NU158 | NU 158 Medical-Surgical Nursing I Final
Exam v2 | Questions with Correct Answers and
Expert Explanation for Each Question | Galen
1. Which nursing action is the most appropriate when witnessing a patient signing an
informed consent form for a surgical procedure?
A. Explain the risks and benefits of the surgery to the patient.
B. Provide alternatives to the proposed surgical treatment.
C. Assess the patient’s understanding of the surgical complications.
D. Verify that the patient is signing the form voluntarily.
Correct Answer: D
Expert Explanation: The nurse’s primary role in witnessing informed consent is to
confirm the signature is authentic and voluntary. It is the responsibility of the
surgeon to explain the procedure, risks, and alternatives to the patient. If the nurse
notes the patient does not understand the procedure, the nurse should notify the
surgeon before the patient signs the form.
2. A patient is diagnosed with fluid volume deficit. Which clinical manifestation should
the nurse expect to find during the assessment?
A. Distended neck veins
B. Bounding peripheral pulses
,C. Poor skin turgor
D. Crackles in the lung bases
Correct Answer: C
Expert Explanation: Poor skin turgor is a classic sign of dehydration or fluid
volume deficit because there is not enough fluid in the interstitial space to maintain
skin elasticity. Distended neck veins and crackles are typically associated with fluid
volume excess rather than a deficit. The nurse should also look for other signs such
as dry mucous membranes and concentrated urine.
3. The nurse is caring for a patient with a potassium level of 2.8 mEq/L. Which cardiac
change is most commonly associated with this condition?
A. Tall, peaked T waves
B. Shortened PR interval
C. Presence of U waves
D. Widened QRS complex
Correct Answer: C
Expert Explanation: Hypokalemia, defined as a potassium level below 3.5 mEq/L,
often presents with the development of U waves on an ECG. In contrast,
hyperkalemia is characterized by tall, peaked T waves and a widened QRS complex.
,The nurse must monitor cardiac rhythm closely as low potassium increases the risk
for life-threatening arrhythmias.
4. Which arterial blood gas (ABG) result is consistent with a patient experiencing
uncompensated respiratory acidosis?
A. pH 7.50, PaCO2 40, HCO3 32
B. pH 7.48, PaCO2 30, HCO3 23
C. pH 7.30, PaCO2 35, HCO3 18
D. pH 7.32, PaCO2 50, HCO3 24
Correct Answer: D
Expert Explanation: Respiratory acidosis is characterized by a low pH (below 7.35)
and an elevated PaCO2 (above 45 mmHg). In this specific result, the bicarbonate
(HCO3) is within the normal range, indicating that compensation has not yet
occurred. This condition often results from hypoventilation or impaired gas
exchange in conditions like COPD or pneumonia.
5. During a post-operative assessment, the nurse notices the patient’s surgical wound
has eviscerated. What is the nurse’s immediate priority action?
A. Gently push the organs back into the abdominal cavity.
B. Cover the protruding organs with sterile gauze moistened with sterile saline.
, C. Cover the wound with a dry sterile dressing.
D. Place the patient in a high-Fowler’s position.
Correct Answer: B
Expert Explanation: Evisceration is a medical emergency where internal organs
protrude through a surgical incision. The nurse must keep the organs moist and
sterile by using saline-soaked gauze to prevent tissue necrosis. The surgeon should
be notified immediately, and the patient should be kept in a low-Fowler’s position
with knees flexed to reduce abdominal tension.
6. A patient who is post-operative day 1 following abdominal surgery reports sudden
shortness of breath and chest pain. What should the nurse suspect first?
A. Atelectasis
B. Pulmonary embolism
C. Pneumonia
D. Myocardial infarction
Correct Answer: B
Expert Explanation: Sudden onset of dyspnea and chest pain in a post-operative
patient is a classic sign of a pulmonary embolism, often caused by a deep vein
thrombosis (DVT) that has traveled to the lungs. While atelectasis and pneumonia
Exam v2 | Questions with Correct Answers and
Expert Explanation for Each Question | Galen
1. Which nursing action is the most appropriate when witnessing a patient signing an
informed consent form for a surgical procedure?
