NURS 120 | NURS120 Final Exam: Med Surg 1 -
WCU Updated and Latest Questions and Correct
Answers with Rationale
1. A nurse is assessing a patient with a fluid volume deficit. Which of the following findings
should the nurse expect?
A. Orthostatic hypotension
B. Increased blood pressure
C. Distended neck veins
D. Bounding peripheral pulses
Correct Answer: A
Rationale: Fluid volume deficit occurs when there is a significant loss of body fluids and
electrolytes. This condition typically leads to decreased circulating volume and low blood
pressure. Orthostatic hypotension is a key indicator of decreased intravascular volume
when changing positions. Distended neck veins and bounding pulses are symptoms of fluid
volume excess rather than a deficit. Nurses should monitor vital signs and skin turgor
closely to assess hydration status.
2. A patient’s potassium level is 6.5 mEq/L. Which of the following electrocardiogram changes
should the nurse anticipate?
A. Tall peaked T waves
B. Prominent U waves
C. Shortened PR interval
D. ST segment depression
Correct Answer: A
Rationale: Hyperkalemia is defined as a serum potassium level greater than 5.0 mEq/L.
Tall peaked T waves are a classic early sign of high potassium levels on an EKG. Prominent
U waves and ST depression are more commonly associated with hypokalemia instead of
hyperkalemia. Cardiac monitoring is critical because hyperkalemia can lead to lethal
dysrhythmias and cardiac arrest. The nurse must notify the provider immediately to
initiate potassium-lowering treatments.
3. The nurse is assessing a patient for hypocalcemia. Which technique should the nurse use to
check for Chvostek’s sign?
A. Inflate a blood pressure cuff on the upper arm
B. Apply pressure to the patient’s femoral artery
,C. Tap the facial nerve just in front of the ear
D. Assess for carpal spasms during hand movement
Correct Answer: C
Rationale: Hypocalcemia causes increased neuromuscular excitability throughout the
body. Chvostek’s sign is elicited by tapping the facial nerve, resulting in a twitch of the
facial muscles. Trousseau’s sign involves inflating a blood pressure cuff to induce carpal
spasms in the hand. Assessing these signs helps the nurse identify dangerously low calcium
levels in postoperative patients. Prompt calcium replacement is necessary to prevent
seizures and laryngospasms.
4. A patient with COPD is experiencing respiratory acidosis. Which of the following arterial
blood gas results matches this condition?
A. pH 7.32, HCO3 18 mEq/L
B. pH 7.50, PaCO2 30 mmHg
C. pH 7.30, PaCO2 50 mmHg
D. pH 7.48, HCO3 30 mEq/L
Correct Answer: C
Rationale: Respiratory acidosis is characterized by a low pH and an elevated carbon
dioxide level. In patients with COPD, hypoventilation leads to the retention of CO2 in the
bloodstream. A pH of 7.30 indicates acidosis, while a PaCO2 of 50 mmHg indicates a
respiratory cause. Option C represents metabolic acidosis due to the low bicarbonate level.
Maintaining adequate oxygenation and ventilation is the primary nursing goal for this
patient.
5. A nurse is preparing a patient for surgery. Which of the following is the nurse’s primary
responsibility regarding informed consent?
A. Explaining the risks and benefits of the procedure
B. Determining the patient’s competence for the procedure
C. Describing alternative treatments to the patient
D. Witnessing the patient’s signature on the consent form
Correct Answer: D
Rationale: The surgeon is legally responsible for explaining the details, risks, and benefits
of a surgery. The nurse serves as a witness to ensure the patient signs the form voluntarily
and appears competent. If the patient has questions about the procedure itself, the nurse
must call the surgeon back to explain. Nurses verify that the signed consent is present in
the medical record before the surgery begins. This role ensures the administrative integrity
of the informed consent process.
, 6. A nurse is providing preoperative teaching. Why is the patient instructed to remain NPO
after midnight before surgery?
A. To prevent postoperative constipation
B. To reduce the risk of surgical site infection
C. To prevent excessive fluid volume during the procedure
D. To minimize the risk of aspiration under anesthesia
Correct Answer: D
Rationale: Anesthesia relaxes the muscles of the digestive tract and suppresses the gag
reflex. If the stomach contains food or liquid, the patient may vomit and inhale contents
into the lungs. Aspiration pneumonia is a severe complication that can occur during or after
the induction of anesthesia. Remaining NPO for a specified period ensures the stomach is
empty during the operation. Nurses must confirm the patient’s last intake to ensure
surgical safety.
7. The nurse teaches a postoperative patient to use an incentive spirometer. What is the main
purpose of this device?
A. To improve cardiac output
B. To decrease postoperative pain
C. To monitor oxygen saturation levels
D. To promote lung expansion and prevent atelectasis
Correct Answer: D
Rationale: Postoperative patients are at high risk for shallow breathing due to pain and
sedation. Incentive spirometry encourages deep breathing by providing visual feedback on
inspiratory volume. Deep breaths help open collapsed alveoli, which reduces the risk of
developing pneumonia. Patients should be encouraged to use the device ten times every
hour while awake. This intervention is a standard component of postoperative respiratory
hygiene.
8. A nurse notes a small loop of bowel protruding from a patient’s abdominal incision. What
is the priority action?
