NU180 | NU180 Nursing and Healthcare II | NCLEX
Style Exam 2 v1 | Questions with Correct Answers
and Expert Explanation for Each Question | Galen
1. A nurse is caring for a client who has a serum potassium level of 2.8 mEq/L. Which
of the following assessment findings should the nurse prioritize?
A. Hyperactive bowel sounds
B. Strong peripheral pulses
C. Increased muscle tone
D. Irregular heart rhythm
Correct Answer: D
Expert Explanation: A potassium level of 2.8 mEq/L indicates severe hypokalemia,
which can lead to life-threatening cardiac dysrhythmias. The nurse must prioritize
cardiac monitoring and assessing the heart rhythm for irregularities. Other
symptoms of hypokalemia include muscle weakness and decreased bowel sounds,
rather than hyperactivity or increased tone.
2. Which of the following actions is the responsibility of the nurse when obtaining
informed consent for a surgical procedure?
A. Witnessing the client’s signature on the consent form
B. Describing alternative treatments available
,C. Explaining the risks and benefits of the procedure
D. Ensuring the surgeon has received their fee
Correct Answer: A
Expert Explanation: The nurse’s role in informed consent is to witness the client’s
signature and verify that the client appears competent to give consent. It is the
surgeon’s responsibility to explain the procedure, risks, benefits, and alternatives.
The nurse should also advocate for the client if they express a lack of understanding
by notifying the surgeon.
3. A client presents with an arterial blood gas (ABG) result of pH 7.30, PaCO2 52
mmHg, and HCO3 26 mEq/L. How should the nurse interpret these findings?
A. Respiratory acidosis
B. Metabolic acidosis
C. Respiratory alkalosis
D. Metabolic alkalosis
Correct Answer: A
Expert Explanation: The pH is below 7.35, indicating acidosis. The PaCO2 is
elevated above 45 mmHg, which points to a respiratory cause for the low pH. Since
,the HCO3 is within the normal range, this is identified as uncompensated
respiratory acidosis.
4. A nurse is preparing to administer regular insulin to a client. Which action is most
important for the nurse to take to ensure safety?
A. Check the dose with another licensed nurse
B. Administer the insulin 60 minutes after a meal
C. Shake the vial vigorously before drawing up the dose
D. Use a 21-gauge needle for administration
Correct Answer: A
Expert Explanation: Insulin is a high-alert medication that requires an
independent double-check by another nurse to prevent dosage errors. Regular
insulin should generally be administered 30 minutes before a meal to align with
glucose spikes. Shaking the vial can create bubbles and lead to inaccurate dosing, so
it should be gently rolled instead.
5. A client is 2 hours postoperative following an abdominal surgery. Which of the
following findings should the nurse report to the provider immediately?
A. Urine output of 20 mL/hr over the last 2 hours
B. Pain level of 6 on a scale of 0 to 10
, C. Serosanguineous drainage on the dressing
D. Hypoactive bowel sounds in all quadrants
Correct Answer: A
Expert Explanation: A urine output of less than 30 mL/hr can indicate fluid volume
deficit or acute kidney injury and requires immediate intervention. Pain of 6/10 is
expected postoperatively and can be managed with prescribed analgesics.
Serosanguineous drainage and hypoactive bowel sounds are common immediately
after abdominal surgery.
6. When assessing a client for signs of fluid volume deficit, which of the following
should the nurse expect to find?
A. Distended neck veins
B. Bounding peripheral pulses
C. Poor skin turgor
D. Increased blood pressure
Correct Answer: C
Expert Explanation: Fluid volume deficit (dehydration) leads to decreased skin
elasticity, resulting in poor skin turgor or tenting. Other signs include tachycardia,
Style Exam 2 v1 | Questions with Correct Answers
and Expert Explanation for Each Question | Galen
1. A nurse is caring for a client who has a serum potassium level of 2.8 mEq/L. Which
of the following assessment findings should the nurse prioritize?
A. Hyperactive bowel sounds
B. Strong peripheral pulses
C. Increased muscle tone
D. Irregular heart rhythm
Correct Answer: D
Expert Explanation: A potassium level of 2.8 mEq/L indicates severe hypokalemia,
which can lead to life-threatening cardiac dysrhythmias. The nurse must prioritize
cardiac monitoring and assessing the heart rhythm for irregularities. Other
symptoms of hypokalemia include muscle weakness and decreased bowel sounds,
rather than hyperactivity or increased tone.
2. Which of the following actions is the responsibility of the nurse when obtaining
informed consent for a surgical procedure?
A. Witnessing the client’s signature on the consent form
B. Describing alternative treatments available
,C. Explaining the risks and benefits of the procedure
D. Ensuring the surgeon has received their fee
Correct Answer: A
Expert Explanation: The nurse’s role in informed consent is to witness the client’s
signature and verify that the client appears competent to give consent. It is the
surgeon’s responsibility to explain the procedure, risks, benefits, and alternatives.
The nurse should also advocate for the client if they express a lack of understanding
by notifying the surgeon.
3. A client presents with an arterial blood gas (ABG) result of pH 7.30, PaCO2 52
mmHg, and HCO3 26 mEq/L. How should the nurse interpret these findings?
A. Respiratory acidosis
B. Metabolic acidosis
C. Respiratory alkalosis
D. Metabolic alkalosis
Correct Answer: A
Expert Explanation: The pH is below 7.35, indicating acidosis. The PaCO2 is
elevated above 45 mmHg, which points to a respiratory cause for the low pH. Since
,the HCO3 is within the normal range, this is identified as uncompensated
respiratory acidosis.
4. A nurse is preparing to administer regular insulin to a client. Which action is most
important for the nurse to take to ensure safety?
A. Check the dose with another licensed nurse
B. Administer the insulin 60 minutes after a meal
C. Shake the vial vigorously before drawing up the dose
D. Use a 21-gauge needle for administration
Correct Answer: A
Expert Explanation: Insulin is a high-alert medication that requires an
independent double-check by another nurse to prevent dosage errors. Regular
insulin should generally be administered 30 minutes before a meal to align with
glucose spikes. Shaking the vial can create bubbles and lead to inaccurate dosing, so
it should be gently rolled instead.
5. A client is 2 hours postoperative following an abdominal surgery. Which of the
following findings should the nurse report to the provider immediately?
A. Urine output of 20 mL/hr over the last 2 hours
B. Pain level of 6 on a scale of 0 to 10
, C. Serosanguineous drainage on the dressing
D. Hypoactive bowel sounds in all quadrants
Correct Answer: A
Expert Explanation: A urine output of less than 30 mL/hr can indicate fluid volume
deficit or acute kidney injury and requires immediate intervention. Pain of 6/10 is
expected postoperatively and can be managed with prescribed analgesics.
Serosanguineous drainage and hypoactive bowel sounds are common immediately
after abdominal surgery.
6. When assessing a client for signs of fluid volume deficit, which of the following
should the nurse expect to find?
A. Distended neck veins
B. Bounding peripheral pulses
C. Poor skin turgor
D. Increased blood pressure
Correct Answer: C
Expert Explanation: Fluid volume deficit (dehydration) leads to decreased skin
elasticity, resulting in poor skin turgor or tenting. Other signs include tachycardia,
