NU158 | NU 158 Medical-Surgical Nursing I Exam 1
v3 | Questions with Correct Answers and Expert
Explanation for Each Question | Galen
1. A nurse is caring for a client who is experiencing severe vomiting for 24 hours.
Which acid-base imbalance should the nurse prioritize in the assessment?
A. Metabolic Acidosis
B. Metabolic Alkalosis
C. Respiratory Alkalosis
D. Respiratory Acidosis
Correct Answer: B
Expert Explanation: Metabolic alkalosis occurs because of the loss of gastric acid
(hydrochloric acid) during vomiting. This loss results in an increased concentration
of bicarbonate in the blood. The nurse must monitor for clinical manifestations such
as irritability, muscle twitching, and shallow respirations.
2. A nurse is reviewing the laboratory results of a client with a potassium level of 2.8
mEq/L. Which of the following findings should the nurse expect on the ECG?
A. Peaked T waves
B. Prominent U waves
C. Widened QRS complex
,D. Shortened PR interval
Correct Answer: B
Expert Explanation: Hypokalemia, defined as a potassium level below 3.5 mEq/L,
typically manifests as prominent U waves on an ECG. It can also cause ST-segment
depression and flattened T waves. The nurse should be aware that these electrical
changes increase the risk of cardiac dysrhythmias and require immediate
intervention.
3. A client is scheduled for elective surgery. The nurse knows that the primary
responsibility for obtaining informed consent belongs to which individual?
A. The circulating nurse
B. The surgeon
C. The anesthesiologist
D. The charge nurse
Correct Answer: B
Expert Explanation: The surgeon is legally responsible for explaining the
procedure, risks, benefits, and alternatives to the client. The nurse’s role is generally
to witness the client’s signature and ensure the client understands their rights. If the
client has questions about the surgery itself, the nurse must notify the surgeon to
return and provide further clarification.
,4. While assessing a postoperative client, the nurse notes the client’s wound has
separated and internal organs are protruding. What is the nurse’s priority action?
A. Push the organs back into the abdominal cavity
B. Ask the client to cough to clear secretions
C. Cover the wound with sterile gauze soaked in normal saline
D. Place the client in a high-Fowler’s position
Correct Answer: C
Expert Explanation: This condition is known as evisceration and is a surgical
emergency. The nurse should cover the exposed organs with sterile, saline-soaked
dressings to keep them moist and prevent infection. The nurse must then notify the
surgical team immediately and keep the client in a low-Fowler’s position with knees
flexed.
5. A nurse is assessing a client with hypocalcemia. Which of the following signs would
the nurse expect to find?
A. Negative Chvostek’s sign
B. Positive Trousseau’s sign
C. Flaccid paralysis
D. Hyporeflexia
, Correct Answer: B
Expert Explanation: A positive Trousseau’s sign, which is carpal spasm induced by
inflating a blood pressure cuff, indicates neuromuscular irritability associated with
hypocalcemia. Another common finding is Chvostek’s sign, which is a facial twitch
elicited by tapping the facial nerve. Low calcium levels lead to increased nerve
excitability and potential tetany.
6. A nurse is teaching a client about the inflammatory response. Which of the
following should the nurse identify as a localized sign of inflammation?
A. Fever
B. Leukocytosis
C. Edema
D. Anorexia
Correct Answer: C
Expert Explanation: Edema is one of the five cardinal local signs of inflammation,
resulting from increased capillary permeability. Other local signs include heat,
redness, pain, and loss of function. Systemic signs, in contrast, include fever and an
elevated white blood cell count (leukocytosis).
v3 | Questions with Correct Answers and Expert
Explanation for Each Question | Galen
1. A nurse is caring for a client who is experiencing severe vomiting for 24 hours.
Which acid-base imbalance should the nurse prioritize in the assessment?
A. Metabolic Acidosis
B. Metabolic Alkalosis
C. Respiratory Alkalosis
D. Respiratory Acidosis
Correct Answer: B
Expert Explanation: Metabolic alkalosis occurs because of the loss of gastric acid
(hydrochloric acid) during vomiting. This loss results in an increased concentration
of bicarbonate in the blood. The nurse must monitor for clinical manifestations such
as irritability, muscle twitching, and shallow respirations.
2. A nurse is reviewing the laboratory results of a client with a potassium level of 2.8
mEq/L. Which of the following findings should the nurse expect on the ECG?
A. Peaked T waves
B. Prominent U waves
C. Widened QRS complex
,D. Shortened PR interval
Correct Answer: B
Expert Explanation: Hypokalemia, defined as a potassium level below 3.5 mEq/L,
typically manifests as prominent U waves on an ECG. It can also cause ST-segment
depression and flattened T waves. The nurse should be aware that these electrical
changes increase the risk of cardiac dysrhythmias and require immediate
intervention.
3. A client is scheduled for elective surgery. The nurse knows that the primary
responsibility for obtaining informed consent belongs to which individual?
A. The circulating nurse
B. The surgeon
C. The anesthesiologist
D. The charge nurse
Correct Answer: B
Expert Explanation: The surgeon is legally responsible for explaining the
procedure, risks, benefits, and alternatives to the client. The nurse’s role is generally
to witness the client’s signature and ensure the client understands their rights. If the
client has questions about the surgery itself, the nurse must notify the surgeon to
return and provide further clarification.
,4. While assessing a postoperative client, the nurse notes the client’s wound has
separated and internal organs are protruding. What is the nurse’s priority action?
A. Push the organs back into the abdominal cavity
B. Ask the client to cough to clear secretions
C. Cover the wound with sterile gauze soaked in normal saline
D. Place the client in a high-Fowler’s position
Correct Answer: C
Expert Explanation: This condition is known as evisceration and is a surgical
emergency. The nurse should cover the exposed organs with sterile, saline-soaked
dressings to keep them moist and prevent infection. The nurse must then notify the
surgical team immediately and keep the client in a low-Fowler’s position with knees
flexed.
5. A nurse is assessing a client with hypocalcemia. Which of the following signs would
the nurse expect to find?
A. Negative Chvostek’s sign
B. Positive Trousseau’s sign
C. Flaccid paralysis
D. Hyporeflexia
, Correct Answer: B
Expert Explanation: A positive Trousseau’s sign, which is carpal spasm induced by
inflating a blood pressure cuff, indicates neuromuscular irritability associated with
hypocalcemia. Another common finding is Chvostek’s sign, which is a facial twitch
elicited by tapping the facial nerve. Low calcium levels lead to increased nerve
excitability and potential tetany.
6. A nurse is teaching a client about the inflammatory response. Which of the
following should the nurse identify as a localized sign of inflammation?
A. Fever
B. Leukocytosis
C. Edema
D. Anorexia
Correct Answer: C
Expert Explanation: Edema is one of the five cardinal local signs of inflammation,
resulting from increased capillary permeability. Other local signs include heat,
redness, pain, and loss of function. Systemic signs, in contrast, include fever and an
elevated white blood cell count (leukocytosis).
