NU180 | NU180 Nursing and Healthcare II | NCLEX
Style Exam 2 v3 | Questions with Correct Answers
and Expert Explanation for Each Question | Galen
1. A patient with persistent vomiting is at risk for which acid-base imbalance?
A. Respiratory acidosis
B. Metabolic acidosis
C. Respiratory alkalosis
D. Metabolic alkalosis
Correct Answer: D
Expert Explanation: Vomiting results in the loss of gastric hydrochloric acid from
the stomach. This loss of acid causes an increase in the serum bicarbonate level as
the body attempts to maintain electrical neutrality. The nurse must monitor the
patient for symptoms such as bradypnea and hypokalemia which often accompany
this metabolic state.
2. The nurse is caring for a patient who is 1 day postoperative. Which assessment
finding is the most reliable indicator of returning gastrointestinal function?
A. Presence of bowel sounds
B. Patient report of hunger
C. Passage of flatus or stool
,D. Absence of nausea
Correct Answer: C
Expert Explanation: The passage of flatus or stool is the most definitive clinical
sign that peristalsis has returned to the lower GI tract. While bowel sounds are
helpful, they can be misleading in the immediate postoperative period. The nurse
should continue to encourage early ambulation to facilitate the return of normal
bowel function.
3. Which clinical manifestation would the nurse expect to find in a patient with
hypocalcemia?
A. Positive Trousseau’s sign
B. Constipation
C. Shortened QT interval
D. Muscle weakness
Correct Answer: A
Expert Explanation: Hypocalcemia increases neuromuscular excitability, leading to
signs like Trousseau’s and Chvostek’s signs. Trousseau’s sign is observed when a
blood pressure cuff is inflated and causes a carpal spasm. The nurse must provide a
safe environment and monitor for potential laryngeal spasms in severe cases.
,4. A nurse is monitoring a patient receiving a blood transfusion. Which action should
the nurse take first if a transfusion reaction is suspected?
A. Notify the healthcare provider
B. Check the patient’s vital signs
C. Switch the IV tubing to normal saline
D. Stop the transfusion immediately
Correct Answer: D
Expert Explanation: Stopping the transfusion is the immediate priority to prevent
further exposure to the potentially incompatible blood product. Following this
action, the nurse should maintain the IV line with normal saline using new tubing
and then notify the provider. Patient safety and the prevention of hemolytic shock
are the primary goals in this emergency.
5. When assessing a patient with a Stage 3 pressure injury, which description should
the nurse expect to observe?
A. Intact skin with non-blanchable redness
B. Full-thickness tissue loss with visible subcutaneous fat
C. Partial-thickness loss of dermis
D. Exposed bone, tendon, or muscle
, Correct Answer: B
Expert Explanation: A Stage 3 pressure injury involves full-thickness skin loss
where adipose tissue is visible in the ulcer. Bone and muscle are not yet exposed,
which would characterize a Stage 4 injury. The nurse should implement wound care
protocols that promote granulation and prevent further infection.
6. Which electrolyte imbalance is a patient with chronic kidney disease most likely to
develop?
A. Hypokalemia
B. Hyponatremia
C. Hyperkalemia
D. Hypophosphatemia
Correct Answer: C
Expert Explanation: The kidneys are the primary route for potassium excretion,
and impaired function leads to potassium retention. Hyperkalemia is a life-
threatening condition because it can cause lethal cardiac dysrhythmias. The nurse
should educate the patient on a low-potassium diet and monitor serum levels
closely.
Style Exam 2 v3 | Questions with Correct Answers
and Expert Explanation for Each Question | Galen
1. A patient with persistent vomiting is at risk for which acid-base imbalance?
A. Respiratory acidosis
B. Metabolic acidosis
C. Respiratory alkalosis
D. Metabolic alkalosis
Correct Answer: D
Expert Explanation: Vomiting results in the loss of gastric hydrochloric acid from
the stomach. This loss of acid causes an increase in the serum bicarbonate level as
the body attempts to maintain electrical neutrality. The nurse must monitor the
patient for symptoms such as bradypnea and hypokalemia which often accompany
this metabolic state.
2. The nurse is caring for a patient who is 1 day postoperative. Which assessment
finding is the most reliable indicator of returning gastrointestinal function?
A. Presence of bowel sounds
B. Patient report of hunger
C. Passage of flatus or stool
,D. Absence of nausea
Correct Answer: C
Expert Explanation: The passage of flatus or stool is the most definitive clinical
sign that peristalsis has returned to the lower GI tract. While bowel sounds are
helpful, they can be misleading in the immediate postoperative period. The nurse
should continue to encourage early ambulation to facilitate the return of normal
bowel function.
3. Which clinical manifestation would the nurse expect to find in a patient with
hypocalcemia?
A. Positive Trousseau’s sign
B. Constipation
C. Shortened QT interval
D. Muscle weakness
Correct Answer: A
Expert Explanation: Hypocalcemia increases neuromuscular excitability, leading to
signs like Trousseau’s and Chvostek’s signs. Trousseau’s sign is observed when a
blood pressure cuff is inflated and causes a carpal spasm. The nurse must provide a
safe environment and monitor for potential laryngeal spasms in severe cases.
,4. A nurse is monitoring a patient receiving a blood transfusion. Which action should
the nurse take first if a transfusion reaction is suspected?
A. Notify the healthcare provider
B. Check the patient’s vital signs
C. Switch the IV tubing to normal saline
D. Stop the transfusion immediately
Correct Answer: D
Expert Explanation: Stopping the transfusion is the immediate priority to prevent
further exposure to the potentially incompatible blood product. Following this
action, the nurse should maintain the IV line with normal saline using new tubing
and then notify the provider. Patient safety and the prevention of hemolytic shock
are the primary goals in this emergency.
5. When assessing a patient with a Stage 3 pressure injury, which description should
the nurse expect to observe?
A. Intact skin with non-blanchable redness
B. Full-thickness tissue loss with visible subcutaneous fat
C. Partial-thickness loss of dermis
D. Exposed bone, tendon, or muscle
, Correct Answer: B
Expert Explanation: A Stage 3 pressure injury involves full-thickness skin loss
where adipose tissue is visible in the ulcer. Bone and muscle are not yet exposed,
which would characterize a Stage 4 injury. The nurse should implement wound care
protocols that promote granulation and prevent further infection.
6. Which electrolyte imbalance is a patient with chronic kidney disease most likely to
develop?
A. Hypokalemia
B. Hyponatremia
C. Hyperkalemia
D. Hypophosphatemia
Correct Answer: C
Expert Explanation: The kidneys are the primary route for potassium excretion,
and impaired function leads to potassium retention. Hyperkalemia is a life-
threatening condition because it can cause lethal cardiac dysrhythmias. The nurse
should educate the patient on a low-potassium diet and monitor serum levels
closely.
