NURS 120 | Introduction to Medical-Surgical Nursing | Study Guide
Exam 3 2026 |WCU
1. A client is scheduled for an elective surgery in two hours. Which nursing
action is the absolute priority before the client receives preoperative sedation?
A. Ensure the surgical consent form is signed and witnessed
B. Assess the client’s knowledge of the surgical procedure
C. Start a large-bore peripheral intravenous line
D. Instruct the client to void to prevent bladder distention
Answer: A
Rationale: The nurse must ensure the legal informed consent is signed before any sedating
medication is given, as sedation renders the client legally incapable of signing.
2. A postoperative client presents with a heart rate of 124 bpm, muscle rigidity,
and a rapidly rising temperature of 103°F. What is the nurse’s immediate
priority action?
A. Administer dantrolene sodium intravenously
B. Apply cooling blankets to the client’s groin and axilla
C. Obtain an arterial blood gas to check for metabolic acidosis
D. Notify the surgeon and the anesthesiologist immediately
Answer: D
Rationale: These are classic signs of Malignant Hyperthermia, a life-threatening
emergency. While dantrolene is the treatment, the immediate priority in a clinical scenario
is to notify the surgical team to stop the triggering agent.
,3. A nurse is reviewing the arterial blood gas (ABG) results for a client with
COPD: pH 7.32, PaCO2 52 mmHg, and HCO3 26 mEq/L. How should the nurse
interpret these results?
A. Metabolic Acidosis
B. Respiratory Acidosis
C. Respiratory Alkalosis
D. Metabolic Alkalosis
Answer: B
Rationale: A pH below 7.35 indicates acidosis. A PaCO2 above 45 mmHg indicates a
respiratory cause. Since the bicarbonate is normal, it is uncompensated respiratory
acidosis.
4. During a dressing change on a client’s abdominal incision, the nurse notes
that the wound has separated and internal organs are protruding. What is the
priority intervention?
A. Cover the organs with sterile gauze moistened with sterile saline
B. Place the client in a High-Fowler’s position
C. Gently push the organs back into the abdominal cavity
D. Call the operating room to prepare for immediate surgery
Answer: A
Rationale: Wound evisceration is an emergency. The nurse must protect the protruding
organs from drying and infection by covering them with sterile, saline-soaked gauze while
keeping the client in a low-Fowler’s position with knees flexed.
, 5. A client’s potassium level is 2.8 mEq/L. Which cardiac monitor finding should
the nurse expect to observe?
A. Peaked T waves
B. Prominent U waves
C. Widened QRS complex
D. Shortened PR interval
Answer: B
Rationale: Hypokalemia (low potassium) typically manifests on an EKG as flat or inverted
T waves and the presence of U waves. Peaked T waves are associated with hyperkalemia.
6. Which assessment finding in a client receiving intravenous fluids is the most
sensitive indicator of fluid volume excess?
A. Pitting edema in the lower extremities
B. Distended jugular veins when sitting at 45 degrees
C. Crackles auscultated in the lung bases
D. A weight gain of 2 pounds in 24 hours
Answer: C
Rationale: While all are signs of fluid excess, crackles (pulmonary edema) represent a
more critical and acute shift that compromises oxygenation, requiring immediate
intervention.
7. A nurse is preparing to administer an opioid analgesic to a postoperative
client. Which vital sign is most critical for the nurse to assess before
administration?
A. Blood pressure
B. Heart rate
C. Oxygen saturation
D. Respiratory rate
Answer: D
Exam 3 2026 |WCU
1. A client is scheduled for an elective surgery in two hours. Which nursing
action is the absolute priority before the client receives preoperative sedation?
A. Ensure the surgical consent form is signed and witnessed
B. Assess the client’s knowledge of the surgical procedure
C. Start a large-bore peripheral intravenous line
D. Instruct the client to void to prevent bladder distention
Answer: A
Rationale: The nurse must ensure the legal informed consent is signed before any sedating
medication is given, as sedation renders the client legally incapable of signing.
2. A postoperative client presents with a heart rate of 124 bpm, muscle rigidity,
and a rapidly rising temperature of 103°F. What is the nurse’s immediate
priority action?
A. Administer dantrolene sodium intravenously
B. Apply cooling blankets to the client’s groin and axilla
C. Obtain an arterial blood gas to check for metabolic acidosis
D. Notify the surgeon and the anesthesiologist immediately
Answer: D
Rationale: These are classic signs of Malignant Hyperthermia, a life-threatening
emergency. While dantrolene is the treatment, the immediate priority in a clinical scenario
is to notify the surgical team to stop the triggering agent.
,3. A nurse is reviewing the arterial blood gas (ABG) results for a client with
COPD: pH 7.32, PaCO2 52 mmHg, and HCO3 26 mEq/L. How should the nurse
interpret these results?
A. Metabolic Acidosis
B. Respiratory Acidosis
C. Respiratory Alkalosis
D. Metabolic Alkalosis
Answer: B
Rationale: A pH below 7.35 indicates acidosis. A PaCO2 above 45 mmHg indicates a
respiratory cause. Since the bicarbonate is normal, it is uncompensated respiratory
acidosis.
4. During a dressing change on a client’s abdominal incision, the nurse notes
that the wound has separated and internal organs are protruding. What is the
priority intervention?
A. Cover the organs with sterile gauze moistened with sterile saline
B. Place the client in a High-Fowler’s position
C. Gently push the organs back into the abdominal cavity
D. Call the operating room to prepare for immediate surgery
Answer: A
Rationale: Wound evisceration is an emergency. The nurse must protect the protruding
organs from drying and infection by covering them with sterile, saline-soaked gauze while
keeping the client in a low-Fowler’s position with knees flexed.
, 5. A client’s potassium level is 2.8 mEq/L. Which cardiac monitor finding should
the nurse expect to observe?
A. Peaked T waves
B. Prominent U waves
C. Widened QRS complex
D. Shortened PR interval
Answer: B
Rationale: Hypokalemia (low potassium) typically manifests on an EKG as flat or inverted
T waves and the presence of U waves. Peaked T waves are associated with hyperkalemia.
6. Which assessment finding in a client receiving intravenous fluids is the most
sensitive indicator of fluid volume excess?
A. Pitting edema in the lower extremities
B. Distended jugular veins when sitting at 45 degrees
C. Crackles auscultated in the lung bases
D. A weight gain of 2 pounds in 24 hours
Answer: C
Rationale: While all are signs of fluid excess, crackles (pulmonary edema) represent a
more critical and acute shift that compromises oxygenation, requiring immediate
intervention.
7. A nurse is preparing to administer an opioid analgesic to a postoperative
client. Which vital sign is most critical for the nurse to assess before
administration?
A. Blood pressure
B. Heart rate
C. Oxygen saturation
D. Respiratory rate
Answer: D