A. Apply a tight abdominal binder over the wound
B. Push the bowel back into the abdominal cavity
C. Cover the area with sterile saline-soaked dressings
D. Instruct the patient to cough to clear their airway
Correct Answer: C
WCU Updated and Latest Questions and Correct
Answers with Rationale
1. A nurse is assessing a patient with a fluid volume deficit. Which of the following findings
should the nurse expect?
A. Orthostatic hypotension
B. Increased blood pressure
C. Distended neck veins
D. Bounding peripheral pulses
Correct Answer: A
Rationale: Fluid volume deficit occurs when there is a significant loss of body fluids and
electrolytes. This condition typically leads to decreased circulating volume and low blood
pressure. Orthostatic hypotension is a key indicator of decreased intravascular volume
when changing positions. Distended neck veins and bounding pulses are symptoms of fluid
volume excess rather than a deficit. Nurses should monitor vital signs and skin turgor
closely to assess hydration status.
2. A patient’s potassium level is 6.5 mEq/L. Which of the following electrocardiogram changes
should the nurse anticipate?
A. Tall peaked T waves
B. Prominent U waves
C. Shortened PR interval
D. ST segment depression
Correct Answer: A
Rationale: Hyperkalemia is defined as a serum potassium level greater than 5.0 mEq/L.
Tall peaked T waves are a classic early sign of high potassium levels on an EKG. Prominent
U waves and ST depression are more commonly associated with hypokalemia instead of
hyperkalemia. Cardiac monitoring is critical because hyperkalemia can lead to lethal
dysrhythmias and cardiac arrest. The nurse must notify the provider immediately to
initiate potassium-lowering treatments.
3. The nurse is assessing a patient for hypocalcemia. Which technique should the nurse use to
check for Chvostek’s sign?
A. Inflate a blood pressure cuff on the upper arm
B. Apply pressure to the patient’s femoral artery
,C. Tap the facial nerve just in front of the ear
D. Assess for carpal spasms during hand movement
Correct Answer: C
Rationale: Hypocalcemia causes increased neuromuscular excitability throughout the
body. Chvostek’s sign is elicited by tapping the facial nerve, resulting in a twitch of the
facial muscles. Trousseau’s sign involves inflating a blood pressure cuff to induce carpal
spasms in the hand. Assessing these signs helps the nurse identify dangerously low calcium
levels in postoperative patients. Prompt calcium replacement is necessary to prevent
seizures and laryngospasms.
4. A patient with COPD is experiencing respiratory acidosis. Which of the following arterial
blood gas results matches this condition?
A. pH 7.32, HCO3 18 mEq/L
B. pH 7.50, PaCO2 30 mmHg
C. pH 7.30, PaCO2 50 mmHg
D. pH 7.48, HCO3 30 mEq/L
Correct Answer: C
Rationale: Respiratory acidosis is characterized by a low pH and an elevated carbon
dioxide level. In patients with COPD, hypoventilation leads to the retention of CO2 in the
bloodstream. A pH of 7.30 indicates acidosis, while a PaCO2 of 50 mmHg indicates a
respiratory cause. Option C represents metabolic acidosis due to the low bicarbonate level.
Maintaining adequate oxygenation and ventilation is the primary nursing goal for this
patient.
5. A nurse is preparing a patient for surgery. Which of the following is the nurse’s primary
responsibility regarding informed consent?
A. Explaining the risks and benefits of the procedure
B. Determining the patient’s competence for the procedure
C. Describing alternative treatments to the patient
D. Witnessing the patient’s signature on the consent form
Correct Answer: D
Rationale: The surgeon is legally responsible for explaining the details, risks, and benefits
of a surgery. The nurse serves as a witness to ensure the patient signs the form voluntarily
and appears competent. If the patient has questions about the procedure itself, the nurse
must call the surgeon back to explain. Nurses verify that the signed consent is present in
the medical record before the surgery begins. This role ensures the administrative integrity
of the informed consent process.
, 6. A nurse is providing preoperative teaching. Why is the patient instructed to remain NPO
after midnight before surgery?
A. To prevent postoperative constipation
B. To reduce the risk of surgical site infection
C. To prevent excessive fluid volume during the procedure
D. To minimize the risk of aspiration under anesthesia
Correct Answer: D
Rationale: Anesthesia relaxes the muscles of the digestive tract and suppresses the gag
reflex. If the stomach contains food or liquid, the patient may vomit and inhale contents
into the lungs. Aspiration pneumonia is a severe complication that can occur during or after
the induction of anesthesia. Remaining NPO for a specified period ensures the stomach is
empty during the operation. Nurses must confirm the patient’s last intake to ensure
surgical safety.
7. The nurse teaches a postoperative patient to use an incentive spirometer. What is the main
purpose of this device?
A. To improve cardiac output
B. To decrease postoperative pain
C. To monitor oxygen saturation levels
D. To promote lung expansion and prevent atelectasis
Correct Answer: D
Rationale: Postoperative patients are at high risk for shallow breathing due to pain and
sedation. Incentive spirometry encourages deep breathing by providing visual feedback on
inspiratory volume. Deep breaths help open collapsed alveoli, which reduces the risk of
developing pneumonia. Patients should be encouraged to use the device ten times every
hour while awake. This intervention is a standard component of postoperative respiratory
hygiene.
8. A nurse notes a small loop of bowel protruding from a patient’s abdominal incision. What
is the priority action?
A. Apply a tight abdominal binder over the wound
B. Push the bowel back into the abdominal cavity
C. Cover the area with sterile saline-soaked dressings
D. Instruct the patient to cough to clear their airway
Correct Answer: C
