Exam 2 V2: NUR170 / NUR 170 (Latest 2026/2027 Update) Concepts of Medical-Surgical Nursing | Questions & Answers | 100% Correct | Galen

Exam 2 V2: NUR170 / NUR 170 (Latest 2026/2027 Update) Concepts of Medical-Surgical Nursing | Questions & Answers | 100% Correct | Galen Q: A charge nurse is reviewing outcome statements written by a novice nurse. The nurse is using the SMART approach. Which patient outcome statement will the charge nurse identify as appropriate to the new nurse? Answer The patient will feed self at all mealtimes today without reports of shortness of breath. Q: A nurse develops a nursing diagnostic statement for a patient with a medical diagnosis of pneumonia with chest x-ray results lower lobe infiltrates. Which nursing diagnosis is written correctly? Answer Impaired gas exchange related to alveolar-capillary membrane changes as evidenced by oxygen saturation of 88% on room air. Q: A nurse is evaluating an expected outcome for a patient that states heart rate will be less than 80 beats/min by 12/3. Which finding will alert the nurse that the goal has been met? Answer Heart rate 78 beats/min on 12/3 Q: A nurse makes a nursing diagnosis of acute pain related to the postoperative abdominal incision. The nurse writes a nursing order to reposition the client in a comfortable by using pillows to splint or support the painful areas. Which type of nursing intervention did the nurse write? Answer Collaborative Q: Using Maslow's hierarchy of needs, rank the following nursing diagnosis in order of importance, beginning with the highest-priority diagnosis: 1. Risk for Infection 2. Diarrhea 3. Disturbed Body Image 4. Impaired Gas Exchange Answer 1. Impaired Gas Exchange 2. Diarrhea 3. Risk for Infection 4. Disturbed Body Image Q: The nurse recognizes which examples of objective data? Answer Blood pressure of 120/80 mmHG Moderate amount of yellow drainage from right ear. Q: A charge nurse is making patient care assignments. Which of the following tasks should the nurse delegate to assistive personnel (AP)? Answer Bathe patient who had an amputation 2 days ago. Assist a patient to ambulate using a gait belt. Feed a patient who had a stroke 3 months ago. Q: A nurse is caring for a patient prescribed IV therapy. Which task will the nurse assign to the nursing assistive personnel? Answer Recording intake and output Q: A charge nurse is delegating tasks to other staff members on the floor including a LPN. Which task should the charge nurse delegate to the LPN? Answer Providing nasopharyngeal suctioning for a patient who has pneumonia. Q: The staff nurse provides care to a stable patient who is newly diagnosed with diabetes. The patient is being prepared to discharge from the hospital. To promote efficiency, the staff nurse delegates care to a UAP. Which task must be completed by the staff nurse? Answer Teaching the patient about symptoms of hypoglycemia. Q: Which of the following activities would be outside the scope of practice for a RN? Answer Writing orders for laboratory tests. Q: It would be a violation of the nurse practice act for an RN to? Answer Delegate assessment to an LPN Q: How many hours of continuing education must a RN get every 2 years? Answer 20 CE Q: RNs can delegate medication administration to other licensed nurses or unlicensed personnel (in-home setting) for oral/subcutaneous/topical/transdermal medications if delegation conditions are met? Answer True Q: RNs may not delegate interventions as part of patient care AFTER completing a comprehensive nursing assessment. After assessment, care coordination may communicate in person, via telephone, or electronically? Answer False Q: LPNs or unlicensed personnel can re-delegate a nursing intervention assigned to them? Answer False Q: Which tasks are part of the RNs scope of practice? Answer Analyzing comprehensive nursing assessment data to determine actual or potential diagnoses, problems, and issues. Delegating nursing interventions to implement the plan of care. Advocating for the patient. Utilizing appropriate resources to plan, provide, and sustain evidence-based nursing services that are safe and effective. Q: A nurse who has a valid license in one state is planning to move to another state. Which action should the nurse take to obtain reciprocity? Answer Apply for a new license in the new state. Q: A nurse just got caught stealing narcotics from the hospital. What consequences can the State of Illinois do to the Nurses License? Answer Suspension Disciplinary Action Refusal to renew a license Q: Definitions related to the Nurse Practice Act: Answer RN: A person who is licensed as a professional nurse under the act and practices nursing as defined