NURS 201: Medical-Surgical Nursing - Exam 2 2026 |WCU
1. A patient’s arterial blood gas (ABG) results are pH 7.30, PaCO2 55 mmHg, and
HCO3 26 mEq/L. Which condition does the nurse suspect?
A. Metabolic Acidosis
B. Respiratory Alkalosis
C. Respiratory Acidosis
D. Metabolic Alkalosis
Answer: C
Rationale: The pH is below 7.35 (acidosis) and the PaCO2 is above 45 mmHg (respiratory
cause), while the HCO3 is within normal range, indicating uncompensated respiratory
acidosis.
2. A nurse is monitoring a patient receiving a blood transfusion. Within the first
15 minutes, the patient reports low back pain and becomes restless. What is the
priority nursing action?
A. Slow the infusion rate and call the provider
B. Stop the transfusion immediately and disconnect the tubing
C. Administer diphenhydramine as ordered
D. Check the patient’s temperature and document findings
Answer: B
Rationale: Low back pain and restlessness are signs of a hemolytic transfusion reaction.
The priority is to stop the transfusion and disconnect the tubing at the hub to prevent
further exposure.
,3. A patient with a serum potassium level of 6.2 mEq/L is admitted. Which
cardiac rhythm change should the nurse expect on the ECG?
A. Prominent U waves
B. ST-segment depression
C. Tall peaked T waves
D. Shortened PR interval
Answer: C
Rationale: Hyperkalemia (K+ > 5.0) causes tall, peaked T waves, widened QRS complexes,
and potentially cardiac arrest.
4. When assessing a patient for Trousseau’s sign, which technique should the
nurse use?
A. Tap the facial nerve in front of the ear
B. Inflate a blood pressure cuff above the systolic pressure for 3 minutes
C. Assess for hyperactive deep tendon reflexes
D. Elicit a positive Babinski reflex
Answer: B
Rationale: Trousseau’s sign is a carpal spasm induced by inflating a BP cuff, indicating
hypocalcemia. Tapping the facial nerve is Chvostek’s sign.
5. A postoperative patient has developed an evisceration. After calling for help,
what is the nurse’s next action?
A. Attempt to push the organs back into the abdominal cavity
B. Apply a dry sterile dressing to the wound
C. Place the patient in High-Fowler’s position
D. Cover the protruding organs with sterile dressings moistened with sterile normal saline
Answer: D
Rationale: Evisceration requires keeping the exposed organs moist with sterile saline to
prevent tissue necrosis while waiting for emergency surgery.
, 6. Which clinical manifestation is most characteristic of right-sided heart failure?
A. Pulmonary crackles
B. Peripheral edema
C. Paroxysmal nocturnal dyspnea
D. Pink frothy sputum
Answer: B
Rationale: Right-sided heart failure leads to systemic venous congestion, causing
peripheral edema, JVD, and hepatomegaly. Pulmonary symptoms are typical of left-sided
failure.
7. A patient is scheduled for surgery and the nurse notices the informed consent
has not been signed. Who is primarily responsible for obtaining the patient’s
signature and explaining the procedure?
A. The surgeon
B. The circulating nurse
C. The charge nurse
D. The anesthesiologist
Answer: A
Rationale: The surgeon is responsible for explaining the risks, benefits, and alternatives of
the procedure. The nurse only witnesses the signature.
8. During the intraoperative phase, a patient develops a heart rate of 120 bpm,
muscle rigidity, and a rapidly rising temperature. Which medication should the
nurse anticipate administering?
A. Atropine sulfate
B. Epinephrine
C. Naloxone hydrochloride
D. Dantrolene sodium
Answer: D
1. A patient’s arterial blood gas (ABG) results are pH 7.30, PaCO2 55 mmHg, and
HCO3 26 mEq/L. Which condition does the nurse suspect?
A. Metabolic Acidosis
B. Respiratory Alkalosis
C. Respiratory Acidosis
D. Metabolic Alkalosis
Answer: C
Rationale: The pH is below 7.35 (acidosis) and the PaCO2 is above 45 mmHg (respiratory
cause), while the HCO3 is within normal range, indicating uncompensated respiratory
acidosis.
2. A nurse is monitoring a patient receiving a blood transfusion. Within the first
15 minutes, the patient reports low back pain and becomes restless. What is the
priority nursing action?
A. Slow the infusion rate and call the provider
B. Stop the transfusion immediately and disconnect the tubing
C. Administer diphenhydramine as ordered
D. Check the patient’s temperature and document findings
Answer: B
Rationale: Low back pain and restlessness are signs of a hemolytic transfusion reaction.
The priority is to stop the transfusion and disconnect the tubing at the hub to prevent
further exposure.
,3. A patient with a serum potassium level of 6.2 mEq/L is admitted. Which
cardiac rhythm change should the nurse expect on the ECG?
A. Prominent U waves
B. ST-segment depression
C. Tall peaked T waves
D. Shortened PR interval
Answer: C
Rationale: Hyperkalemia (K+ > 5.0) causes tall, peaked T waves, widened QRS complexes,
and potentially cardiac arrest.
4. When assessing a patient for Trousseau’s sign, which technique should the
nurse use?
A. Tap the facial nerve in front of the ear
B. Inflate a blood pressure cuff above the systolic pressure for 3 minutes
C. Assess for hyperactive deep tendon reflexes
D. Elicit a positive Babinski reflex
Answer: B
Rationale: Trousseau’s sign is a carpal spasm induced by inflating a BP cuff, indicating
hypocalcemia. Tapping the facial nerve is Chvostek’s sign.
5. A postoperative patient has developed an evisceration. After calling for help,
what is the nurse’s next action?
A. Attempt to push the organs back into the abdominal cavity
B. Apply a dry sterile dressing to the wound
C. Place the patient in High-Fowler’s position
D. Cover the protruding organs with sterile dressings moistened with sterile normal saline
Answer: D
Rationale: Evisceration requires keeping the exposed organs moist with sterile saline to
prevent tissue necrosis while waiting for emergency surgery.
, 6. Which clinical manifestation is most characteristic of right-sided heart failure?
A. Pulmonary crackles
B. Peripheral edema
C. Paroxysmal nocturnal dyspnea
D. Pink frothy sputum
Answer: B
Rationale: Right-sided heart failure leads to systemic venous congestion, causing
peripheral edema, JVD, and hepatomegaly. Pulmonary symptoms are typical of left-sided
failure.
7. A patient is scheduled for surgery and the nurse notices the informed consent
has not been signed. Who is primarily responsible for obtaining the patient’s
signature and explaining the procedure?
A. The surgeon
B. The circulating nurse
C. The charge nurse
D. The anesthesiologist
Answer: A
Rationale: The surgeon is responsible for explaining the risks, benefits, and alternatives of
the procedure. The nurse only witnesses the signature.
8. During the intraoperative phase, a patient develops a heart rate of 120 bpm,
muscle rigidity, and a rapidly rising temperature. Which medication should the
nurse anticipate administering?
A. Atropine sulfate
B. Epinephrine
C. Naloxone hydrochloride
D. Dantrolene sodium
Answer: D
