NU158 | NU 158 Medical-Surgical Nursing I Exam 1
v2 | Questions with Correct Answers and Expert
Explanation for Each Question | Galen
1. A patient is admitted with a serum sodium level of 128 mEq/L. Which nursing
intervention is a priority for this patient?
A. Encouraging increased oral fluid intake
B. Providing a low-sodium diet
C. Administering a dose of oral diuretics
D. Initiating seizure precautions
Correct Answer: D
Expert Explanation: A serum sodium level of 128 mEq/L indicates hyponatremia,
which can cause cerebral edema and increase the risk for seizures. Implementing
seizure precautions is the priority to ensure patient safety during severe electrolyte
shifts. The nurse should also monitor neurological status frequently for changes in
consciousness.
2. The nurse is interpreting ABG results for a patient: pH 7.30, PaCO2 50 mmHg, and
HCO3 24 mEq/L. Which acid-base imbalance does this represent?
A. Respiratory Acidosis
B. Respiratory Alkalosis
,C. Metabolic Alkalosis
D. Metabolic Acidosis
Correct Answer: A
Expert Explanation: The pH is below 7.35, indicating acidosis, and the PaCO2 is
elevated above 45 mmHg, indicating a respiratory cause. Since the bicarbonate level
is within the normal range, the imbalance is respiratory acidosis. This condition
often results from hypoventilation or impaired gas exchange in the lungs.
3. Which assessment finding should the nurse prioritize in a patient receiving an IV
infusion of 3% sodium chloride?
A. Decreased bowel sounds
B. Increased urine output
C. Dry mucous membranes
D. Shortness of breath and crackles
Correct Answer: D
Expert Explanation: Hypertonic solutions like 3% sodium chloride pull fluid from
the intracellular space into the intravascular space, increasing the risk of fluid
volume excess. Shortness of breath and crackles are signs of pulmonary edema,
,which is a life-threatening complication of fluid overload. The nurse must monitor
for these respiratory changes and slow the infusion rate if they occur.
4. A patient’s ECG shows tall, peaked T waves. The nurse should suspect an imbalance
in which electrolyte?
A. Potassium
B. Calcium
C. Magnesium
D. Sodium
Correct Answer: A
Expert Explanation: Tall, peaked T waves are a classic electrocardiogram change
associated with hyperkalemia. As potassium levels rise, cardiac conductivity is
affected, potentially leading to lethal arrhythmias. The nurse should immediately
report this finding and prepare to administer medications such as calcium gluconate
or insulin with glucose.
5. The nurse is caring for a patient who is 1-day postoperative and notices the surgical
dressing is saturated with bright red blood. Which action is the priority?
A. Draw a circle around the drainage to monitor
B. Change the dressing to a sterile one
, C. Reinforce the dressing and call the surgeon
D. Administer prescribed pain medication
Correct Answer: C
Expert Explanation: Bright red blood (sanguineous drainage) on a postoperative
dressing suggests active hemorrhage and requires immediate medical attention. The
nurse should reinforce the dressing to control the bleed rather than removing it,
which could disturb a forming clot. Notifying the surgeon is essential to address the
source of the bleeding.
6. While assessing a patient with a potassium level of 3.2 mEq/L, which finding is the
nurse most likely to observe?
A. Diarrhea and hyperactive bowel sounds
B. Positive Chvostek’s sign
C. Increased deep tendon reflexes
D. Muscle weakness and leg cramps
Correct Answer: D
Expert Explanation: Hypokalemia, defined as a potassium level below 3.5 mEq/L,
affects muscle contraction and nerve conduction. Patients often experience muscle
v2 | Questions with Correct Answers and Expert
Explanation for Each Question | Galen
1. A patient is admitted with a serum sodium level of 128 mEq/L. Which nursing
intervention is a priority for this patient?
A. Encouraging increased oral fluid intake
B. Providing a low-sodium diet
C. Administering a dose of oral diuretics
D. Initiating seizure precautions
Correct Answer: D
Expert Explanation: A serum sodium level of 128 mEq/L indicates hyponatremia,
which can cause cerebral edema and increase the risk for seizures. Implementing
seizure precautions is the priority to ensure patient safety during severe electrolyte
shifts. The nurse should also monitor neurological status frequently for changes in
consciousness.
2. The nurse is interpreting ABG results for a patient: pH 7.30, PaCO2 50 mmHg, and
HCO3 24 mEq/L. Which acid-base imbalance does this represent?
A. Respiratory Acidosis
B. Respiratory Alkalosis
,C. Metabolic Alkalosis
D. Metabolic Acidosis
Correct Answer: A
Expert Explanation: The pH is below 7.35, indicating acidosis, and the PaCO2 is
elevated above 45 mmHg, indicating a respiratory cause. Since the bicarbonate level
is within the normal range, the imbalance is respiratory acidosis. This condition
often results from hypoventilation or impaired gas exchange in the lungs.
3. Which assessment finding should the nurse prioritize in a patient receiving an IV
infusion of 3% sodium chloride?
A. Decreased bowel sounds
B. Increased urine output
C. Dry mucous membranes
D. Shortness of breath and crackles
Correct Answer: D
Expert Explanation: Hypertonic solutions like 3% sodium chloride pull fluid from
the intracellular space into the intravascular space, increasing the risk of fluid
volume excess. Shortness of breath and crackles are signs of pulmonary edema,
,which is a life-threatening complication of fluid overload. The nurse must monitor
for these respiratory changes and slow the infusion rate if they occur.
4. A patient’s ECG shows tall, peaked T waves. The nurse should suspect an imbalance
in which electrolyte?
A. Potassium
B. Calcium
C. Magnesium
D. Sodium
Correct Answer: A
Expert Explanation: Tall, peaked T waves are a classic electrocardiogram change
associated with hyperkalemia. As potassium levels rise, cardiac conductivity is
affected, potentially leading to lethal arrhythmias. The nurse should immediately
report this finding and prepare to administer medications such as calcium gluconate
or insulin with glucose.
5. The nurse is caring for a patient who is 1-day postoperative and notices the surgical
dressing is saturated with bright red blood. Which action is the priority?
A. Draw a circle around the drainage to monitor
B. Change the dressing to a sterile one
, C. Reinforce the dressing and call the surgeon
D. Administer prescribed pain medication
Correct Answer: C
Expert Explanation: Bright red blood (sanguineous drainage) on a postoperative
dressing suggests active hemorrhage and requires immediate medical attention. The
nurse should reinforce the dressing to control the bleed rather than removing it,
which could disturb a forming clot. Notifying the surgeon is essential to address the
source of the bleeding.
6. While assessing a patient with a potassium level of 3.2 mEq/L, which finding is the
nurse most likely to observe?
A. Diarrhea and hyperactive bowel sounds
B. Positive Chvostek’s sign
C. Increased deep tendon reflexes
D. Muscle weakness and leg cramps
Correct Answer: D
Expert Explanation: Hypokalemia, defined as a potassium level below 3.5 mEq/L,
affects muscle contraction and nerve conduction. Patients often experience muscle
