NU158 | NU 158 Medical-Surgical Nursing I Final
Exam v1 | Questions with Correct Answers and
Expert Explanation for Each Question | Galen
1. A nurse is preparing a patient for surgery. Which action is the nurse’s primary
responsibility regarding informed consent?
A. Witnessing the patient’s signature on the consent form.
B. Explaining the risks and benefits of the procedure.
C. Determining the patient’s capacity to understand the surgery.
D. Providing alternative treatment options to the patient.
Correct Answer: A
Expert Explanation: The nurse’s primary role in informed consent is to witness the
patient signing the document and ensuring the signature is authentic. It is the
surgeon’s responsibility to explain the procedure, risks, and alternatives. If the
nurse realizes the patient does not understand the procedure, the nurse must notify
the surgeon before the patient signs the form.
2. A patient presents with a serum potassium level of 6.2 mEq/L. Which nursing
intervention is the priority?
A. Placing the patient on a cardiac monitor.
B. Encouraging intake of bananas and orange juice.
,C. Administering a potassium-sparing diuretic.
D. Assessing the patient’s deep tendon reflexes.
Correct Answer: A
Expert Explanation: Hyperkalemia, defined as a potassium level above 5.0 mEq/L,
can cause life-threatening cardiac dysrhythmias and arrest. Placing the patient on a
cardiac monitor allows for immediate detection of EKG changes such as peaked T
waves. The nurse should also prepare for treatments that lower potassium, such as
sodium polystyrene sulfonate or insulin with dextrose.
3. Which clinical manifestation should the nurse expect to find in a patient with fluid
volume deficit?
A. Distended neck veins.
B. Increased blood pressure.
C. Crackles upon lung auscultation.
D. Tachycardia and orthostatic hypotension.
Correct Answer: D
Expert Explanation: Fluid volume deficit results in decreased circulating blood
volume, leading to compensatory tachycardia to maintain cardiac output.
Orthostatic hypotension occurs because there is insufficient volume to maintain
,blood pressure when changing positions. Distended neck veins and crackles are
typically signs of fluid volume excess, not deficit.
4. A nurse is caring for a postoperative patient. Which finding is the earliest sign of
poor oxygenation?
A. Cyanosis of the lips.
B. Restlessness and apprehension.
C. Clubbing of the fingers.
D. A decrease in respiratory rate.
Correct Answer: B
Expert Explanation: Restlessness and apprehension are early signs of hypoxia due
to the brain’s sensitivity to low oxygen levels. Cyanosis is a late sign and indicates
severe desaturation. Monitoring changes in mental status is a critical nursing
assessment for patients at risk for respiratory distress.
5. The nurse is educating a patient on the use of an incentive spirometer. What should
the nurse emphasize?
A. Exhale forcefully into the device.
B. Inhale deeply and slowly through the mouthpiece.
C. Use the device only if you feel short of breath.
, D. Hold your breath for at least 30 seconds after inhalation.
Correct Answer: B
Expert Explanation: The incentive spirometer is used to encourage deep breathing
and prevent atelectasis by having the patient inhale slowly and deeply. The goal is to
expand the lungs and hold the breath for 3 to 5 seconds at the peak of inspiration.
Regular use, typically 10 times every hour while awake, is essential for
postoperative lung recovery.
6. A patient is diagnosed with metabolic acidosis. Which compensatory mechanism
should the nurse expect to observe?
A. Increased urinary output.
B. Hypoventilation.
C. Kussmaul respirations.
D. Decreased heart rate.
Correct Answer: C
Expert Explanation: Kussmaul respirations are deep, rapid breaths that occur as
the body tries to ‘blow off’ excess CO2 to compensate for metabolic acidosis. This
respiratory compensation helps to increase the blood pH back toward the normal
range. Monitoring the patient’s respiratory pattern and arterial blood gases is
essential in managing acid-base imbalances.
Exam v1 | Questions with Correct Answers and
Expert Explanation for Each Question | Galen
1. A nurse is preparing a patient for surgery. Which action is the nurse’s primary
responsibility regarding informed consent?
A. Witnessing the patient’s signature on the consent form.
B. Explaining the risks and benefits of the procedure.
C. Determining the patient’s capacity to understand the surgery.
D. Providing alternative treatment options to the patient.
Correct Answer: A
Expert Explanation: The nurse’s primary role in informed consent is to witness the
patient signing the document and ensuring the signature is authentic. It is the
surgeon’s responsibility to explain the procedure, risks, and alternatives. If the
nurse realizes the patient does not understand the procedure, the nurse must notify
the surgeon before the patient signs the form.
2. A patient presents with a serum potassium level of 6.2 mEq/L. Which nursing
intervention is the priority?
A. Placing the patient on a cardiac monitor.
B. Encouraging intake of bananas and orange juice.
,C. Administering a potassium-sparing diuretic.
D. Assessing the patient’s deep tendon reflexes.
Correct Answer: A
Expert Explanation: Hyperkalemia, defined as a potassium level above 5.0 mEq/L,
can cause life-threatening cardiac dysrhythmias and arrest. Placing the patient on a
cardiac monitor allows for immediate detection of EKG changes such as peaked T
waves. The nurse should also prepare for treatments that lower potassium, such as
sodium polystyrene sulfonate or insulin with dextrose.
3. Which clinical manifestation should the nurse expect to find in a patient with fluid
volume deficit?
A. Distended neck veins.
B. Increased blood pressure.
C. Crackles upon lung auscultation.
D. Tachycardia and orthostatic hypotension.
Correct Answer: D
Expert Explanation: Fluid volume deficit results in decreased circulating blood
volume, leading to compensatory tachycardia to maintain cardiac output.
Orthostatic hypotension occurs because there is insufficient volume to maintain
,blood pressure when changing positions. Distended neck veins and crackles are
typically signs of fluid volume excess, not deficit.
4. A nurse is caring for a postoperative patient. Which finding is the earliest sign of
poor oxygenation?
A. Cyanosis of the lips.
B. Restlessness and apprehension.
C. Clubbing of the fingers.
D. A decrease in respiratory rate.
Correct Answer: B
Expert Explanation: Restlessness and apprehension are early signs of hypoxia due
to the brain’s sensitivity to low oxygen levels. Cyanosis is a late sign and indicates
severe desaturation. Monitoring changes in mental status is a critical nursing
assessment for patients at risk for respiratory distress.
5. The nurse is educating a patient on the use of an incentive spirometer. What should
the nurse emphasize?
A. Exhale forcefully into the device.
B. Inhale deeply and slowly through the mouthpiece.
C. Use the device only if you feel short of breath.
, D. Hold your breath for at least 30 seconds after inhalation.
Correct Answer: B
Expert Explanation: The incentive spirometer is used to encourage deep breathing
and prevent atelectasis by having the patient inhale slowly and deeply. The goal is to
expand the lungs and hold the breath for 3 to 5 seconds at the peak of inspiration.
Regular use, typically 10 times every hour while awake, is essential for
postoperative lung recovery.
6. A patient is diagnosed with metabolic acidosis. Which compensatory mechanism
should the nurse expect to observe?
A. Increased urinary output.
B. Hypoventilation.
C. Kussmaul respirations.
D. Decreased heart rate.
Correct Answer: C
Expert Explanation: Kussmaul respirations are deep, rapid breaths that occur as
the body tries to ‘blow off’ excess CO2 to compensate for metabolic acidosis. This
respiratory compensation helps to increase the blood pH back toward the normal
range. Monitoring the patient’s respiratory pattern and arterial blood gases is
essential in managing acid-base imbalances.