by the act. Impaired Nurse: Means a nurse licensed under the act who is unable to practice with reasonable judgement, skills, and safety because of a physical or mental disability. Collaboration: Means a process involving 2 or more healthcare professionals working together, each contributing ones respective area of expertise to provide more comprehensive patient care. Delegation: Means transferring to a specific individual the authority to perform a specific nursing intervention in a specific situation. Stability: Means a registered professional nurse or advanced practice registered nurse has determined that the individuals clinical status and nursing care needs are consistent. Q: Which tip would help the RN appropriately delegate patient care to AP? Answer Listen attentively to the AP Communicate clearly with the AP Assess the knowledge and skills of the AP The charge nurse on a surgical unit is making staff assignments for the 3-11 shift. Which patient would be assigned to the LPN? Answer The patient who had a vaginal hysterectomy 2 days ago and is being discharged tomorrow. Which task is appropriate for a RN to delegate to the nursing assistant? Answer Assisting the patient to the bathroom. Which task is appropriate for the nurse to delegate to the AP? Answer Obtain and record vital signs. The nurse would expect which signs and symptoms for a patient with a suspected UTI? Answer Urinary frequency Dysuria Foul-smelling urine A patient is admitted with blood urea nitrogen (BUN) and creatinine levels, as well as anuria. Based on these findings, the nurse suspects which diagnosis? Renal Failure The nurse educator is preparing a teaching plan on preventing UTIs for a group of female college students. Which information will the nurse include in the plan? Avoid tight-fitting clothes over the groin area The nurse educator is preparing a teaching plan on preventing UTIs for a group of female college students. What information will the nurse include in the plan? Empty bladder soon after sexual intercourse Urinate when you first feel the urge to void Avoid tight fitting clothes over the groin area Which urine specific gravity would be expected in a patient with dehydration? 1.040 The nurse associates which assessment finding in the diabetic patient with decreasing renal function? Protein in the urine during a random urinalysis. An older adult comes into the emergency room with diarrhea that has been going for 2 days. Which of the following is a complication with diarrhea? Potassium Imbalance A patient has a history of chronic constipation. Which medications prescribed to the patient would alert the nurse to be especially vigilant in observing for constipation and teach them about preventive measure? Opiates Which factors place the patient at risk for constipation? Sedentary Lifestyle High-dose calcium supplements The mother of a 3-month old infant comes into the ER and states "My baby has been having severe diarrhea for 4 days. She is crying all the time." In formulating a plan of care for diarrhea, the nurse focuses on outcomes of which of the following? Fluid management Electrolyte balance Skin integrity What is the Glasgow Coma Scale and what does it measure? The GCS measured level of consciousness and is scored from 3 to 15, with 3 being the worst and 15 being the best. The score is calculated by adding together the scores from each of the three categories: eye opening, motor response, and verbal response What are miotics? Drug that causes the pupil to constrict, decreasing IOP What are mydriatics? Drug that cause the pupil to dilate, increasing IOP What is presbyopia? Presbyopia is a common age-related disorder that results from the ciliary muscles becoming less flexible and functional, effecting the patient's ability to see close up. Usually begins around age 40. What are cataracts? A clouding of the eye's lens that can lead to vision loss. As the crystalline lens becomes more dense, light cannot reach the macula where vision is the clearest, causing eyesight to appear cloudy. ~The exact cause is unknown, but possible causes are: congenital (present at birth), trauma, disease, steroid use, over-exposure to UV light What are the 3 stages of cataracts? 1. Immature: Lens is lightly cloudy and the cortex is mostly clear 2. Mature: Lens is entirely cloudy and can be removed easily from its capsule 3. Hyper mature: The normal lens protein is degraded and absorbed or escapes, lens is yellow, shrunken, and the capsule is wrinkled. TRUE OR FALSE: "The lens can spontaneously dislocate and cause acute angle-closure glaucoma." TRUE Symptoms of Cataracts - Distorted, hazy, or yellow vision. - Poor night vision - Glare is an issue because the light rays are scattered What is cataract surgery? -Procedure to remove the lens of the eye and, in most cases, replace it with an artificial lens *Surgery is 95% successful *Most frequently preformed in people aged 65+ *Usually done in an outpatient setting; eye centers *Local anesthetic-safe What are the 2 cataract surgery removal methods? 