NU158 | NU 158 Medical-Surgical Nursing I Exam 2
v2 | Questions with Correct Answers and Expert
Explanation for Each Question | Galen
1. A patient is diagnosed with fluid volume excess. Which clinical manifestation should
the nurse expect to find during the assessment?
A. Flat neck veins when supine
B. Orthostatic hypotension
C. Decreased skin turgor
D. Full, bounding pulse
Correct Answer: D
Expert Explanation: Fluid volume excess, or hypervolemia, typically presents with
a full, bounding pulse and distended neck veins due to the increased intravascular
volume. This condition can also cause peripheral edema and pulmonary crackles if
the heart cannot handle the volume. Monitoring the patient’s weight and fluid intake
is essential for managing this condition effectively.
2. A nurse is reviewing the lab results of a patient and notes a potassium level of 5.8
mEq/L. Which cardiac monitor finding is most consistent with this lab value?
A. Tall, peaked T waves
B. Prominent U waves
,C. ST-segment depression
D. Inverted T waves
Correct Answer: A
Expert Explanation: Hyperkalemia, defined as a potassium level above 5.0 mEq/L,
is known to cause specific ECG changes such as tall, peaked T waves. If left
untreated, this can progress to a widened QRS complex and potentially life-
threatening ventricular arrhythmias. The nurse must notify the provider
immediately and prepare for interventions such as sodium polystyrene sulfonate or
insulin with glucose.
3. A patient is scheduled for surgery. The nurse knows that the primary responsibility
for obtaining the patient’s informed consent lies with whom?
A. The circulating nurse
B. The anesthesiologist
C. The surgeon
D. The hospital administrator
Correct Answer: C
Expert Explanation: The surgeon is legally responsible for explaining the
procedure, its risks, and benefits to the patient before obtaining informed consent.
,The nurse’s role is to witness the signature and verify that the patient understands
the information provided. If the patient has further questions about the procedure
itself, the nurse must contact the surgeon to provide clarification.
4. During a post-operative assessment, the nurse notes that a patient’s wound has
eviscerated. What should be the nurse’s immediate action?
A. Attempt to push the organs back into the abdominal cavity.
B. Call the family to inform them of the emergency.
C. Place the patient in a high-Fowler’s position to ease breathing.
D. Cover the protruding organs with sterile gauze soaked in normal saline.
Correct Answer: D
Expert Explanation: Wound evisceration is a surgical emergency where internal
organs protrude through a dehisced incision. The nurse must cover the area with
sterile saline-soaked dressings to keep the organs moist and prevent infection. The
patient should be kept in a low-Fowler’s position with knees flexed, and the surgical
team should be notified immediately.
5. A patient’s arterial blood gas (ABG) results are: pH 7.30, PaCO2 55 mmHg, and HCO3
24 mEq/L. Which acid-base imbalance does this represent?
A. Metabolic Acidosis
B. Metabolic Alkalosis
, C. Respiratory Alkalosis
D. Respiratory Acidosis
Correct Answer: D
Expert Explanation: Respiratory acidosis is characterized by a low pH (less than
7.35) and a high PaCO2 (greater than 45 mmHg). This often occurs when a patient is
hypoventilating, leading to the retention of carbon dioxide. In this case, the
bicarbonate (HCO3) is within the normal range, indicating that compensation has
not yet occurred.
6. Which electrolyte imbalance is most commonly associated with a positive
Chvostek’s sign?
A. Hypocalcemia
B. Hypermagnesemia
C. Hyperkalemia
D. Hyponatremia
Correct Answer: A
Expert Explanation: Hypocalcemia increases neuromuscular excitability, which can
be assessed via Chvostek’s sign (facial twitching when the facial nerve is tapped).
Another common indicator is Trousseau’s sign, which involves a carpal spasm when
v2 | Questions with Correct Answers and Expert
Explanation for Each Question | Galen
1. A patient is diagnosed with fluid volume excess. Which clinical manifestation should
the nurse expect to find during the assessment?
A. Flat neck veins when supine
B. Orthostatic hypotension
C. Decreased skin turgor
D. Full, bounding pulse
Correct Answer: D
Expert Explanation: Fluid volume excess, or hypervolemia, typically presents with
a full, bounding pulse and distended neck veins due to the increased intravascular
volume. This condition can also cause peripheral edema and pulmonary crackles if
the heart cannot handle the volume. Monitoring the patient’s weight and fluid intake
is essential for managing this condition effectively.
2. A nurse is reviewing the lab results of a patient and notes a potassium level of 5.8
mEq/L. Which cardiac monitor finding is most consistent with this lab value?
A. Tall, peaked T waves
B. Prominent U waves
,C. ST-segment depression
D. Inverted T waves
Correct Answer: A
Expert Explanation: Hyperkalemia, defined as a potassium level above 5.0 mEq/L,
is known to cause specific ECG changes such as tall, peaked T waves. If left
untreated, this can progress to a widened QRS complex and potentially life-
threatening ventricular arrhythmias. The nurse must notify the provider
immediately and prepare for interventions such as sodium polystyrene sulfonate or
insulin with glucose.
3. A patient is scheduled for surgery. The nurse knows that the primary responsibility
for obtaining the patient’s informed consent lies with whom?
A. The circulating nurse
B. The anesthesiologist
C. The surgeon
D. The hospital administrator
Correct Answer: C
Expert Explanation: The surgeon is legally responsible for explaining the
procedure, its risks, and benefits to the patient before obtaining informed consent.
,The nurse’s role is to witness the signature and verify that the patient understands
the information provided. If the patient has further questions about the procedure
itself, the nurse must contact the surgeon to provide clarification.
4. During a post-operative assessment, the nurse notes that a patient’s wound has
eviscerated. What should be the nurse’s immediate action?
A. Attempt to push the organs back into the abdominal cavity.
B. Call the family to inform them of the emergency.
C. Place the patient in a high-Fowler’s position to ease breathing.
D. Cover the protruding organs with sterile gauze soaked in normal saline.
Correct Answer: D
Expert Explanation: Wound evisceration is a surgical emergency where internal
organs protrude through a dehisced incision. The nurse must cover the area with
sterile saline-soaked dressings to keep the organs moist and prevent infection. The
patient should be kept in a low-Fowler’s position with knees flexed, and the surgical
team should be notified immediately.
5. A patient’s arterial blood gas (ABG) results are: pH 7.30, PaCO2 55 mmHg, and HCO3
24 mEq/L. Which acid-base imbalance does this represent?
A. Metabolic Acidosis
B. Metabolic Alkalosis
, C. Respiratory Alkalosis
D. Respiratory Acidosis
Correct Answer: D
Expert Explanation: Respiratory acidosis is characterized by a low pH (less than
7.35) and a high PaCO2 (greater than 45 mmHg). This often occurs when a patient is
hypoventilating, leading to the retention of carbon dioxide. In this case, the
bicarbonate (HCO3) is within the normal range, indicating that compensation has
not yet occurred.
6. Which electrolyte imbalance is most commonly associated with a positive
Chvostek’s sign?
A. Hypocalcemia
B. Hypermagnesemia
C. Hyperkalemia
D. Hyponatremia
Correct Answer: A
Expert Explanation: Hypocalcemia increases neuromuscular excitability, which can
be assessed via Chvostek’s sign (facial twitching when the facial nerve is tapped).
Another common indicator is Trousseau’s sign, which involves a carpal spasm when
