NU158 | NU 158 Medical-Surgical Nursing I Exam 2
v1 | Questions with Correct Answers and Expert
Explanation for Each Question | Galen
1. A nurse is assessing a client who is 24 hours postoperative. Which of the following
findings should the nurse prioritize as a sign of a potential complication?
A. Serosanguinous drainage on the dressing
B. Absence of bowel sounds in all quadrants
C. Pain level of 5 on a scale of 0 to 10
D. Urine output of 20 mL/hr for the past 2 hours
Correct Answer: D
Expert Explanation: A urine output of less than 30 mL/hr can indicate
hypovolemia or renal failure and requires immediate notification of the provider.
Serosanguinous drainage and absent bowel sounds are common findings in the first
24 hours after surgery. Pain management is important, but physiological stability
regarding perfusion and organ function takes priority.
2. Which client is at the highest risk for developing metabolic alkalosis?
A. A client with a high fever and rapid respirations
B. A client receiving continuous nasogastric suctioning
C. A client who has had severe diarrhea for 3 days
,D. A client with type 1 diabetes and high blood glucose
Correct Answer: B
Expert Explanation: Metabolic alkalosis often results from the loss of gastric acids
through vomiting or nasogastric suctioning. Diarrhea typically leads to metabolic
acidosis due to the loss of bicarbonate. High fever leads to respiratory alkalosis,
while diabetic ketoacidosis leads to metabolic acidosis.
3. A nurse is caring for a client with a serum potassium level of 2.8 mEq/L. Which of
the following should the nurse monitor for?
A. Hyperactive deep tendon reflexes
B. Flattened T waves and presence of U waves
C. Peaked T waves on the ECG
D. Positive Chvostek’s sign
Correct Answer: B
Expert Explanation: Hypokalemia, defined as a potassium level below 3.5 mEq/L,
is associated with flattened T waves and the development of U waves on an
electrocardiogram. Peaked T waves are a sign of hyperkalemia rather than
hypokalemia. Chvostek’s sign is associated with hypocalcemia or hypomagnesemia,
not potassium imbalances.
,4. What is the primary rationale for keeping a client NPO (nothing by mouth) for 8
hours before general anesthesia?
A. To reduce the risk of aspiration pneumonia
B. To prevent the formation of gas during surgery
C. To prevent postoperative constipation
D. To ensure the patient loses weight before the procedure
Correct Answer: A
Expert Explanation: General anesthesia relaxes the muscles of the esophagus and
reduces the gag reflex, putting the patient at risk for vomiting. If the stomach
contains food or liquid, this can be aspirated into the lungs, leading to severe
pneumonia or airway obstruction. The NPO status is a critical safety measure used
to ensure the stomach is empty during the induction of anesthesia.
5. A nurse is reviewing the laboratory results for a client with a sodium level of 155
mEq/L. Which of the following interventions is appropriate?
A. Administering 3% sodium chloride IV infusion
B. Administering 0.45% sodium chloride IV infusion
C. Encouraging the use of salt substitutes
D. Restricting oral fluid intake
, Correct Answer: B
Expert Explanation: A sodium level of 155 mEq/L indicates hypernatremia, which
requires the administration of hypotonic fluids like 0.45% sodium chloride to dilute
the extracellular fluid. Giving 3% sodium chloride would worsen the condition
because it is a hypertonic solution. Fluid restriction is used for hyponatremia, not
hypernatremia where the client is often dehydrated.
6. The nurse is preparing a client for surgery. Which task is the nurse’s responsibility
regarding informed consent?
A. Explaining the risks and benefits of the procedure
B. Describing alternative treatments to the client
C. Determining if the surgery is medically necessary
D. Witnessing the client’s signature on the consent form
Correct Answer: D
Expert Explanation: The nurse’s role in the informed consent process is to witness
the client’s signature and verify that the client is competent to sign. The surgeon is
legally responsible for explaining the procedure, risks, benefits, and alternatives. If
the nurse feels the client does not understand the surgery, the nurse must contact
the surgeon to provide further clarification.
v1 | Questions with Correct Answers and Expert
Explanation for Each Question | Galen
1. A nurse is assessing a client who is 24 hours postoperative. Which of the following
findings should the nurse prioritize as a sign of a potential complication?