1. Extracapsular extraction (ECCE) * 98% of all procedures, used for mature cataract removal, remember: "E for EASY removal" 2. Intracapsular extraction (ICCE) * Used for about 10% of hyper-mature cataract, remember: "I for ICKY removal" Sharp sudden pain in the eye could be a sign of what? Hemorrhage or increased IOP Post-Op Complications of cataract surgery - Lens dislocation - Infection What is glaucoma? Disease of the optic nerve damage, caused by increased pressure of aqueous humor * Occurs in the front portion of the eye * Leading cause of blindness in the U.S. * Affects 2 million people in the U.S. TRUE OR FALSE: If glaucoma is left untreated, the central vision is lost, then peripheral vision. FALSE: Peripheral vision is lost first, THEN central vision Is glaucoma asymptomatic or symptomatic? Glaucoma can often remains asymptomatic until extensive damage has already been done to the optic nerve (cannot regenerate). This is why it is important to keep up with routine eye exams that include measurements of your eye pressure, that way it can be diagnosed as early as possible. What is a normal Intraocular Pressure (IOP)? 10-21 mm Hg What is open-angle glaucoma? The drainage angle of the eye becomes less efficient over time (decrease in outflow) and the pressure in the eye increases. * Occurs over time; gradual, chronic, bilateral * Most common of the 2 types * Symptoms are vague and care may not be sought until after changes are noticed in vision Symptoms of open-angle glaucoma? - Tired eyes - Headaches at bedtime or awakening - Transient blurred vision - Halo around lights - Gradual loss of peripheral vision - Poor vision at night What are some nursing interventions of open-angle glaucoma? - Teach patient the importance of routine eye exams (usually every 6-12 months) - Educate patient about eyedrop compliance - People with glaucoma should wear medi-alert bracelet - Educate patient about glaucoma. What is acute angle-closure glaucoma? Acute angle-closure glaucoma is a medical emergency where the drainage angle of the eye suddenly becomes blocked, leading to a rapid increase in intraocular pressure. *Uncommon *EMERGENCY: blindness can occur if left untreated from 3-4 days. Symptoms of acute angle-closure glaucoma? - Sudden, severe pain, in and around the eye - Photophobia - Blurred Vision - Increased IOP Treatments for acute angle-closure glaucoma? - Osmotic diuretics - mannitol or glycerin po - Miotics and carbonic anhydrase inhibitors - Surgery, laser trabeculoplasty may be neccesary What is macular degeneration? - Progressive loss of central vision, due to damage or deterioration of the photoreceptor cells in the area of the macula. *NO CURE *CAUSE: Unknown, Genetically linked. *Leading cause of blindness in people older than 55 years old. What are the 2 types of macular degeneration? WET: *Rapid vision loss *Abnormal new blood vessels grow under the retina *May leak, bleed, or scar the retina *Distorts vision *One eye may affect the other eye later DRY: *Slow vision loss *Most common form of MD *Gradual breakdown of cells in the macula *Blurred vision *Single or multiple small, round, yellow-white spots called DRUSEN are key identifiers for the dry type How do you assess cranial nerve: I (olfactory) ask the patient to identify different smells How do you assess cranial nerve: II (optic) test visual activity with snellen chart How do you assess cranial nerve: III (oculomotor), IV ( trochlear), & VI (abducens) III: check for pupil size and reactiveness to light with pen light. IV: ask patient to follow your finger with their eyes only in an "H" pattern to test extraocular movements, VI: follow pen side to side How do you assess cranial nerve: V (trigeminal) -Ask the patient to close their eyes and report when they feel the touch. Lightly touch the forehead, cheek, and jaw on both sides. - Ask the patient to clench their teeth while you palpate the masseter and temporalis muscles to assess strength. How do you assess cranial nerve: VII (facial) ask patient to smile, frown, or puff out their cheeks. How do you assess cranial nerve: VIII (vestibulocochlear) check hearing, rub fingers near patients ears, ask what side they hear it on (left or right) How do you assess cranial nerve: IX (glossopharyngeal) have patient open mouth and say "ahhh", check for uvula