D. Standard precautions only
Correct Answer: A
Rationale: Contact precautions are required for organisms spread by direct or indirect contact, such as C.
diff. The nurse must wear gloves and a gown when entering the room to prevent cross-contamination.
Hand hygiene must be performed with soap and water because alcohol-based rubs do not kill C. diff
spores. Dedicated equipment should be used for the patient to minimize the spread of the infection.
Environmental cleaning with bleach-based solutions is also necessary for this specific pathogen.
4. A nurse is monitoring a patient receiving 3% sodium chloride intravenously. Which assessment finding
requires immediate intervention?
A. Increased urine output
B. Improved level of consciousness
, C. Crackles in the lung bases
D. Sodium level of 136 mEq/L
Correct Answer: C
Rationale: Hypertonic solutions like 3% sodium chloride pull fluid from the cells into the vascular space.
This rapid shift increases the risk of pulmonary edema and fluid volume overload in the patient. Crackles
in the lungs are an early sign that the heart cannot handle the increased fluid volume. The nurse must
stop the infusion and notify the provider immediately to prevent respiratory distress. Monitoring
neurological status is also crucial because hypertonic fluids can cause cerebral shrinkage.
5. When assessing a patient for Trousseau’s sign, which technique should the nurse use?
A. Tap the facial nerve in front of the ear.
B. Inflate a blood pressure cuff on the upper arm for several minutes.
C. Assess for hyperactive deep tendon reflexes.
D. Palpate the patient’s calf for tenderness and warmth.
Correct Answer: B
Rationale: Trousseau’s sign is a clinical indicator of hypocalcemia that involves carpal spasm induced by
ischemia. The nurse inflates a blood pressure cuff above the systolic pressure to trigger the spasm. This
occurs because low calcium levels increase neuromuscular irritability and excitability. Chvostek’s sign,
which involves tapping the facial nerve, is another assessment for the same condition. Identifying these
signs early helps prevent complications like tetany or seizures.
6. A patient is admitted with a diagnosis of dehydration. Which laboratory result is the nurse most likely to
find?
A. Decreased serum sodium
