NU158 | NU 158 Medical-Surgical Nursing I Final
Exam v3 | Questions with Correct Answers and
Expert Explanation for Each Question | Galen
1. A nurse is caring for a patient who has a serum potassium level of 5.5 mEq/L. Which
of the following ECG changes should the nurse expect to see?
A. Prominent U waves
B. ST segment depression
C. Shortened PR interval
D. Peaked T waves
Correct Answer: D
Expert Explanation: Hyperkalemia is characterized by a potassium level greater
than 5.0 mEq/L and can cause significant cardiac conduction changes. Peaked T
waves are one of the earliest signs of hyperkalemia on an electrocardiogram. The
nurse must notify the provider immediately as high potassium levels can lead to life-
threatening ventricular arrhythmias.
2. A patient presents with a pH of 7.25, PaCO2 of 50 mmHg, and HCO3 of 24 mEq/L.
How should the nurse interpret these arterial blood gas (ABG) results?
A. Metabolic acidosis
B. Respiratory acidosis
,C. Respiratory alkalosis
D. Metabolic alkalosis
Correct Answer: B
Expert Explanation: A pH below 7.35 indicates acidosis, and a PaCO2 above 45
mmHg indicates a respiratory cause. Since the bicarbonate level is within the
normal range of 22 to 26 mEq/L, the imbalance is uncompensated. This condition
often occurs in patients with hypoventilation or obstructive lung diseases like COPD.
3. Which of the following assessments is the priority for a nurse caring for a patient in
the immediate postoperative period?
A. Assessing the surgical dressing for drainage
B. Measuring the patient’s urinary output
C. Monitoring airway patency and oxygen saturation
D. Auscultating bowel sounds
Correct Answer: C
Expert Explanation: The priority in immediate postoperative care always follows
the ABC (Airway, Breathing, Circulation) framework. Maintaining a patent airway
and ensuring adequate ventilation is critical as the patient recovers from anesthesia.
,Other assessments like wound checks and urine output are important but secondary
to respiratory stability.
4. A nurse is teaching a patient about a low-sodium diet. Which food choice by the
patient indicates an understanding of the teaching?
A. Canned soup
B. Smoked ham
C. Fresh orange slices
D. Pickled vegetables
Correct Answer: C
Expert Explanation: Fresh fruits like oranges are naturally low in sodium and are
excellent choices for a heart-healthy or low-sodium diet. Canned, smoked, and
pickled foods are typically high in added sodium used for preservation and
flavoring. Educating patients on reading food labels is essential for successful
dietary management of conditions like hypertension.
5. During the preoperative interview, a patient reports a severe allergy to avocados
and bananas. For which of the following should the nurse further assess the patient?
A. Penicillin allergy
B. Iodine allergy
, C. Latex allergy
D. Adhesive tape sensitivity
Correct Answer: C
Expert Explanation: Certain food allergies, particularly to bananas, avocados,
kiwis, and chestnuts, are known to have a cross-reactivity with latex. This is referred
to as the latex-fruit syndrome due to similar proteins found in these substances. The
nurse must document this risk and ensure a latex-free environment is maintained
during surgery to prevent anaphylaxis.
6. A patient is diagnosed with hypocalcemia. Which clinical manifestation should the
nurse expect to observe?
A. Constipation
B. Positive Trousseau’s sign
C. Hyporeflexia
D. Polyuria
Correct Answer: B
Expert Explanation: Hypocalcemia increases neuromuscular excitability, leading to
signs such as Trousseau’s sign (carpal spasm induced by inflating a blood pressure
cuff). Chvostek’s sign is another common assessment finding associated with low
Exam v3 | Questions with Correct Answers and
Expert Explanation for Each Question | Galen
1. A nurse is caring for a patient who has a serum potassium level of 5.5 mEq/L. Which
of the following ECG changes should the nurse expect to see?
A. Prominent U waves
B. ST segment depression
C. Shortened PR interval
D. Peaked T waves
Correct Answer: D
Expert Explanation: Hyperkalemia is characterized by a potassium level greater
than 5.0 mEq/L and can cause significant cardiac conduction changes. Peaked T
waves are one of the earliest signs of hyperkalemia on an electrocardiogram. The
nurse must notify the provider immediately as high potassium levels can lead to life-
threatening ventricular arrhythmias.
2. A patient presents with a pH of 7.25, PaCO2 of 50 mmHg, and HCO3 of 24 mEq/L.
How should the nurse interpret these arterial blood gas (ABG) results?
A. Metabolic acidosis
B. Respiratory acidosis
,C. Respiratory alkalosis
D. Metabolic alkalosis
Correct Answer: B
Expert Explanation: A pH below 7.35 indicates acidosis, and a PaCO2 above 45
mmHg indicates a respiratory cause. Since the bicarbonate level is within the
normal range of 22 to 26 mEq/L, the imbalance is uncompensated. This condition
often occurs in patients with hypoventilation or obstructive lung diseases like COPD.
3. Which of the following assessments is the priority for a nurse caring for a patient in
the immediate postoperative period?
A. Assessing the surgical dressing for drainage
B. Measuring the patient’s urinary output
C. Monitoring airway patency and oxygen saturation
D. Auscultating bowel sounds
Correct Answer: C
Expert Explanation: The priority in immediate postoperative care always follows
the ABC (Airway, Breathing, Circulation) framework. Maintaining a patent airway
and ensuring adequate ventilation is critical as the patient recovers from anesthesia.
,Other assessments like wound checks and urine output are important but secondary
to respiratory stability.
4. A nurse is teaching a patient about a low-sodium diet. Which food choice by the
patient indicates an understanding of the teaching?
A. Canned soup
B. Smoked ham
C. Fresh orange slices
D. Pickled vegetables
Correct Answer: C
Expert Explanation: Fresh fruits like oranges are naturally low in sodium and are
excellent choices for a heart-healthy or low-sodium diet. Canned, smoked, and
pickled foods are typically high in added sodium used for preservation and
flavoring. Educating patients on reading food labels is essential for successful
dietary management of conditions like hypertension.
5. During the preoperative interview, a patient reports a severe allergy to avocados
and bananas. For which of the following should the nurse further assess the patient?
A. Penicillin allergy
B. Iodine allergy
, C. Latex allergy
D. Adhesive tape sensitivity
Correct Answer: C
Expert Explanation: Certain food allergies, particularly to bananas, avocados,
kiwis, and chestnuts, are known to have a cross-reactivity with latex. This is referred
to as the latex-fruit syndrome due to similar proteins found in these substances. The
nurse must document this risk and ensure a latex-free environment is maintained
during surgery to prevent anaphylaxis.
6. A patient is diagnosed with hypocalcemia. Which clinical manifestation should the
nurse expect to observe?
A. Constipation
B. Positive Trousseau’s sign
C. Hyporeflexia
D. Polyuria
Correct Answer: B
Expert Explanation: Hypocalcemia increases neuromuscular excitability, leading to
signs such as Trousseau’s sign (carpal spasm induced by inflating a blood pressure
cuff). Chvostek’s sign is another common assessment finding associated with low
