MEDSURG NUR 170 Exam 1 – 2025/2026 MEDSURG NUR 170 Exam 1 – Newest Updated Questions with Correct A+ Graded Answers | Verified for Learners
(2025/2026)
Exam 1 Question 1:A client with chronic heart failure reports a weight gain of 4 pounds in 2 days.Which action should the nurse take first?A.Encourage increased physical activity.B.Notify the healthcare provider.C.Restrict all fluid intake.D.Administer an extra dose of diuretic.Rationale:Rapid weight gain (e.g., 2–3 pounds in days) in heart failure indicates fluid reten- tion, requiring immediate provider notification for potential diuretic adjustment. Per 2025 AHA guidelines, this is a priority. Activity, fluid restriction, or extra doses require further assessment or orders.Question 2:A client with type 2 diabetes mellitus presents with a blood glucose level of 320 mg/dL. Which assessment finding requires immediate intervention?A.Polyuria.B.Kussmaul respirations.C.Dry skin.D.Fatigue.Rationale:Kussmaul respirations indicate diabetic ketoacidosis (DKA), a life-threatening com- plication requiring immediate intervention. Per 2025 ADA standards, DKA is characterized by hyperglycemia and acidosis. Polyuria, dry skin, and fatigue are expected but less urgent.Question 3:A postoperative client develops a temperature of 101.5°F and redness at the surgical site. Which action should the nurse prioritize?A.Administer acetaminophen.B.Apply a cool compress.C.Notify the healthcare provider.D.Increase fluid intake.Rationale:Fever and redness suggest a surgical site infection, requiring prompt provider no- tification for evaluation and possible antibiotics. Per 2025 CDC guidelines, early recognition prevents complications. Other actions are supportive but secondary.
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MEDSURG NUR 170 Exam 1 – 2025/2026 Question 4:A client with chronic obstructive pulmonary disease (COPD) has an oxygen satu- ration of 87%. Which action should the nurse take first?A.Position the client in a high Fowler’s position.B.Administer oxygen via nasal cannula at 2 L/min.C.Administer a bronchodilator.D.Obtain a sputum culture.Rationale:Hypoxemia (SpO2 < 90%) in COPD requires immediate oxygen administration to improve oxygenation. Per 2025 ATS guidelines, this is the priority. Positioning and bron- chodilators are secondary, and sputum cultures are diagnostic, not therapeutic.Question 5:A client with a peptic ulcer reports severe epigastric pain and a rigid abdomen.Which condition should the nurse suspect?A.Gastritis.B.Perforation.C.Esophagitis.D.Pancreatitis.Rationale:A rigid abdomen and severe pain suggest perforation, a surgical emergency. Per 2025 gastroenterology standards, this requires immediate reporting. Other conditions are less likely to cause a rigid abdomen.Question 6:A client with a new colostomy reports leakage around the stoma. Which action should the nurse take first?A.Change the ostomy pouch.B.Assess the stoma and skin barrier.C.Apply a skin protectant.D.Notify the surgeon.Rationale:Assessing the stoma and skin barrier identifies the cause of leakage, such as im- proper fit. Per 2025 WOCN guidelines, assessment guides interventions. Other actions follow based on findings.Question 7:A client with a myocardial infarction is receiving heparin. Which laboratory value should the nurse monitor?A.International normalized ratio (INR).B.Activated partial thromboplastin time (aPTT).C.Platelet count.D.Prothrombin time (PT).
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MEDSURG NUR 170 Exam 1 – 2025/2026 Rationale:Heparin’s anticoagulant effect is monitored via aPTT to ensure therapeutic levels.Per 2025 ACC guidelines, this is standard. INR and PT are for warfarin, and platelet count is monitored for other risks.Question 8:A client with rheumatoid arthritis reports increased joint stiffness. Which inter- vention should the nurse recommend?A.Apply cold packs.B.Perform gentle range-of-motion exercises.C.Restrict all movement.D.Increase rest periods.Rationale:Gentle range-of-motion exercises reduce stiffness and maintain joint function in rheumatoid arthritis. Per 2025 ACR guidelines, this is essential. Cold packs are for acute in- flammation, and restricting movement worsens stiffness.Question 9:A client with pneumonia reports shortness of breath. Which position should the nurse recommend?A.Supine.B.High Fowler’s.C.Prone.D.Trendelenburg.Rationale:High Fowler’s position promotes lung expansion and eases breathing in pneumo- nia. Per 2025 IDSA guidelines, this is a key intervention. Other positions are less effective or contraindicated.Question 10:A client with chronic kidney disease is on a low-potassium diet. Which food should the nurse instruct the client to avoid?A.Apples.B.Bananas.C.Carrots.D.White rice.Rationale:Bananas are high in potassium and should be avoided to prevent hyperkalemia in chronic kidney disease. Per 2025 NKF guidelines, dietary potassium restriction is essential.Other foods listed are low-potassium options.Question 11:A client with a spinal cord injury at T5 reports a headache and flushing. Which action should the nurse take first?
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