NU158 | NU 158 Medical-Surgical Nursing I Final
Exam v3 | Questions with Correct Answers and
Expert Explanation for Each Question | Galen
1. A patient is diagnosed with fluid volume deficit. Which clinical manifestation should
the nurse expect to find during the assessment?
A. Orthostatic hypotension
B. Bounding peripheral pulses
C. Distended neck veins
D. Crackles in the lungs
Correct Answer: A
Expert Explanation: Orthostatic hypotension occurs because there is insufficient
intravascular volume to maintain blood pressure when changing positions. The
nurse should also look for other signs such as poor skin turgor and dry mucous
membranes. This condition differs from fluid volume excess, which presents with
distended neck veins and crackles.
2. Which laboratory value is the most critical for the nurse to monitor in a patient
receiving a loop diuretic?
A. Serum sodium of 138 mEq/L
B. Serum potassium of 3.1 mEq/L
,C. Serum calcium of 9.5 mg/dL
D. Serum glucose of 110 mg/dL
Correct Answer: B
Expert Explanation: Loop diuretics like furosemide cause the kidneys to excrete
significant amounts of potassium. A level of 3.1 mEq/L is below the normal range of
3.5 to 5.0 mEq/L and poses a risk for cardiac dysrhythmias. The nurse must notify
the provider and anticipate a potassium supplement order.
3. The nurse is caring for a patient with respiratory acidosis. Which arterial blood gas
(ABG) result is consistent with this diagnosis?
A. pH 7.48, PaCO2 32 mmHg
B. pH 7.32, HCO3 18 mEq/L
C. pH 7.30, PaCO2 55 mmHg
D. pH 7.50, HCO3 30 mEq/L
Correct Answer: C
Expert Explanation: Respiratory acidosis is characterized by a low pH (below 7.35)
and an elevated PaCO2 (above 45 mmHg). This condition often occurs when the
patient is hypoventilating and retaining carbon dioxide. Treatment focuses on
improving ventilation to clear the excess CO2 from the bloodstream.
,4. A patient is scheduled for surgery. Who is legally responsible for obtaining the
informed consent?
A. The circulating nurse
B. The surgeon
C. The anesthesiologist
D. The unit charge nurse
Correct Answer: B
Expert Explanation: The surgeon is legally responsible for explaining the
procedure, risks, and benefits to the patient. The nurse’s role is to witness the
patient’s signature and verify that the patient understands the information. If the
patient has questions about the surgery itself, the nurse must call the surgeon back
to explain further.
5. During the preoperative assessment, a patient reports an allergy to avocados and
bananas. For which sensitivity should the nurse further assess?
A. Penicillin
B. Latex
C. Iodine
D. Adhesive tape
, Correct Answer: B
Expert Explanation: There is a known cross-reactivity between certain fruits like
bananas, avocados, and kiwi with latex. Patients with these food allergies are at a
higher risk for developing a latex allergy or sensitivity. The surgical team must be
notified to use latex-free equipment to prevent anaphylaxis.
6. A postoperative patient has not voided for 8 hours after surgery. What is the
nurse’s first action?
A. Insert a straight catheter immediately
B. Encourage the patient to drink 500 mL of water
C. Increase the IV fluid rate
D. Perform a bladder scan
Correct Answer: D
Expert Explanation: A bladder scan is a non-invasive way to determine the amount
of urine currently held in the bladder. This assessment helps determine if the issue
is urinary retention or a lack of urine production. Depending on the volume found,
the nurse will then decide if catheterization is necessary based on facility protocol.
7. Which assessment finding is a classic sign of hypocalcemia?
A. Negative Chvostek’s sign
Exam v3 | Questions with Correct Answers and
Expert Explanation for Each Question | Galen
1. A patient is diagnosed with fluid volume deficit. Which clinical manifestation should
the nurse expect to find during the assessment?
A. Orthostatic hypotension
B. Bounding peripheral pulses
C. Distended neck veins
D. Crackles in the lungs
Correct Answer: A
Expert Explanation: Orthostatic hypotension occurs because there is insufficient
intravascular volume to maintain blood pressure when changing positions. The
nurse should also look for other signs such as poor skin turgor and dry mucous
membranes. This condition differs from fluid volume excess, which presents with
distended neck veins and crackles.
2. Which laboratory value is the most critical for the nurse to monitor in a patient
receiving a loop diuretic?
A. Serum sodium of 138 mEq/L
B. Serum potassium of 3.1 mEq/L
,C. Serum calcium of 9.5 mg/dL
D. Serum glucose of 110 mg/dL
Correct Answer: B
Expert Explanation: Loop diuretics like furosemide cause the kidneys to excrete
significant amounts of potassium. A level of 3.1 mEq/L is below the normal range of
3.5 to 5.0 mEq/L and poses a risk for cardiac dysrhythmias. The nurse must notify
the provider and anticipate a potassium supplement order.
3. The nurse is caring for a patient with respiratory acidosis. Which arterial blood gas
(ABG) result is consistent with this diagnosis?
A. pH 7.48, PaCO2 32 mmHg
B. pH 7.32, HCO3 18 mEq/L
C. pH 7.30, PaCO2 55 mmHg
D. pH 7.50, HCO3 30 mEq/L
Correct Answer: C
Expert Explanation: Respiratory acidosis is characterized by a low pH (below 7.35)
and an elevated PaCO2 (above 45 mmHg). This condition often occurs when the
patient is hypoventilating and retaining carbon dioxide. Treatment focuses on
improving ventilation to clear the excess CO2 from the bloodstream.
,4. A patient is scheduled for surgery. Who is legally responsible for obtaining the
informed consent?
A. The circulating nurse
B. The surgeon
C. The anesthesiologist
D. The unit charge nurse
Correct Answer: B
Expert Explanation: The surgeon is legally responsible for explaining the
procedure, risks, and benefits to the patient. The nurse’s role is to witness the
patient’s signature and verify that the patient understands the information. If the
patient has questions about the surgery itself, the nurse must call the surgeon back
to explain further.
5. During the preoperative assessment, a patient reports an allergy to avocados and
bananas. For which sensitivity should the nurse further assess?
A. Penicillin
B. Latex
C. Iodine
D. Adhesive tape
, Correct Answer: B
Expert Explanation: There is a known cross-reactivity between certain fruits like
bananas, avocados, and kiwi with latex. Patients with these food allergies are at a
higher risk for developing a latex allergy or sensitivity. The surgical team must be
notified to use latex-free equipment to prevent anaphylaxis.
6. A postoperative patient has not voided for 8 hours after surgery. What is the
nurse’s first action?
A. Insert a straight catheter immediately
B. Encourage the patient to drink 500 mL of water
C. Increase the IV fluid rate
D. Perform a bladder scan
Correct Answer: D
Expert Explanation: A bladder scan is a non-invasive way to determine the amount
of urine currently held in the bladder. This assessment helps determine if the issue
is urinary retention or a lack of urine production. Depending on the volume found,
the nurse will then decide if catheterization is necessary based on facility protocol.
7. Which assessment finding is a classic sign of hypocalcemia?
A. Negative Chvostek’s sign
