NU158 | NU 158 Medical-Surgical Nursing I Exam 1
v3 | Questions with Correct Answers and Expert
Explanation for Each Question | Galen
1. A patient is admitted with a serum sodium level of 125 mEq/L. Which assessment
finding is the priority for the nurse to report?
A. Dry mucous membranes
B. Increased thirst
C. Confusion and seizures
D. Reduced skin turgor
Correct Answer: C
Expert Explanation: Hyponatremia causes a shift of water into the brain cells,
leading to cerebral edema. Neurological changes such as confusion and seizures are
critical indicators of worsening status. The nurse must prioritize patient safety and
neurological monitoring to prevent permanent damage.
2. A nurse is caring for a patient with a potassium level of 6.2 mEq/L. Which ECG
change should the nurse expect to see?
A. Prominent U waves
B. Tall, peaked T waves
C. ST segment depression
,D. Inverted P waves
Correct Answer: B
Expert Explanation: Hyperkalemia primarily affects the cardiac conduction system
by narrowing the T wave and making it taller. As levels increase further, the QRS
complex may widen and lead to cardiac arrest. Immediate intervention is required
to shift potassium back into cells or eliminate it from the body.
3. The nurse is reviewing ABG results: pH 7.30, PaCO2 52 mmHg, HCO3 24 mEq/L. How
should the nurse interpret these findings?
A. Respiratory Acidosis
B. Respiratory Alkalosis
C. Metabolic Acidosis
D. Metabolic Alkalosis
Correct Answer: A
Expert Explanation: A pH below 7.35 indicates acidosis, and a PaCO2 above 45
mmHg indicates a respiratory cause. Since the bicarbonate level is normal, there is
no compensation occurring yet. This condition is often seen in patients with
hypoventilation or COPD.
,4. Which electrolyte imbalance is characterized by a positive Chvostek’s sign and
Trousseau’s sign?
A. Hypercalcemia
B. Hypocalcemia
C. Hyperkalemia
D. Hyponatremia
Correct Answer: B
Expert Explanation: Hypocalcemia increases neuromuscular irritability, leading to
spasms and tetany. Chvostek’s sign is elicited by tapping the facial nerve, while
Trousseau’s sign is seen when inflating a blood pressure cuff. Nurses should
monitor these patients for laryngeal spasms and potential airway obstruction.
5. A patient is scheduled for surgery. Who is legally responsible for obtaining the
patient’s informed consent?
A. The registered nurse
B. The anesthesiologist
C. The surgeon
D. The charge nurse
Correct Answer: C
, Expert Explanation: The surgeon is the individual performing the procedure and
holds the legal duty to explain risks, benefits, and alternatives. The nurse’s role is
typically to witness the signature and ensure the patient understands the
information. If the patient has questions, the nurse must call the surgeon back to
explain further.
6. A post-operative patient reports sudden chest pain and shortness of breath. Which
complication should the nurse suspect first?
A. Pneumonia
B. Atelectasis
C. Hemorrhage
D. Pulmonary Embolism
Correct Answer: D
Expert Explanation: Sudden onset of dyspnea and chest pain in a post-op patient is
a classic sign of a pulmonary embolism. This is often caused by a deep vein
thrombosis that has migrated to the lungs. Rapid response and oxygen
administration are necessary interventions.
7. What is the primary purpose of the ‘Time-Out’ procedure in the operating room?
A. To allow the anesthesia to take effect
B. To count all sponges and instruments
v3 | Questions with Correct Answers and Expert
Explanation for Each Question | Galen
1. A patient is admitted with a serum sodium level of 125 mEq/L. Which assessment
finding is the priority for the nurse to report?
A. Dry mucous membranes
B. Increased thirst
C. Confusion and seizures
D. Reduced skin turgor
Correct Answer: C
Expert Explanation: Hyponatremia causes a shift of water into the brain cells,
leading to cerebral edema. Neurological changes such as confusion and seizures are
critical indicators of worsening status. The nurse must prioritize patient safety and
neurological monitoring to prevent permanent damage.
2. A nurse is caring for a patient with a potassium level of 6.2 mEq/L. Which ECG
change should the nurse expect to see?
A. Prominent U waves
B. Tall, peaked T waves
C. ST segment depression
,D. Inverted P waves
Correct Answer: B
Expert Explanation: Hyperkalemia primarily affects the cardiac conduction system
by narrowing the T wave and making it taller. As levels increase further, the QRS
complex may widen and lead to cardiac arrest. Immediate intervention is required
to shift potassium back into cells or eliminate it from the body.
3. The nurse is reviewing ABG results: pH 7.30, PaCO2 52 mmHg, HCO3 24 mEq/L. How
should the nurse interpret these findings?
A. Respiratory Acidosis
B. Respiratory Alkalosis
C. Metabolic Acidosis
D. Metabolic Alkalosis
Correct Answer: A
Expert Explanation: A pH below 7.35 indicates acidosis, and a PaCO2 above 45
mmHg indicates a respiratory cause. Since the bicarbonate level is normal, there is
no compensation occurring yet. This condition is often seen in patients with
hypoventilation or COPD.
,4. Which electrolyte imbalance is characterized by a positive Chvostek’s sign and
Trousseau’s sign?
A. Hypercalcemia
B. Hypocalcemia
C. Hyperkalemia
D. Hyponatremia
Correct Answer: B
Expert Explanation: Hypocalcemia increases neuromuscular irritability, leading to
spasms and tetany. Chvostek’s sign is elicited by tapping the facial nerve, while
Trousseau’s sign is seen when inflating a blood pressure cuff. Nurses should
monitor these patients for laryngeal spasms and potential airway obstruction.
5. A patient is scheduled for surgery. Who is legally responsible for obtaining the
patient’s informed consent?
A. The registered nurse
B. The anesthesiologist
C. The surgeon
D. The charge nurse
Correct Answer: C
, Expert Explanation: The surgeon is the individual performing the procedure and
holds the legal duty to explain risks, benefits, and alternatives. The nurse’s role is
typically to witness the signature and ensure the patient understands the
information. If the patient has questions, the nurse must call the surgeon back to
explain further.
6. A post-operative patient reports sudden chest pain and shortness of breath. Which
complication should the nurse suspect first?
A. Pneumonia
B. Atelectasis
C. Hemorrhage
D. Pulmonary Embolism
Correct Answer: D
Expert Explanation: Sudden onset of dyspnea and chest pain in a post-op patient is
a classic sign of a pulmonary embolism. This is often caused by a deep vein
thrombosis that has migrated to the lungs. Rapid response and oxygen
administration are necessary interventions.
7. What is the primary purpose of the ‘Time-Out’ procedure in the operating room?
A. To allow the anesthesia to take effect
B. To count all sponges and instruments
