NUR 170 Final Exam: Med Surg - Galen College of Nursing
Updated and Latest Questions and Correct Answers with
Rationale
1. A patient presents with a pH of 7.28, PaCO2 of 50 mmHg, and HCO3 of 24 mEq/L. Which acid-base
imbalance is occurring?
A. Respiratory alkalosis
B. Respiratory acidosis
C. Metabolic acidosis
D. Metabolic alkalosis
Correct Answer: B
Rationale: The pH level of 7.28 indicates a state of acidosis because it is below the normal range. An
elevated PaCO2 of 50 mmHg suggests that the respiratory system is the primary cause of the imbalance.
Since the bicarbonate level is within the normal range, the condition is currently uncompensated. This
state typically results from hypoventilation or impaired gas exchange in the lungs. Therefore, the nurse
correctly identifies this clinical finding as respiratory acidosis.
2. Which clinical manifestation should a nurse expect to find in a patient with fluid volume deficit?
A. Distended neck veins
B. Bounding peripheral pulses
C. Orthostatic hypotension
D. Crackles upon lung auscultation
Correct Answer: C
,Rationale: Fluid volume deficit leads to a decrease in circulating blood volume within the vascular space.
As a result, the patient will often experience a significant drop in blood pressure when changing
positions. Other common signs include poor skin turgor, dry mucous membranes, and a rapid, thready
pulse. Distended neck veins and crackles are typically associated with fluid volume excess rather than
deficit. Monitoring blood pressure and heart rate is essential for assessing the severity of dehydration.
3. A patient has a potassium level of 6.2 mEq/L. Which cardiac change should the nurse monitor for on the
EKG?
A. Prominent U waves
B. ST-segment depression
C. Inverted T waves
D. Tall, peaked T waves
Correct Answer: D
Rationale: Hyperkalemia is defined as a serum potassium level greater than 5.0 mEq/L and can be life-
threatening. Potassium plays a critical role in the repolarization of cardiac muscle cells during the
heartbeat cycle. One of the earliest and most characteristic EKG changes seen in hyperkalemia is the
appearance of tall, peaked T waves. If the potassium level continues to rise, it can lead to a widened QRS
complex or cardiac arrest. The nurse must prioritize monitoring the patient’s cardiac rhythm and
preparing for emergency treatment.
4. Which assessment finding is a hallmark sign of hypocalcemia?
A. Negative Trousseau sign
B. Positive Chvostek sign
C. Abdominal distension
, D. Hyporeflexia
Correct Answer: B
Rationale: Hypocalcemia increases neuromuscular excitability, making the nerves more sensitive to
stimulation. A positive Chvostek sign is elicited by tapping the facial nerve, resulting in twitching of the
facial muscles. This response indicates a deficit in serum calcium levels that requires clinical intervention.
Other signs include carpopedal spasms, known as a positive Trousseau sign, and tingling in the
extremities. Nurses should monitor calcium levels closely to prevent tetany or seizures in high-risk
patients.
5. Before surgery, a nurse is verifying the informed consent. What is the primary responsibility of the nurse
in this process?
A. Explain the risks and benefits of the procedure
B. Obtain the patient’s signature and witness it
C. Decide if the surgery is necessary for the patient
D. Provide alternative treatment options to the patient
Correct Answer: B
Rationale: The primary role of the nurse in the consent process is to serve as a witness to the patient’s
signature. It is the surgeon’s legal responsibility to explain the procedure, risks, benefits, and alternatives
to the patient. The nurse ensures that the patient appears competent and is signing the document
voluntarily. If the patient has further questions about the surgery, the nurse must notify the surgeon to
provide clarification. Documentation of the witnessed signature is a crucial step in preoperative nursing
care.
Updated and Latest Questions and Correct Answers with
Rationale
1. A patient presents with a pH of 7.28, PaCO2 of 50 mmHg, and HCO3 of 24 mEq/L. Which acid-base
imbalance is occurring?
A. Respiratory alkalosis
B. Respiratory acidosis
C. Metabolic acidosis
D. Metabolic alkalosis
Correct Answer: B
Rationale: The pH level of 7.28 indicates a state of acidosis because it is below the normal range. An
elevated PaCO2 of 50 mmHg suggests that the respiratory system is the primary cause of the imbalance.
Since the bicarbonate level is within the normal range, the condition is currently uncompensated. This
state typically results from hypoventilation or impaired gas exchange in the lungs. Therefore, the nurse
correctly identifies this clinical finding as respiratory acidosis.
2. Which clinical manifestation should a nurse expect to find in a patient with fluid volume deficit?
A. Distended neck veins
B. Bounding peripheral pulses
C. Orthostatic hypotension
D. Crackles upon lung auscultation
Correct Answer: C
,Rationale: Fluid volume deficit leads to a decrease in circulating blood volume within the vascular space.
As a result, the patient will often experience a significant drop in blood pressure when changing
positions. Other common signs include poor skin turgor, dry mucous membranes, and a rapid, thready
pulse. Distended neck veins and crackles are typically associated with fluid volume excess rather than
deficit. Monitoring blood pressure and heart rate is essential for assessing the severity of dehydration.
3. A patient has a potassium level of 6.2 mEq/L. Which cardiac change should the nurse monitor for on the
EKG?
A. Prominent U waves
B. ST-segment depression
C. Inverted T waves
D. Tall, peaked T waves
Correct Answer: D
Rationale: Hyperkalemia is defined as a serum potassium level greater than 5.0 mEq/L and can be life-
threatening. Potassium plays a critical role in the repolarization of cardiac muscle cells during the
heartbeat cycle. One of the earliest and most characteristic EKG changes seen in hyperkalemia is the
appearance of tall, peaked T waves. If the potassium level continues to rise, it can lead to a widened QRS
complex or cardiac arrest. The nurse must prioritize monitoring the patient’s cardiac rhythm and
preparing for emergency treatment.
4. Which assessment finding is a hallmark sign of hypocalcemia?
A. Negative Trousseau sign
B. Positive Chvostek sign
C. Abdominal distension
, D. Hyporeflexia
Correct Answer: B
Rationale: Hypocalcemia increases neuromuscular excitability, making the nerves more sensitive to
stimulation. A positive Chvostek sign is elicited by tapping the facial nerve, resulting in twitching of the
facial muscles. This response indicates a deficit in serum calcium levels that requires clinical intervention.
Other signs include carpopedal spasms, known as a positive Trousseau sign, and tingling in the
extremities. Nurses should monitor calcium levels closely to prevent tetany or seizures in high-risk
patients.
5. Before surgery, a nurse is verifying the informed consent. What is the primary responsibility of the nurse
in this process?
A. Explain the risks and benefits of the procedure
B. Obtain the patient’s signature and witness it
C. Decide if the surgery is necessary for the patient
D. Provide alternative treatment options to the patient
Correct Answer: B
Rationale: The primary role of the nurse in the consent process is to serve as a witness to the patient’s
signature. It is the surgeon’s legal responsibility to explain the procedure, risks, benefits, and alternatives
to the patient. The nurse ensures that the patient appears competent and is signing the document
voluntarily. If the patient has further questions about the surgery, the nurse must notify the surgeon to
provide clarification. Documentation of the witnessed signature is a crucial step in preoperative nursing
care.
