NU158 | NU 158 Medical-Surgical Nursing I Exam 1
v1 | Questions with Correct Answers and Expert
Explanation for Each Question | Galen
1. A nurse is preparing a client for an elective surgical procedure. Which of the
following actions is the nurse’s responsibility regarding informed consent?
A. Witnessing the client’s signature on the consent form
B. Explaining the risks and benefits of the procedure
C. Describing alternative treatments to the client
D. Obtaining the initial consent from the client
Correct Answer: A
Expert Explanation: The nurse’s primary role in informed consent is to witness the
client’s signature and verify that the client is competent to sign. It is the surgeon’s
responsibility to explain the procedure, risks, benefits, and alternatives. If the nurse
identifies that the client does not understand the procedure, the nurse must notify
the surgeon to provide further clarification before the client signs the form.
2. A client is in the postanesthesia care unit (PACU) following abdominal surgery.
Which of the following assessments is the nurse’s priority?
A. Surgical dressing integrity
B. Level of consciousness
,C. Airway patency
D. Urinary output
Correct Answer: C
Expert Explanation: Airway patency is the highest priority assessment in the
immediate postoperative period because anesthesia and muscle relaxants can
suppress the respiratory system. The nurse must ensure the client can maintain
their own airway and has adequate gas exchange. Other assessments like wound
care and urine output are important but follow the ABC (Airway, Breathing,
Circulation) hierarchy of care.
3. A nurse is caring for a client who is 24 hours postoperative. The nurse should
encourage the use of an incentive spirometer to prevent which complication?
A. Pulmonary embolism
B. Deep vein thrombosis
C. Paralytic ileus
D. Atelectasis
Correct Answer: D
Expert Explanation: Incentive spirometry encourages deep breathing and lung
expansion, which helps prevent atelectasis, or the collapse of alveoli. This is a
,common postoperative complication due to shallow breathing from pain or
anesthesia. By expanding the lungs, the client also reduces the risk of developing
secondary pneumonia.
4. During a pre-operative assessment, a client reports an allergy to bananas and
avocados. Which of the following actions should the nurse take?
A. Ask the client if they are allergic to penicillin
B. Document the food allergy and proceed as normal
C. Notify the surgical team of a possible latex allergy
D. Ensure the client receives a prophylactic antihistamine
Correct Answer: C
Expert Explanation: Cross-reactivity exists between certain foods, such as bananas,
avocados, and kiwi, and latex. A client with these food allergies is at a significantly
higher risk for a latex allergy, which must be communicated to the surgical team to
ensure a latex-free environment. Failing to identify this risk could lead to an
intraoperative anaphylactic reaction.
5. A nurse is reviewing a client’s laboratory results and notes a potassium level of 2.8
mEq/L. Which of the following findings should the nurse expect?
A. Peaked T waves on ECG
B. Hyperactive bowel sounds and diarrhea
, C. Muscle weakness and cardiac dysrhythmias
D. Numbness and tingling in the extremities
Correct Answer: C
Expert Explanation: Hypokalemia, defined as a potassium level below 3.5 mEq/L,
affects muscle contraction and nerve conduction. Clients often exhibit muscle
weakness, leg cramps, and potentially fatal cardiac dysrhythmias. Peaked T waves
and hyperactive bowel sounds are typically associated with hyperkalemia, not
hypokalemia.
6. Which of the following is an early sign of malignant hyperthermia during general
anesthesia?
A. High fever of 104°F (40°C)
B. Muscle rigidity
C. Tachycardia
D. Bradycardia
Correct Answer: C
Expert Explanation: Tachycardia is often the earliest sign of malignant
hyperthermia, a life-threatening hypermetabolic reaction to certain anesthetic
agents. Muscle rigidity and an increased end-tidal CO2 level are also early
v1 | Questions with Correct Answers and Expert
Explanation for Each Question | Galen
1. A nurse is preparing a client for an elective surgical procedure. Which of the
following actions is the nurse’s responsibility regarding informed consent?
A. Witnessing the client’s signature on the consent form
B. Explaining the risks and benefits of the procedure
C. Describing alternative treatments to the client
D. Obtaining the initial consent from the client
Correct Answer: A
Expert Explanation: The nurse’s primary role in informed consent is to witness the
client’s signature and verify that the client is competent to sign. It is the surgeon’s
responsibility to explain the procedure, risks, benefits, and alternatives. If the nurse
identifies that the client does not understand the procedure, the nurse must notify
the surgeon to provide further clarification before the client signs the form.
2. A client is in the postanesthesia care unit (PACU) following abdominal surgery.
Which of the following assessments is the nurse’s priority?
A. Surgical dressing integrity
B. Level of consciousness
,C. Airway patency
D. Urinary output
Correct Answer: C
Expert Explanation: Airway patency is the highest priority assessment in the
immediate postoperative period because anesthesia and muscle relaxants can
suppress the respiratory system. The nurse must ensure the client can maintain
their own airway and has adequate gas exchange. Other assessments like wound
care and urine output are important but follow the ABC (Airway, Breathing,
Circulation) hierarchy of care.
3. A nurse is caring for a client who is 24 hours postoperative. The nurse should
encourage the use of an incentive spirometer to prevent which complication?
A. Pulmonary embolism
B. Deep vein thrombosis
C. Paralytic ileus
D. Atelectasis
Correct Answer: D
Expert Explanation: Incentive spirometry encourages deep breathing and lung
expansion, which helps prevent atelectasis, or the collapse of alveoli. This is a
,common postoperative complication due to shallow breathing from pain or
anesthesia. By expanding the lungs, the client also reduces the risk of developing
secondary pneumonia.
4. During a pre-operative assessment, a client reports an allergy to bananas and
avocados. Which of the following actions should the nurse take?
A. Ask the client if they are allergic to penicillin
B. Document the food allergy and proceed as normal
C. Notify the surgical team of a possible latex allergy
D. Ensure the client receives a prophylactic antihistamine
Correct Answer: C
Expert Explanation: Cross-reactivity exists between certain foods, such as bananas,
avocados, and kiwi, and latex. A client with these food allergies is at a significantly
higher risk for a latex allergy, which must be communicated to the surgical team to
ensure a latex-free environment. Failing to identify this risk could lead to an
intraoperative anaphylactic reaction.
5. A nurse is reviewing a client’s laboratory results and notes a potassium level of 2.8
mEq/L. Which of the following findings should the nurse expect?
A. Peaked T waves on ECG
B. Hyperactive bowel sounds and diarrhea
, C. Muscle weakness and cardiac dysrhythmias
D. Numbness and tingling in the extremities
Correct Answer: C
Expert Explanation: Hypokalemia, defined as a potassium level below 3.5 mEq/L,
affects muscle contraction and nerve conduction. Clients often exhibit muscle
weakness, leg cramps, and potentially fatal cardiac dysrhythmias. Peaked T waves
and hyperactive bowel sounds are typically associated with hyperkalemia, not
hypokalemia.
6. Which of the following is an early sign of malignant hyperthermia during general
anesthesia?
A. High fever of 104°F (40°C)
B. Muscle rigidity
C. Tachycardia
D. Bradycardia
Correct Answer: C
Expert Explanation: Tachycardia is often the earliest sign of malignant
hyperthermia, a life-threatening hypermetabolic reaction to certain anesthetic
agents. Muscle rigidity and an increased end-tidal CO2 level are also early
