NU189 | NU 189 Medical-Surgical Nursing II Exam
1 v3 | Questions with Correct Answers and Expert
Explanation for Each Question | Galen
1. A patient presents with a pH of 7.31, PaCO2 of 52 mmHg, and HCO3 of 25 mEq/L.
Which acid-base imbalance is occurring?
A. Metabolic Acidosis
B. Metabolic Alkalosis
C. Respiratory Alkalosis
D. Respiratory Acidosis
Correct Answer: D
Expert Explanation: The pH is below 7.35, indicating acidosis, and the PaCO2 is
above 45 mmHg, indicating a respiratory cause. The bicarbonate level is normal,
suggesting there is no compensation yet. This condition often results from
hypoventilation or airway obstruction.
2. Which clinical manifestation should the nurse expect in a patient diagnosed with
right-sided heart failure?
A. Dependent edema
B. Pulmonary crackles
C. Pink frothy sputum
,D. Dyspnea on exertion
Correct Answer: A
Expert Explanation: Right-sided heart failure leads to systemic venous congestion,
which manifests as peripheral or dependent edema. Fluid backs up into the systemic
circulation rather than the lungs. Left-sided heart failure would more likely cause
pulmonary symptoms like crackles and sputum.
3. A patient is being treated for a massive pulmonary embolism. Which priority
assessment finding should the nurse report immediately?
A. Oxygen saturation of 94% on 2L NC
B. Calf pain and swelling
C. Sudden onset of confusion or restlessness
D. Heart rate of 98 beats per minute
Correct Answer: C
Expert Explanation: Mental status changes like confusion or restlessness are early
indicators of hypoxia and decreased cerebral perfusion. While calf pain is common
in DVT, the acute neurological change suggests worsening respiratory or cardiac
failure. The nurse must prioritize ABCs and notify the provider for rapid
intervention.
,4. The nurse is caring for a patient with a chest tube. What should the nurse do if the
chest tube becomes accidentally dislodged from the patient’s chest?
A. Immediately clamp the chest tube
B. Place the end of the tube in sterile water
C. Apply an occlusive dressing taped on three sides
D. Perform a needle thoracostomy
Correct Answer: C
Expert Explanation: Applying a sterile occlusive dressing taped on three sides
prevents atmospheric air from entering the pleural space during inspiration while
allowing air to escape. This action prevents the development of a tension
pneumothorax. The nurse should then stay with the patient and call for emergency
assistance.
5. A patient with COPD is receiving oxygen therapy. What is the most appropriate
oxygen saturation target for this patient?
A. 95% to 100%
B. 88% to 92%
C. Above 98%
D. 70% to 80%
, Correct Answer: B
Expert Explanation: Patients with COPD often rely on a hypoxic drive to breathe,
and excessive oxygen can suppress their respiratory rate. A target range of 88-92%
is generally considered safe and effective to maintain oxygenation without causing
hypercapnia. Higher targets could lead to carbon dioxide retention and respiratory
arrest.
6. Which EKG rhythm is characterized by a ‘sawtooth’ pattern and a rapid atrial rate?
A. Atrial Fibrillation
B. Ventricular Tachycardia
C. Atrial Flutter
D. Sinus Bradycardia
Correct Answer: C
Expert Explanation: Atrial flutter is classically identified by the rapid, regular atrial
waves that resemble the teeth of a saw. These are called F-waves and are distinct
from the disorganized activity of atrial fibrillation. This rhythm requires monitoring
for stable cardiac output and potential anticoagulation.
7. The nurse is assessing a patient with Cushing’s syndrome. Which finding is
characteristic of this condition?
A. Bronze skin pigmentation
1 v3 | Questions with Correct Answers and Expert
Explanation for Each Question | Galen
1. A patient presents with a pH of 7.31, PaCO2 of 52 mmHg, and HCO3 of 25 mEq/L.
Which acid-base imbalance is occurring?
A. Metabolic Acidosis
B. Metabolic Alkalosis
C. Respiratory Alkalosis
D. Respiratory Acidosis
Correct Answer: D
Expert Explanation: The pH is below 7.35, indicating acidosis, and the PaCO2 is
above 45 mmHg, indicating a respiratory cause. The bicarbonate level is normal,
suggesting there is no compensation yet. This condition often results from
hypoventilation or airway obstruction.
2. Which clinical manifestation should the nurse expect in a patient diagnosed with
right-sided heart failure?
A. Dependent edema
B. Pulmonary crackles
C. Pink frothy sputum
,D. Dyspnea on exertion
Correct Answer: A
Expert Explanation: Right-sided heart failure leads to systemic venous congestion,
which manifests as peripheral or dependent edema. Fluid backs up into the systemic
circulation rather than the lungs. Left-sided heart failure would more likely cause
pulmonary symptoms like crackles and sputum.
3. A patient is being treated for a massive pulmonary embolism. Which priority
assessment finding should the nurse report immediately?
A. Oxygen saturation of 94% on 2L NC
B. Calf pain and swelling
C. Sudden onset of confusion or restlessness
D. Heart rate of 98 beats per minute
Correct Answer: C
Expert Explanation: Mental status changes like confusion or restlessness are early
indicators of hypoxia and decreased cerebral perfusion. While calf pain is common
in DVT, the acute neurological change suggests worsening respiratory or cardiac
failure. The nurse must prioritize ABCs and notify the provider for rapid
intervention.
,4. The nurse is caring for a patient with a chest tube. What should the nurse do if the
chest tube becomes accidentally dislodged from the patient’s chest?
A. Immediately clamp the chest tube
B. Place the end of the tube in sterile water
C. Apply an occlusive dressing taped on three sides
D. Perform a needle thoracostomy
Correct Answer: C
Expert Explanation: Applying a sterile occlusive dressing taped on three sides
prevents atmospheric air from entering the pleural space during inspiration while
allowing air to escape. This action prevents the development of a tension
pneumothorax. The nurse should then stay with the patient and call for emergency
assistance.
5. A patient with COPD is receiving oxygen therapy. What is the most appropriate
oxygen saturation target for this patient?
A. 95% to 100%
B. 88% to 92%
C. Above 98%
D. 70% to 80%
, Correct Answer: B
Expert Explanation: Patients with COPD often rely on a hypoxic drive to breathe,
and excessive oxygen can suppress their respiratory rate. A target range of 88-92%
is generally considered safe and effective to maintain oxygenation without causing
hypercapnia. Higher targets could lead to carbon dioxide retention and respiratory
arrest.
6. Which EKG rhythm is characterized by a ‘sawtooth’ pattern and a rapid atrial rate?
A. Atrial Fibrillation
B. Ventricular Tachycardia
C. Atrial Flutter
D. Sinus Bradycardia
Correct Answer: C
Expert Explanation: Atrial flutter is classically identified by the rapid, regular atrial
waves that resemble the teeth of a saw. These are called F-waves and are distinct
from the disorganized activity of atrial fibrillation. This rhythm requires monitoring
for stable cardiac output and potential anticoagulation.
7. The nurse is assessing a patient with Cushing’s syndrome. Which finding is
characteristic of this condition?
A. Bronze skin pigmentation
