NU158 | NU 158 Medical-Surgical Nursing I
Midterm v1 | Questions with Correct Answers and
Expert Explanation for Each Question | Galen
1. A nurse is caring for a patient with a potassium level of 6.2 mEq/L. Which of the
following is the priority intervention?
A. Administer oral potassium supplements
B. Document the finding as a normal variation
C. Encourage the intake of bananas and orange juice
D. Place the patient on a cardiac monitor
Correct Answer: D
Expert Explanation: Hyperkalemia is defined as a potassium level above 5.0 mEq/L
and poses a significant risk for life-threatening cardiac arrhythmias. Placing the
patient on a cardiac monitor allows the nurse to detect ECG changes such as peaked
T waves or widened QRS complexes immediately. This is the priority action to
ensure patient safety before initiating medical treatments to lower potassium.
2. Which assessment finding should the nurse expect in a patient experiencing fluid
volume deficit?
A. Distended neck veins
B. Bounding pulse
,C. Crackles in the lungs
D. Decreased skin turgor
Correct Answer: D
Expert Explanation: Fluid volume deficit, or dehydration, results in a loss of
interstitial fluid which leads to decreased skin turgor and tenting. The patient’s
blood pressure usually decreases and the pulse becomes weak or thready rather
than bounding. Distended neck veins and crackles are associated with fluid volume
excess rather than deficit.
3. A patient’s arterial blood gas (ABG) results are: pH 7.30, PaCO2 55 mmHg, and HCO3
24 mEq/L. How should the nurse interpret these results?
A. Respiratory Acidosis
B. Metabolic Alkalosis
C. Metabolic Acidosis
D. Respiratory Alkalosis
Correct Answer: A
Expert Explanation: The pH is below 7.35, indicating acidosis. The PaCO2 is
elevated above 45 mmHg, which is the respiratory component, while the HCO3 is
,within the normal range. Because the low pH corresponds with the high CO2, this
indicates a primary respiratory acidosis.
4. Which preoperative task is the primary responsibility of the nurse regarding
informed consent?
A. Explaining the risks and benefits of the surgery
B. Deciding if the patient needs the procedure
C. Obtaining the patient’s signature and witnessing it
D. Describing alternative treatments to the patient
Correct Answer: C
Expert Explanation: The nurse’s role in informed consent is to act as a witness to
the patient’s signature and ensure the patient appears competent to sign. It is the
surgeon’s responsibility to explain the procedure, risks, benefits, and alternatives.
The nurse should verify that the patient has had their questions answered by the
surgeon before the signature is obtained.
5. A patient is 2 days postoperative and complains of calf pain and swelling. What
should be the nurse’s first action?
A. Elevate the extremity and notify the provider
B. Apply a heating pad to the area
, C. Massage the calf to relieve pain
D. Encourage the patient to walk in the hallway
Correct Answer: A
Expert Explanation: Calf pain and swelling are classic signs of Deep Vein
Thrombosis (DVT), a common postoperative complication. The nurse should elevate
the limb to promote venous return and notify the healthcare provider for further
diagnostic testing like a venous duplex ultrasound. Massaging or walking could
dislodge the clot and cause a pulmonary embolism.
6. Which electrolyte imbalance is most closely associated with the presence of
Trousseau’s sign?
A. Hypermagnesemia
B. Hyperkalemia
C. Hypocalcemia
D. Hyponatremia
Correct Answer: C
Expert Explanation: Trousseau’s sign, characterized by carpal spasm after inflating
a blood pressure cuff, is a classic indicator of hypocalcemia. This occurs because low
Midterm v1 | Questions with Correct Answers and
Expert Explanation for Each Question | Galen
1. A nurse is caring for a patient with a potassium level of 6.2 mEq/L. Which of the
following is the priority intervention?
A. Administer oral potassium supplements
B. Document the finding as a normal variation
C. Encourage the intake of bananas and orange juice
D. Place the patient on a cardiac monitor
Correct Answer: D
Expert Explanation: Hyperkalemia is defined as a potassium level above 5.0 mEq/L
and poses a significant risk for life-threatening cardiac arrhythmias. Placing the
patient on a cardiac monitor allows the nurse to detect ECG changes such as peaked
T waves or widened QRS complexes immediately. This is the priority action to
ensure patient safety before initiating medical treatments to lower potassium.
2. Which assessment finding should the nurse expect in a patient experiencing fluid
volume deficit?
A. Distended neck veins
B. Bounding pulse
,C. Crackles in the lungs
D. Decreased skin turgor
Correct Answer: D
Expert Explanation: Fluid volume deficit, or dehydration, results in a loss of
interstitial fluid which leads to decreased skin turgor and tenting. The patient’s
blood pressure usually decreases and the pulse becomes weak or thready rather
than bounding. Distended neck veins and crackles are associated with fluid volume
excess rather than deficit.
3. A patient’s arterial blood gas (ABG) results are: pH 7.30, PaCO2 55 mmHg, and HCO3
24 mEq/L. How should the nurse interpret these results?
A. Respiratory Acidosis
B. Metabolic Alkalosis
C. Metabolic Acidosis
D. Respiratory Alkalosis
Correct Answer: A
Expert Explanation: The pH is below 7.35, indicating acidosis. The PaCO2 is
elevated above 45 mmHg, which is the respiratory component, while the HCO3 is
,within the normal range. Because the low pH corresponds with the high CO2, this
indicates a primary respiratory acidosis.
4. Which preoperative task is the primary responsibility of the nurse regarding
informed consent?
A. Explaining the risks and benefits of the surgery
B. Deciding if the patient needs the procedure
C. Obtaining the patient’s signature and witnessing it
D. Describing alternative treatments to the patient
Correct Answer: C
Expert Explanation: The nurse’s role in informed consent is to act as a witness to
the patient’s signature and ensure the patient appears competent to sign. It is the
surgeon’s responsibility to explain the procedure, risks, benefits, and alternatives.
The nurse should verify that the patient has had their questions answered by the
surgeon before the signature is obtained.
5. A patient is 2 days postoperative and complains of calf pain and swelling. What
should be the nurse’s first action?
A. Elevate the extremity and notify the provider
B. Apply a heating pad to the area
, C. Massage the calf to relieve pain
D. Encourage the patient to walk in the hallway
Correct Answer: A
Expert Explanation: Calf pain and swelling are classic signs of Deep Vein
Thrombosis (DVT), a common postoperative complication. The nurse should elevate
the limb to promote venous return and notify the healthcare provider for further
diagnostic testing like a venous duplex ultrasound. Massaging or walking could
dislodge the clot and cause a pulmonary embolism.
6. Which electrolyte imbalance is most closely associated with the presence of
Trousseau’s sign?
A. Hypermagnesemia
B. Hyperkalemia
C. Hypocalcemia
D. Hyponatremia
Correct Answer: C
Expert Explanation: Trousseau’s sign, characterized by carpal spasm after inflating
a blood pressure cuff, is a classic indicator of hypocalcemia. This occurs because low
