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 caring for a patient with a serum potassium level of 2.8 mEq/L. Which
assessment finding should the nurse prioritize?
A. Hyperactive bowel sounds
B. Increased muscle strength
C. Irregular heart rhythm
D. Elevated blood pressure
Correct Answer: C
Expert Explanation: The patient is experiencing hypokalemia, which can cause
significant cardiac dysrhythmias and ECG changes. A potassium level of 2.8 mEq/L is
critically low and requires immediate cardiac monitoring. The nurse must prioritize
cardiovascular assessment to ensure patient safety and prevent cardiac arrest.
2. The nurse is witnessing a patient sign an informed consent form for surgery. Which
statement best describes the nurse’s primary responsibility?
A. Explaining the risks and benefits of the procedure
B. Ensuring the patient understands the surgical alternative
C. Providing a detailed description of the anesthesia used
,D. Confirming that the signature is authentic and voluntary
Correct Answer: D
Expert Explanation: The nurse’s role in the informed consent process is to act as a
witness to the patient’s signature. It is the surgeon’s legal responsibility to explain
the procedure, risks, and benefits to the patient. If the patient expresses a lack of
understanding, the nurse must notify the surgeon before the patient signs the form.
3. A patient’s ABG results are: pH 7.32, PaCO2 52 mmHg, and HCO3 24 mEq/L. How
should the nurse interpret these findings?
A. Respiratory Acidosis
B. Metabolic Acidosis
C. Metabolic Alkalosis
D. Respiratory Alkalosis
Correct Answer: A
Expert Explanation: The pH of 7.32 indicates acidosis since it is below the normal
range of 7.35 to 7.45. The PaCO2 is elevated at 52 mmHg, which points to a
respiratory cause for the acidosis. Since the bicarbonate level is normal, this is an
uncompensated respiratory acidosis likely caused by hypoventilation.
,4. Which clinical manifestation should the nurse expect to find in a patient with fluid
volume deficit?
A. Orthostatic hypotension
B. Bounding peripheral pulses
C. Distended neck veins
D. Crackles in the lung bases
Correct Answer: A
Expert Explanation: Fluid volume deficit leads to decreased circulating blood
volume, which often manifests as orthostatic hypotension. Patients may also present
with a rapid, thready pulse and poor skin turgor. Other findings such as crackles and
distended neck veins are signs of fluid volume excess.
5. A patient is diagnosed with hypercalcemia. Which intervention is most appropriate
for the nurse to include in the care plan?
A. Administering calcium supplements
B. Encouraging fluid intake of 3,000 to 4,000 mL daily
C. Restricting weight-bearing physical activity
D. Monitoring for a positive Chvostek’s sign
Correct Answer: B
, Expert Explanation: High levels of calcium increase the risk of developing renal
calculi (kidney stones). Increasing fluid intake helps to dilute the urine and promote
the excretion of excess calcium. Weight-bearing exercise is actually encouraged to
help keep calcium in the bones rather than the bloodstream.
6. During a surgical procedure, the patient develops a heart rate of 140 bpm, muscle
rigidity, and a rapidly rising temperature. Which medication should the nurse
prepare?
A. Dantrolene sodium
B. Atropine sulfate
C. Epinephrine
D. Naloxone
Correct Answer: A
Expert Explanation: These symptoms are classic signs of malignant hyperthermia,
a life-threatening complication of general anesthesia. Dantrolene sodium is the
specific skeletal muscle relaxant used to treat this condition. It works by interfering
with the release of calcium in muscle cells to stop the hypermetabolic state.
7. A patient is using a patient-controlled analgesia (PCA) pump following abdominal
surgery. Which instruction is vital for the nurse to give the family?
A. Press the button whenever the patient looks uncomfortable.
v1 | Questions with Correct Answers and Expert
Explanation for Each Question | Galen
1. A nurse is caring for a patient with a serum potassium level of 2.8 mEq/L. Which
assessment finding should the nurse prioritize?
A. Hyperactive bowel sounds
B. Increased muscle strength
C. Irregular heart rhythm
D. Elevated blood pressure
Correct Answer: C
Expert Explanation: The patient is experiencing hypokalemia, which can cause
significant cardiac dysrhythmias and ECG changes. A potassium level of 2.8 mEq/L is
critically low and requires immediate cardiac monitoring. The nurse must prioritize
cardiovascular assessment to ensure patient safety and prevent cardiac arrest.
2. The nurse is witnessing a patient sign an informed consent form for surgery. Which
statement best describes the nurse’s primary responsibility?
A. Explaining the risks and benefits of the procedure
B. Ensuring the patient understands the surgical alternative
C. Providing a detailed description of the anesthesia used
,D. Confirming that the signature is authentic and voluntary
Correct Answer: D
Expert Explanation: The nurse’s role in the informed consent process is to act as a
witness to the patient’s signature. It is the surgeon’s legal responsibility to explain
the procedure, risks, and benefits to the patient. If the patient expresses a lack of
understanding, the nurse must notify the surgeon before the patient signs the form.
3. A patient’s ABG results are: pH 7.32, PaCO2 52 mmHg, and HCO3 24 mEq/L. How
should the nurse interpret these findings?
A. Respiratory Acidosis
B. Metabolic Acidosis
C. Metabolic Alkalosis
D. Respiratory Alkalosis
Correct Answer: A
Expert Explanation: The pH of 7.32 indicates acidosis since it is below the normal
range of 7.35 to 7.45. The PaCO2 is elevated at 52 mmHg, which points to a
respiratory cause for the acidosis. Since the bicarbonate level is normal, this is an
uncompensated respiratory acidosis likely caused by hypoventilation.
,4. Which clinical manifestation should the nurse expect to find in a patient with fluid
volume deficit?
A. Orthostatic hypotension
B. Bounding peripheral pulses
C. Distended neck veins
D. Crackles in the lung bases
Correct Answer: A
Expert Explanation: Fluid volume deficit leads to decreased circulating blood
volume, which often manifests as orthostatic hypotension. Patients may also present
with a rapid, thready pulse and poor skin turgor. Other findings such as crackles and
distended neck veins are signs of fluid volume excess.
5. A patient is diagnosed with hypercalcemia. Which intervention is most appropriate
for the nurse to include in the care plan?
A. Administering calcium supplements
B. Encouraging fluid intake of 3,000 to 4,000 mL daily
C. Restricting weight-bearing physical activity
D. Monitoring for a positive Chvostek’s sign
Correct Answer: B
, Expert Explanation: High levels of calcium increase the risk of developing renal
calculi (kidney stones). Increasing fluid intake helps to dilute the urine and promote
the excretion of excess calcium. Weight-bearing exercise is actually encouraged to
help keep calcium in the bones rather than the bloodstream.
6. During a surgical procedure, the patient develops a heart rate of 140 bpm, muscle
rigidity, and a rapidly rising temperature. Which medication should the nurse
prepare?
A. Dantrolene sodium
B. Atropine sulfate
C. Epinephrine
D. Naloxone
Correct Answer: A
Expert Explanation: These symptoms are classic signs of malignant hyperthermia,
a life-threatening complication of general anesthesia. Dantrolene sodium is the
specific skeletal muscle relaxant used to treat this condition. It works by interfering
with the release of calcium in muscle cells to stop the hypermetabolic state.
7. A patient is using a patient-controlled analgesia (PCA) pump following abdominal
surgery. Which instruction is vital for the nurse to give the family?
A. Press the button whenever the patient looks uncomfortable.
