NUR 170 Exam 2: Med Surg - Galen College of Nursing
Updated and Latest Questions and Correct Answers with
Rationale
1. A patient’s lab results show a potassium level of 6.2 mEq/L. Which EKG change should the nurse expect to
observe?
A. Presence of U waves
B. Tall, peaked T waves
C. Flattened T waves
D. ST segment depression
Correct Answer: B
Rationale: A serum potassium level of 6.2 mEq/L indicates hyperkalemia. High potassium levels
interfere with the electrical conductivity of the heart muscles. Tall, peaked T waves are a classic early sign
of this electrolyte imbalance on an EKG. If left untreated, this condition can lead to life-threatening
ventricular arrhythmias or cardiac arrest. The nurse must monitor the patient closely and notify the
provider for immediate intervention.
2. Which assessment finding is a hallmark sign of hypocalcemia?
A. Hyperactive deep tendon reflexes
B. Shortened QT interval
C. Constipation and lethargy
D. Positive Chvostek’s sign
Correct Answer: D
,Rationale: Chvostek’s sign is a clinical indicator of hypocalcemia characterized by facial twitching when
the facial nerve is tapped. This occurs because low calcium levels increase neuromuscular irritability.
Another common sign of hypocalcemia is Trousseau’s sign, which involves carpal spasms when a blood
pressure cuff is inflated. The nurse should also monitor for numbness or tingling in the extremities and
around the mouth. Seizure precautions are often necessary for patients with severely low calcium levels.
3. A nurse is caring for a patient with a sodium level of 125 mEq/L. Which nursing intervention is a priority?
A. Encouraging oral fluid intake
B. Administering hypotonic IV fluids
C. Providing a high-sodium snack
D. Implementing seizure precautions
Correct Answer: D
Rationale: A sodium level of 125 mEq/L indicates hyponatremia, which can cause significant
neurological changes. Low sodium levels lead to water shifting into the brain cells, causing swelling and
potential seizures. The nurse’s priority is to ensure patient safety by implementing seizure precautions.
Fluid restriction is often ordered to prevent further dilution of the serum sodium. Monitoring
neurological status and mental clarity is essential for detecting worsening hyponatremia.
4. Which arterial blood gas (ABG) result indicates uncompensated respiratory acidosis?
A. pH 7.48, PaCO2 30, HCO3 24
B. pH 7.35, PaCO2 45, HCO3 26
C. pH 7.32, PaCO2 38, HCO3 18
D. pH 7.30, PaCO2 50, HCO3 24
Correct Answer: D
, Rationale: Respiratory acidosis is characterized by a low pH and a high PaCO2 level. In this case, the pH
of 7.30 is below the normal range, indicating acidosis. The PaCO2 of 50 is above the normal range,
identifying the cause as respiratory. Because the HCO3 is within the normal range of 22-26, no
compensation has occurred yet. This condition is often caused by hypoventilation due to factors like
opioid overdose or respiratory failure.
5. A patient is scheduled for surgery and has not been NPO since midnight. What is the nurse’s priority
action?
A. Proceed with the surgery as planned
B. Administer an antiemetic medication
C. Place a nasogastric tube immediately
D. Notify the surgeon and anesthesiologist
Correct Answer: D
Rationale: The NPO status is critical for preventing pulmonary aspiration of gastric contents during
general anesthesia. If a patient has eaten, the risk of vomiting and aspiration significantly increases. The
nurse must communicate this information to the surgical team immediately to ensure patient safety. The
surgery may need to be delayed or canceled depending on the timing and type of intake. Documentation
of the communication and the patient’s last meal is also necessary.
6. During the pre-operative assessment, the patient reports an allergy to avocados and bananas. Which
potential allergy should the nurse suspect?
A. Iodine allergy
B. Penicillin allergy
C. Latex allergy
Updated and Latest Questions and Correct Answers with
Rationale
1. A patient’s lab results show a potassium level of 6.2 mEq/L. Which EKG change should the nurse expect to
observe?
A. Presence of U waves
B. Tall, peaked T waves
C. Flattened T waves
D. ST segment depression
Correct Answer: B
Rationale: A serum potassium level of 6.2 mEq/L indicates hyperkalemia. High potassium levels
interfere with the electrical conductivity of the heart muscles. Tall, peaked T waves are a classic early sign
of this electrolyte imbalance on an EKG. If left untreated, this condition can lead to life-threatening
ventricular arrhythmias or cardiac arrest. The nurse must monitor the patient closely and notify the
provider for immediate intervention.
2. Which assessment finding is a hallmark sign of hypocalcemia?
A. Hyperactive deep tendon reflexes
B. Shortened QT interval
C. Constipation and lethargy
D. Positive Chvostek’s sign
Correct Answer: D
,Rationale: Chvostek’s sign is a clinical indicator of hypocalcemia characterized by facial twitching when
the facial nerve is tapped. This occurs because low calcium levels increase neuromuscular irritability.
Another common sign of hypocalcemia is Trousseau’s sign, which involves carpal spasms when a blood
pressure cuff is inflated. The nurse should also monitor for numbness or tingling in the extremities and
around the mouth. Seizure precautions are often necessary for patients with severely low calcium levels.
3. A nurse is caring for a patient with a sodium level of 125 mEq/L. Which nursing intervention is a priority?
A. Encouraging oral fluid intake
B. Administering hypotonic IV fluids
C. Providing a high-sodium snack
D. Implementing seizure precautions
Correct Answer: D
Rationale: A sodium level of 125 mEq/L indicates hyponatremia, which can cause significant
neurological changes. Low sodium levels lead to water shifting into the brain cells, causing swelling and
potential seizures. The nurse’s priority is to ensure patient safety by implementing seizure precautions.
Fluid restriction is often ordered to prevent further dilution of the serum sodium. Monitoring
neurological status and mental clarity is essential for detecting worsening hyponatremia.
4. Which arterial blood gas (ABG) result indicates uncompensated respiratory acidosis?
A. pH 7.48, PaCO2 30, HCO3 24
B. pH 7.35, PaCO2 45, HCO3 26
C. pH 7.32, PaCO2 38, HCO3 18
D. pH 7.30, PaCO2 50, HCO3 24
Correct Answer: D
, Rationale: Respiratory acidosis is characterized by a low pH and a high PaCO2 level. In this case, the pH
of 7.30 is below the normal range, indicating acidosis. The PaCO2 of 50 is above the normal range,
identifying the cause as respiratory. Because the HCO3 is within the normal range of 22-26, no
compensation has occurred yet. This condition is often caused by hypoventilation due to factors like
opioid overdose or respiratory failure.
5. A patient is scheduled for surgery and has not been NPO since midnight. What is the nurse’s priority
action?
A. Proceed with the surgery as planned
B. Administer an antiemetic medication
C. Place a nasogastric tube immediately
D. Notify the surgeon and anesthesiologist
Correct Answer: D
Rationale: The NPO status is critical for preventing pulmonary aspiration of gastric contents during
general anesthesia. If a patient has eaten, the risk of vomiting and aspiration significantly increases. The
nurse must communicate this information to the surgical team immediately to ensure patient safety. The
surgery may need to be delayed or canceled depending on the timing and type of intake. Documentation
of the communication and the patient’s last meal is also necessary.
6. During the pre-operative assessment, the patient reports an allergy to avocados and bananas. Which
potential allergy should the nurse suspect?
A. Iodine allergy
B. Penicillin allergy
C. Latex allergy
