NU180 | NU180 Nursing and Healthcare II | NCLEX
Style Exam 2 v2 | Questions with Correct Answers
and Expert Explanation for Each Question | Galen
1. A nurse is assessing a client with fluid volume excess. Which of the following
findings should the nurse expect?
A. Flattened neck veins
B. Increased hematocrit
C. Dry mucous membranes
D. Distended jugular veins
Correct Answer: D
Expert Explanation: Fluid volume excess leads to an increase in intravascular
volume, which causes distension of the jugular veins when the client is sitting or
lying. The nurse should also look for other signs like peripheral edema and crackles
in the lungs. In contrast, flattened neck veins and dry mucous membranes are
typically signs of fluid volume deficit.
2. A client’s potassium level is 3.2 mEq/L. Which of the following ECG changes is most
consistent with this finding?
A. Peaked T waves
B. Shortened PR interval
,C. Widened QRS complex
D. Presence of U waves
Correct Answer: D
Expert Explanation: Hypokalemia, defined as a potassium level below 3.5 mEq/L,
can cause the appearance of U waves on an ECG. Other common changes include ST-
segment depression and flattened T waves. Peaked T waves and widened QRS
complexes are more indicative of hyperkalemia rather than hypokalemia.
3. Which of the following patients is at the highest risk for developing metabolic
alkalosis?
A. A patient with chronic obstructive pulmonary disease (COPD)
B. A patient with uncontrolled Type 1 Diabetes
C. A patient with severe diarrhea
D. A patient with prolonged nasogastric suctioning
Correct Answer: D
Expert Explanation: Prolonged nasogastric suctioning results in the loss of gastric
acid, which can lead to metabolic alkalosis. Diarrhea usually causes metabolic
acidosis due to the loss of bicarbonate from the lower GI tract. Type 1 Diabetes often
leads to diabetic ketoacidosis, which is a metabolic acidosis condition.
,4. A nurse is caring for a client who is postoperative and reports sudden chest pain
and dyspnea. Which action should the nurse take first?
A. Administer pain medication
B. Apply supplemental oxygen
C. Obtain an ECG
D. Call the provider
Correct Answer: B
Expert Explanation: Sudden chest pain and dyspnea in a postoperative client are
classic signs of a pulmonary embolism, which is a medical emergency. Oxygen
administration is the priority to improve oxygenation and stabilize the client’s
respiratory status. After applying oxygen, the nurse should notify the rapid response
team or the healthcare provider immediately.
5. A nurse is reviewing the arterial blood gas (ABG) results for a client: pH 7.30, PaCO2
50 mm Hg, HCO3 24 mEq/L. Which acid-base imbalance does this represent?
A. Metabolic acidosis
B. Respiratory alkalosis
C. Respiratory acidosis
D. Metabolic alkalosis
, Correct Answer: C
Expert Explanation: A pH below 7.35 indicates acidosis, and a PaCO2 above 45 mm
Hg indicates a respiratory cause. Since the bicarbonate (HCO3) is within the normal
range, the imbalance is primarily respiratory. This condition occurs when the lungs
fail to remove enough carbon dioxide from the blood.
6. What is the priority nursing intervention for a client with a sodium level of 128
mEq/L?
A. Encourage increased water intake
B. Place the client on seizure precautions
C. Administer a loop diuretic
D. Monitor for hyperactive bowel sounds
Correct Answer: B
Expert Explanation: Hyponatremia, or a low sodium level, places the client at
significant risk for neurological changes and seizures. Seizure precautions are
essential for patient safety until the sodium level is corrected. Increasing water
intake would likely worsen the hyponatremia by further diluting the serum sodium.
7. The nurse is monitoring a client receiving a blood transfusion. Within 15 minutes,
the client develops a fever and chills. What is the nurse’s first action?
A. Stop the transfusion
Style Exam 2 v2 | Questions with Correct Answers
and Expert Explanation for Each Question | Galen
1. A nurse is assessing a client with fluid volume excess. Which of the following
findings should the nurse expect?
A. Flattened neck veins
B. Increased hematocrit
C. Dry mucous membranes
D. Distended jugular veins
Correct Answer: D
Expert Explanation: Fluid volume excess leads to an increase in intravascular
volume, which causes distension of the jugular veins when the client is sitting or
lying. The nurse should also look for other signs like peripheral edema and crackles
in the lungs. In contrast, flattened neck veins and dry mucous membranes are
typically signs of fluid volume deficit.
2. A client’s potassium level is 3.2 mEq/L. Which of the following ECG changes is most
consistent with this finding?
A. Peaked T waves
B. Shortened PR interval
,C. Widened QRS complex
D. Presence of U waves
Correct Answer: D
Expert Explanation: Hypokalemia, defined as a potassium level below 3.5 mEq/L,
can cause the appearance of U waves on an ECG. Other common changes include ST-
segment depression and flattened T waves. Peaked T waves and widened QRS
complexes are more indicative of hyperkalemia rather than hypokalemia.
3. Which of the following patients is at the highest risk for developing metabolic
alkalosis?
A. A patient with chronic obstructive pulmonary disease (COPD)
B. A patient with uncontrolled Type 1 Diabetes
C. A patient with severe diarrhea
D. A patient with prolonged nasogastric suctioning
Correct Answer: D
Expert Explanation: Prolonged nasogastric suctioning results in the loss of gastric
acid, which can lead to metabolic alkalosis. Diarrhea usually causes metabolic
acidosis due to the loss of bicarbonate from the lower GI tract. Type 1 Diabetes often
leads to diabetic ketoacidosis, which is a metabolic acidosis condition.
,4. A nurse is caring for a client who is postoperative and reports sudden chest pain
and dyspnea. Which action should the nurse take first?
A. Administer pain medication
B. Apply supplemental oxygen
C. Obtain an ECG
D. Call the provider
Correct Answer: B
Expert Explanation: Sudden chest pain and dyspnea in a postoperative client are
classic signs of a pulmonary embolism, which is a medical emergency. Oxygen
administration is the priority to improve oxygenation and stabilize the client’s
respiratory status. After applying oxygen, the nurse should notify the rapid response
team or the healthcare provider immediately.
5. A nurse is reviewing the arterial blood gas (ABG) results for a client: pH 7.30, PaCO2
50 mm Hg, HCO3 24 mEq/L. Which acid-base imbalance does this represent?
A. Metabolic acidosis
B. Respiratory alkalosis
C. Respiratory acidosis
D. Metabolic alkalosis
, Correct Answer: C
Expert Explanation: A pH below 7.35 indicates acidosis, and a PaCO2 above 45 mm
Hg indicates a respiratory cause. Since the bicarbonate (HCO3) is within the normal
range, the imbalance is primarily respiratory. This condition occurs when the lungs
fail to remove enough carbon dioxide from the blood.
6. What is the priority nursing intervention for a client with a sodium level of 128
mEq/L?
A. Encourage increased water intake
B. Place the client on seizure precautions
C. Administer a loop diuretic
D. Monitor for hyperactive bowel sounds
Correct Answer: B
Expert Explanation: Hyponatremia, or a low sodium level, places the client at
significant risk for neurological changes and seizures. Seizure precautions are
essential for patient safety until the sodium level is corrected. Increasing water
intake would likely worsen the hyponatremia by further diluting the serum sodium.
7. The nurse is monitoring a client receiving a blood transfusion. Within 15 minutes,
the client develops a fever and chills. What is the nurse’s first action?
A. Stop the transfusion
