NU158 | NU 158 Medical-Surgical Nursing I Exam 2
v3 | Questions with Correct Answers and Expert
Explanation for Each Question | Galen
1. A nurse is caring for a patient with a potassium level of 2.8 mEq/L. Which
assessment finding should the nurse prioritize?
A. Prominent U-waves on the ECG
B. Hyperactive bowel sounds
C. Positive Chvostek’s sign
D. Tall, peaked T-waves
Correct Answer: A
Expert Explanation: Hypokalemia is characterized by a potassium level below 3.5
mEq/L and can cause significant cardiac electrical changes. The presence of U-
waves is a classic electrocardiogram finding associated with low potassium levels.
The nurse must monitor for life-threatening dysrhythmias and prepare for
potassium replacement therapy as ordered.
2. Which ABG result indicates compensated respiratory acidosis?
A. pH 7.36, PaCO2 55, HCO3 30
B. pH 7.30, PaCO2 50, HCO3 24
C. pH 7.48, PaCO2 30, HCO3 22
,D. pH 7.25, PaCO2 35, HCO3 18
Correct Answer: A
Expert Explanation: In compensated respiratory acidosis, the pH returns to the
normal range but remains on the acidic side of 7.4. The PaCO2 is elevated, indicating
the primary respiratory problem, while the HCO3 is also elevated as the kidneys
retain bicarbonate to buffer the acid. This reflects a chronic condition where the
body has had time to adjust its chemistry.
3. A patient with heart failure is prescribed furosemide. What should the nurse
include in the teaching?
A. Increase intake of spinach and kale
B. Eat more potassium-rich foods like potatoes
C. Limit intake of bananas and oranges
D. Take the medication at bedtime
Correct Answer: B
Expert Explanation: Furosemide is a loop diuretic that causes the excretion of
potassium along with water and sodium. Patients should be encouraged to consume
potassium-rich foods to prevent hypokalemia. It is also important to advise the
patient to take the dose in the morning to avoid nocturia.
,4. A nurse is assessing a patient for a suspected DVT. Which clinical manifestation is
most common?
A. Bilateral pitting edema
B. Unilateral calf swelling and tenderness
C. Cool, pale skin on the affected extremity
D. Absent pedal pulses
Correct Answer: B
Expert Explanation: Deep vein thrombosis (DVT) typically presents in only one
extremity, leading to unilateral swelling. The area may also be warm to the touch
and tender upon palpation. Nurses should measure the calf circumference to
objectively monitor for changes in swelling over time.
5. Which position is most appropriate for a patient immediately following a
thoracentesis?
A. High-Fowler’s position
B. Prone with a pillow under the chest
C. Side-lying on the unaffected side
D. Supine with the head of the bed flat
Correct Answer: C
, Expert Explanation: Positioning the patient on the unaffected side for about an
hour helps to promote expansion of the lung on the side that was procedure. This
position also allows the puncture site to be uppermost, reducing the risk of fluid
leakage. The nurse should continue to monitor the patient for signs of
pneumothorax or respiratory distress.
6. A patient with COPD is receiving oxygen at 2L/min via nasal cannula. Why is higher
flow oxygen often contraindicated?
A. It causes oxygen toxicity in the alveoli
B. It leads to rapid dehydration of mucous membranes
C. It increases the risk of combustion in the room
D. It can suppress the patient’s drive to breathe
Correct Answer: D
Expert Explanation: Patients with chronic CO2 retention rely on low oxygen levels
(hypoxic drive) to stimulate their breathing. Providing excessive oxygen can satisfy
this drive and cause the patient to stop breathing or develop respiratory arrest.
Nurses must carefully titrate oxygen to maintain an SpO2 between 88% and 92% in
these specific patients.
v3 | Questions with Correct Answers and Expert
Explanation for Each Question | Galen
1. A nurse is caring for a patient with a potassium level of 2.8 mEq/L. Which
assessment finding should the nurse prioritize?
A. Prominent U-waves on the ECG
B. Hyperactive bowel sounds
C. Positive Chvostek’s sign
D. Tall, peaked T-waves
Correct Answer: A
Expert Explanation: Hypokalemia is characterized by a potassium level below 3.5
mEq/L and can cause significant cardiac electrical changes. The presence of U-
waves is a classic electrocardiogram finding associated with low potassium levels.
The nurse must monitor for life-threatening dysrhythmias and prepare for
potassium replacement therapy as ordered.
2. Which ABG result indicates compensated respiratory acidosis?
A. pH 7.36, PaCO2 55, HCO3 30
B. pH 7.30, PaCO2 50, HCO3 24
C. pH 7.48, PaCO2 30, HCO3 22
,D. pH 7.25, PaCO2 35, HCO3 18
Correct Answer: A
Expert Explanation: In compensated respiratory acidosis, the pH returns to the
normal range but remains on the acidic side of 7.4. The PaCO2 is elevated, indicating
the primary respiratory problem, while the HCO3 is also elevated as the kidneys
retain bicarbonate to buffer the acid. This reflects a chronic condition where the
body has had time to adjust its chemistry.
3. A patient with heart failure is prescribed furosemide. What should the nurse
include in the teaching?
A. Increase intake of spinach and kale
B. Eat more potassium-rich foods like potatoes
C. Limit intake of bananas and oranges
D. Take the medication at bedtime
Correct Answer: B
Expert Explanation: Furosemide is a loop diuretic that causes the excretion of
potassium along with water and sodium. Patients should be encouraged to consume
potassium-rich foods to prevent hypokalemia. It is also important to advise the
patient to take the dose in the morning to avoid nocturia.
,4. A nurse is assessing a patient for a suspected DVT. Which clinical manifestation is
most common?
A. Bilateral pitting edema
B. Unilateral calf swelling and tenderness
C. Cool, pale skin on the affected extremity
D. Absent pedal pulses
Correct Answer: B
Expert Explanation: Deep vein thrombosis (DVT) typically presents in only one
extremity, leading to unilateral swelling. The area may also be warm to the touch
and tender upon palpation. Nurses should measure the calf circumference to
objectively monitor for changes in swelling over time.
5. Which position is most appropriate for a patient immediately following a
thoracentesis?
A. High-Fowler’s position
B. Prone with a pillow under the chest
C. Side-lying on the unaffected side
D. Supine with the head of the bed flat
Correct Answer: C
, Expert Explanation: Positioning the patient on the unaffected side for about an
hour helps to promote expansion of the lung on the side that was procedure. This
position also allows the puncture site to be uppermost, reducing the risk of fluid
leakage. The nurse should continue to monitor the patient for signs of
pneumothorax or respiratory distress.
6. A patient with COPD is receiving oxygen at 2L/min via nasal cannula. Why is higher
flow oxygen often contraindicated?
A. It causes oxygen toxicity in the alveoli
B. It leads to rapid dehydration of mucous membranes
C. It increases the risk of combustion in the room
D. It can suppress the patient’s drive to breathe
Correct Answer: D
Expert Explanation: Patients with chronic CO2 retention rely on low oxygen levels
(hypoxic drive) to stimulate their breathing. Providing excessive oxygen can satisfy
this drive and cause the patient to stop breathing or develop respiratory arrest.
Nurses must carefully titrate oxygen to maintain an SpO2 between 88% and 92% in
these specific patients.