A. Serosanguinous drainage on the dressing
B. Absence of bowel sounds in all quadrants
C. Pain level of 5 on a scale of 0 to 10
D. Urine output of 20 mL/hr for the past 2 hours
Correct Answer: D
Expert Explanation: A urine output of less than 30 mL/hr can indicate
hypovolemia or renal failure and requires immediate notification of the provider.
Serosanguinous drainage and absent bowel sounds are common findings in the first
24 hours after surgery. Pain management is important, but physiological stability
regarding perfusion and organ function takes priority.
2. Which client is at the highest risk for developing metabolic alkalosis?
A. A client with a high fever and rapid respirations
B. A client receiving continuous nasogastric suctioning
C. A client who has had severe diarrhea for 3 days
,D. A client with type 1 diabetes and high blood glucose
Correct Answer: B
Expert Explanation: Metabolic alkalosis often results from the loss of gastric acids
through vomiting or nasogastric suctioning. Diarrhea typically leads to metabolic
acidosis due to the loss of bicarbonate. High fever leads to respiratory alkalosis,
while diabetic ketoacidosis leads to metabolic acidosis.
3. A nurse is caring for a client with a serum potassium level of 2.8 mEq/L. Which of
the following should the nurse monitor for?
A. Hyperactive deep tendon reflexes
B. Flattened T waves and presence of U waves
C. Peaked T waves on the ECG
D. Positive Chvostek’s sign
Correct Answer: B
Expert Explanation: Hypokalemia, defined as a potassium level below 3.5 mEq/L,
is associated with flattened T waves and the development of U waves on an
electrocardiogram. Peaked T waves are a sign of hyperkalemia rather than
hypokalemia. Chvostek’s sign is associated with hypocalcemia or hypomagnesemia,
not potassium imbalances.
,4. What is the primary rationale for keeping a client NPO (nothing by mouth) for 8
hours before general anesthesia?
A. To reduce the risk of aspiration pneumonia
B. To prevent the formation of gas during surgery
C. To prevent postoperative constipation
D. To ensure the patient loses weight before the procedure
Correct Answer: A
Expert Explanation: General anesthesia relaxes the muscles of the esophagus and
reduces the gag reflex, putting the patient at risk for vomiting. If the stomach
contains food or liquid, this can be aspirated into the lungs, leading to severe
pneumonia or airway obstruction. The NPO status is a critical safety measure used
to ensure the stomach is empty during the induction of anesthesia.
5. A nurse is reviewing the laboratory results for a client with a sodium level of 155
mEq/L. Which of the following interventions is appropriate?
A. Administering 3% sodium chloride IV infusion
B. Administering 0.45% sodium chloride IV infusion
C. Encouraging the use of salt substitutes
D. Restricting oral fluid intake
, Correct Answer: B
Expert Explanation: A sodium level of 155 mEq/L indicates hypernatremia, which
requires the administration of hypotonic fluids like 0.45% sodium chloride to dilute
the extracellular fluid. Giving 3% sodium chloride would worsen the condition
because it is a hypertonic solution. Fluid restriction is used for hyponatremia, not
hypernatremia where the client is often dehydrated.
6. The nurse is preparing a client for surgery. Which task is the nurse’s responsibility
regarding informed consent?
A. Explaining the risks and benefits of the procedure
B. Describing alternative treatments to the client
C. Determining if the surgery is medically necessary
D. Witnessing the client’s signature on the consent form
Correct Answer: D
Expert Explanation: The nurse’s role in the informed consent process is to witness
the client’s signature and verify that the client is competent to sign. The surgeon is
legally responsible for explaining the procedure, risks, benefits, and alternatives. If
the nurse feels the client does not understand the surgery, the nurse must contact
the surgeon to provide further clarification.