movement, test gag reflex How do you assess cranial nerve: X (vagus) assess swallowing and speech How do you assess cranial nerve: XI (accessory) ask patient to move head side to side, up and down, then ask patient to shrug shoulders against your resistance How do you assess cranial nerve: XII (hypoglossal) have patient stick out tongue and move it side to side. this assesses tongue strength and symmetry Name some common causes of constipation. low fiber diet, sedentary lifestyle, constant or daily laxative usage, not drinking enough water What is the term for involuntary loss of urine (happens especially when coughing, sneezing, or sudden movements) urinary stress incontinence What is the term for painful urination? Dysuria What is the term for peeing at night? Nocturia What is the term for low urine output? Oliguria 30mL/hr, 500mL/day What does the term 'anuria' mean? a condition where the body produces little to no urine. What is the minimum urine output for adults per hour? 30mL/hr What are the characteristics of normal urine? Pale yellow, straw colored, faint smell, clear What are the characteristics of abnormal urine? dark, tea colored, purulent, thick, foamy, sediment What is the term for excessive thirst? polydipsia What factors can effect urination? medications, time, privacy, age What does the term 'enuresis' mean? bedwetting (typically young children but it can be an issue for adults too) What is 'urge incontinence'? Overactive bladder- the loss of urine as soon as you feel the urge to go to the bathroom. What is 'functional incontinence'? -Loss of sphincter control *Form of urinary incontinence in which a person is usually aware of the need to urinate, but for one or more physical or mental reasons they are unable to get to a bathroom. The loss of urine can vary, from small leakages to full emptying of the bladder. What is the typical age frame for bedwetting? 6-10 years old What is the typical potty training age range? 2-5 years old What does the term 'flatus' mean? gas (7-10L/day) What is 'bowel obstruction'? A partial or complete blockage of the small or large intestine that prevents food, fluids, and gas from passing through normally. (high bowel) What is 'bowel impaction'? When a large, hard, dry stool gets stuck in the rectum or colon What is 'peristalsis'? Wave-like muscle contractions that move food through the digestive tract What is 'C. Diff'? Overgrowth of normal flora, severe diarrhea, very contagious. Use contact isolation and frequently wash hands if you come in contact with it! What does normal feces look like? Brown, solid, soft How frequently should people defecate? 2-4x/day, every 3 days. *After 3 days of no poop, the person will be more than likely feeling very uncomfortable. What is 'chyme'? a mixture of partially digested food, water, and gastric juices (acids from/to stomach) What factors can affect defecation? diet, fluid intake, fiber intake, comfort, location, privacy What effect does iron have on a person's stools? If the person is on iron supplements, it can make them constipated and their stools appear black and tarry. What effect do opioids have on a person's stools? Opioids inhibit gastric emptying and peristalsis in the GI tract which results in delayed absorption of medications and increased absorption of fluid. The lack of fluid in the intestine leads to hardening of stool and constipation. In what order do you assess the abdomen? inspection, auscultation, percussion, and palpation. *Changing the order of these assessment techniques could alter the frequency of bowel sounds and make your findings less accurate. What role does diet play in bowel elimination? A high-fiber diet promotes regular bowel movements; low fiber can lead to constipation. What is the purpose of Urinary Catheters and what types are there? Purpose: To drain urine from the bladder when patients cannot void independently. Types: Foley Catheter: Indwelling catheter that remains in place. Intermittent Catheter (straight): Inserted and removed at regular intervals. What is the purpose of a bedside urinal? Purpose: For male patients to urinate while in bed. Types: Portable containers designed for bedside use. What is the purpose of Incontinence Pads and Briefs? Purpose: To absorb urine leakage in patients with incontinence. Types: Disposable or washable, designed for different levels of incontinence. What is the purpose of a colostomy bag? Purpose: To collect stool from patients who have undergone colostomy surgery. Types: One-piece system: Bag and wafer are combined. Two-piece system: Separate bag and adhesive wafer How often should you change a colostomy bag? When its 1/3-1/2 full or 3-5 days What are some nursing