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 who is 24 hours postoperative following abdominal
surgery. The patient reports sudden chest pain and shortness of breath. Which action
should the nurse take first?
A. Administer the prescribed PRN pain medication.
B. Perform a complete head-to-toe assessment.
C. Encourage the use of the incentive spirometer.
D. Apply oxygen and elevate the head of the bed.
Correct Answer: D
Expert Explanation: The patient’s symptoms are highly suggestive of a pulmonary
embolism, which is a life-threatening postoperative complication. Applying oxygen
and elevating the head of the bed are immediate interventions to improve
oxygenation and respiratory effort. These actions prioritize the ABCs (Airway,
Breathing, and Circulation) before further diagnostics are performed.
2. A patient has a potassium level of 3.1 mEq/L. Which of the following clinical
manifestations should the nurse expect to find?
A. Hyperactive bowel sounds and diarrhea.
,B. Muscle weakness and shallow respirations.
C. Peaked T waves on the EKG.
D. Hyperreflexia and twitching.
Correct Answer: B
Expert Explanation: Hypokalemia, defined as a potassium level below 3.5 mEq/L,
can lead to significant muscle weakness and respiratory depression. Lower levels of
potassium decrease the excitability of muscle tissues, leading to lethargy or even
paralysis. The nurse should monitor for cardiac dysrhythmias and respiratory
failure in these patients.
3. The nurse is preparing a patient for surgery. The patient states, ‘I am not sure I want
to have this surgery anymore because I don’t understand the risks.’ Which action is
most appropriate?
A. Explain the risks of the surgery to the patient.
B. Ask the patient to sign the consent form anyway.
C. Notify the surgeon that the patient needs further clarification.
D. Reassure the patient that the surgeon is very experienced.
Correct Answer: C
,Expert Explanation: It is the surgeon’s legal responsibility to explain the risks,
benefits, and alternatives of a procedure to provide informed consent. The nurse
acts as a witness to the signature but cannot provide the primary education
regarding the procedure itself. Notifying the surgeon ensures that the patient’s legal
rights and safety are maintained before going to the operating room.
4. A patient’s ABG results are: pH 7.30, PaCO2 52 mmHg, and HCO3 24 mEq/L. How
should the nurse interpret these findings?
A. Metabolic Acidosis
B. Metabolic Alkalosis
C. Respiratory Acidosis
D. Respiratory Alkalosis
Correct Answer: C
Expert Explanation: The pH is below 7.35, indicating acidosis, and the PaCO2 is
elevated above 45 mmHg, which points to a respiratory cause. The bicarbonate level
is within the normal range, suggesting that compensation has not yet occurred. This
pattern is consistent with respiratory acidosis, often caused by hypoventilation.
5. A nurse is assessing a patient for Chvostek’s sign. Which condition is the nurse
screening for?
A. Hyperkalemia
, B. Hyponatremia
C. Hypocalcemia
D. Hypermagnesemia
Correct Answer: C
Expert Explanation: Chvostek’s sign is a clinical indicator of hypocalcemia and is
elicited by tapping the facial nerve in front of the ear. A positive response consists of
twitching of the facial muscles on the same side. This occurs because low calcium
levels increase neuromuscular irritability.
6. Which of the following is a priority nursing intervention for a patient with a sodium
level of 120 mEq/L?
A. Encouraging increased fluid intake.
B. Administering a hypotonic IV solution.
C. Initiating seizure precautions.
D. Providing a high-salt diet.
Correct Answer: C
Expert Explanation: Severe hyponatremia (levels below 125 mEq/L) places the
patient at high risk for cerebral edema and seizures. Seizure precautions are a
priority safety intervention to prevent injury during a potential neurological event.
v3 | Questions with Correct Answers and Expert
Explanation for Each Question | Galen
1. A nurse is caring for a patient who is 24 hours postoperative following abdominal
surgery. The patient reports sudden chest pain and shortness of breath. Which action
should the nurse take first?
A. Administer the prescribed PRN pain medication.
B. Perform a complete head-to-toe assessment.
C. Encourage the use of the incentive spirometer.
D. Apply oxygen and elevate the head of the bed.
Correct Answer: D
Expert Explanation: The patient’s symptoms are highly suggestive of a pulmonary
embolism, which is a life-threatening postoperative complication. Applying oxygen
and elevating the head of the bed are immediate interventions to improve
oxygenation and respiratory effort. These actions prioritize the ABCs (Airway,
Breathing, and Circulation) before further diagnostics are performed.
2. A patient has a potassium level of 3.1 mEq/L. Which of the following clinical
manifestations should the nurse expect to find?
A. Hyperactive bowel sounds and diarrhea.
,B. Muscle weakness and shallow respirations.
C. Peaked T waves on the EKG.
D. Hyperreflexia and twitching.
Correct Answer: B
Expert Explanation: Hypokalemia, defined as a potassium level below 3.5 mEq/L,
can lead to significant muscle weakness and respiratory depression. Lower levels of
potassium decrease the excitability of muscle tissues, leading to lethargy or even
paralysis. The nurse should monitor for cardiac dysrhythmias and respiratory
failure in these patients.
3. The nurse is preparing a patient for surgery. The patient states, ‘I am not sure I want
to have this surgery anymore because I don’t understand the risks.’ Which action is
most appropriate?
A. Explain the risks of the surgery to the patient.
B. Ask the patient to sign the consent form anyway.
C. Notify the surgeon that the patient needs further clarification.
D. Reassure the patient that the surgeon is very experienced.
Correct Answer: C
,Expert Explanation: It is the surgeon’s legal responsibility to explain the risks,
benefits, and alternatives of a procedure to provide informed consent. The nurse
acts as a witness to the signature but cannot provide the primary education
regarding the procedure itself. Notifying the surgeon ensures that the patient’s legal
rights and safety are maintained before going to the operating room.
4. A patient’s ABG results are: pH 7.30, PaCO2 52 mmHg, and HCO3 24 mEq/L. How
should the nurse interpret these findings?
A. Metabolic Acidosis
B. Metabolic Alkalosis
C. Respiratory Acidosis
D. Respiratory Alkalosis
Correct Answer: C
Expert Explanation: The pH is below 7.35, indicating acidosis, and the PaCO2 is
elevated above 45 mmHg, which points to a respiratory cause. The bicarbonate level
is within the normal range, suggesting that compensation has not yet occurred. This
pattern is consistent with respiratory acidosis, often caused by hypoventilation.
5. A nurse is assessing a patient for Chvostek’s sign. Which condition is the nurse
screening for?
A. Hyperkalemia
, B. Hyponatremia
C. Hypocalcemia
D. Hypermagnesemia
Correct Answer: C
Expert Explanation: Chvostek’s sign is a clinical indicator of hypocalcemia and is
elicited by tapping the facial nerve in front of the ear. A positive response consists of
twitching of the facial muscles on the same side. This occurs because low calcium
levels increase neuromuscular irritability.
6. Which of the following is a priority nursing intervention for a patient with a sodium
level of 120 mEq/L?
A. Encouraging increased fluid intake.
B. Administering a hypotonic IV solution.
C. Initiating seizure precautions.
D. Providing a high-salt diet.
Correct Answer: C
Expert Explanation: Severe hyponatremia (levels below 125 mEq/L) places the
patient at high risk for cerebral edema and seizures. Seizure precautions are a
priority safety intervention to prevent injury during a potential neurological event.