A. Explain the risks and benefits of the surgery to the patient.
B. Provide alternatives to the proposed surgical treatment.
C. Assess the patient’s understanding of the surgical complications.
D. Verify that the patient is signing the form voluntarily.
Correct Answer: D
Expert Explanation: The nurse’s primary role in witnessing informed consent is to
confirm the signature is authentic and voluntary. It is the responsibility of the
surgeon to explain the procedure, risks, and alternatives to the patient. If the nurse
notes the patient does not understand the procedure, the nurse should notify the
surgeon before the patient signs the form.
2. A patient is diagnosed with fluid volume deficit. Which clinical manifestation should
the nurse expect to find during the assessment?
A. Distended neck veins
B. Bounding peripheral pulses
,C. Poor skin turgor
D. Crackles in the lung bases
Correct Answer: C
Expert Explanation: Poor skin turgor is a classic sign of dehydration or fluid
volume deficit because there is not enough fluid in the interstitial space to maintain
skin elasticity. Distended neck veins and crackles are typically associated with fluid
volume excess rather than a deficit. The nurse should also look for other signs such
as dry mucous membranes and concentrated urine.
3. The nurse is caring for a patient with a potassium level of 2.8 mEq/L. Which cardiac
change is most commonly associated with this condition?
A. Tall, peaked T waves
B. Shortened PR interval
C. Presence of U waves
D. Widened QRS complex
Correct Answer: C
Expert Explanation: Hypokalemia, defined as a potassium level below 3.5 mEq/L,
often presents with the development of U waves on an ECG. In contrast,
hyperkalemia is characterized by tall, peaked T waves and a widened QRS complex.
,The nurse must monitor cardiac rhythm closely as low potassium increases the risk
for life-threatening arrhythmias.
4. Which arterial blood gas (ABG) result is consistent with a patient experiencing
uncompensated respiratory acidosis?
A. pH 7.50, PaCO2 40, HCO3 32
B. pH 7.48, PaCO2 30, HCO3 23
C. pH 7.30, PaCO2 35, HCO3 18
D. pH 7.32, PaCO2 50, HCO3 24
Correct Answer: D
Expert Explanation: Respiratory acidosis is characterized by a low pH (below 7.35)
and an elevated PaCO2 (above 45 mmHg). In this specific result, the bicarbonate
(HCO3) is within the normal range, indicating that compensation has not yet
occurred. This condition often results from hypoventilation or impaired gas
exchange in conditions like COPD or pneumonia.
5. During a post-operative assessment, the nurse notices the patient’s surgical wound
has eviscerated. What is the nurse’s immediate priority action?
A. Gently push the organs back into the abdominal cavity.
B. Cover the protruding organs with sterile gauze moistened with sterile saline.
, C. Cover the wound with a dry sterile dressing.
D. Place the patient in a high-Fowler’s position.
Correct Answer: B
Expert Explanation: Evisceration is a medical emergency where internal organs
protrude through a surgical incision. The nurse must keep the organs moist and
sterile by using saline-soaked gauze to prevent tissue necrosis. The surgeon should
be notified immediately, and the patient should be kept in a low-Fowler’s position
with knees flexed to reduce abdominal tension.
6. A patient who is post-operative day 1 following abdominal surgery reports sudden
shortness of breath and chest pain. What should the nurse suspect first?
A. Atelectasis
B. Pulmonary embolism
C. Pneumonia
D. Myocardial infarction
Correct Answer: B
Expert Explanation: Sudden onset of dyspnea and chest pain in a post-operative
patient is a classic sign of a pulmonary embolism, often caused by a deep vein
thrombosis (DVT) that has traveled to the lungs. While atelectasis and pneumonia