interventions for administering enemas? Position the patient on their left side, lubricate the nozzle, and instill the solution slowly. What are expected outcomes when administering rectal suppositories? Effective stool softening, bowel movement within the expected time frame, and minimal discomfort. What is an important nursing intervention when performing digital removal of stool? Monitor the patient for signs of vagal response and ensure proper hand hygiene. How should documentation related to bladder and bowel elimination be completed? Document frequency, consistency, color of stools, and any abnormalities in urine output or appearance per facility protocols. What should a care plan for a patient with urinary and bowel function alterations include? Goals for maintaining skin integrity, promoting regular elimination, and education on self-care practices. What is wound assessment? The process of evaluating a wound's characteristics to determine appropriate care. What are the phases of normal wound healing? inflammation, proliferation, and maturation. How do you stage a pressure ulcer? Based on depth: Stage I (non-blanchable redness) to Stage IV (full-thickness tissue loss). What is the difference between sterile and non-sterile dressing changes? Sterile changes are for open wounds; non-sterile for closed or low-risk wounds. What does basic wound assessment include? Size, depth, location, tissue type, drainage, odor, and surrounding skin condition What nursing interventions prevent pressure ulcers? Regular repositioning, use of pressure-relieving devices, and maintaining skin hygiene What factors impair wound healing? Poor nutrition, diabetes, infection, hypoxia, and chronic diseases. What essential documentation is needed for wound assessment? Size, stage, appearance, drainage type, pain level, and patient response. How can you integrate infection control when obtaining a wound culture? Use sterile technique and ensure the specimen is collected properly to avoid contamination. Why is mobility important for patients? It promotes circulation, prevents complications, and enhances recovery. What are complications of immobility? Pressure ulcers, deep vein thrombosis, muscle atrophy, and pneumonia. What principles of safe body mechanics should nurses follow? Use proper lifting techniques, maintain a wide base of support, and bend at the knees. What are the benefits of active range of motion (ROM)? Increases flexibility, strength, and joint mobility. What is passive range of motion (PROM)? Movements performed by a caregiver without patient effort. How do you perform passive range of motion? Gently move the joints through their full range while supporting the limb. What methods are used for patient transfer? Use of gait belts, sliding boards, or lifts depending on the patient's ability. What are assistive devices for mobility? Walkers, canes, crutches, and wheelchairs. How do you ambulate a patient safely? Assess readiness, use gait belts, and maintain proper posture. What are the roles of the healthcare team in mobility care? Collaborate on assessments, interventions, and discharge planning. What is the significance of positioning in mobility care? Proper positioning prevents complications like pressure ulcers and promotes comfort. What should be monitored during patient ambulation? Balance, strength, fatigue, and signs of distress. What is the impact of moisture on wound healing? Balanced moisture levels promote healing; too much moisture can lead to maceration. What psychological factors may affect a patient's mobility? Anxiety, depression, and fear of falling can hinder participation in mobility activities When educating the patient about the use of a cane, the nurse knows to place the cane on strong or weak side and move forward with left or right leg? The cane on the strong side and move forward with the weak leg. What are signs of infection in a wound? Increased redness, warmth, swelling, pain, and purulent drainage. How often should a patient at risk for pressure ulcers be repositioned? At least every two hours. What is the purpose of the Braden Scale, and what are its main categories used to assess a patient's risk for pressure ulcers? The Braden Scale is used to assess a patient's risk for developing pressure ulcers by evaluating six categories: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Each category is scored, with lower total scores indicating a higher risk for skin breakdown. What is 'ptosis'? Eye drooping What does P.E.R.R.L.A pupil, equal, round, reactive, light, accommodation What is 'dehisence'? wound closure seperates and opens up What is 'eviceration'? protusion of internal organs from wound