NURS 120 | Introduction to Medical-Surgical Nursing | Study Guide
Exam 2 2026 |WCU
1. A patient in the PACU exhibits tachycardia, tachypnea, and a rapidly rising
body temperature of 103°F (39.4°C). The nurse suspects malignant
hyperthermia. What is the priority nursing intervention?
A. Prepare for the administration of intravenous dantrolene sodium
B. Initiate cooling blankets and ice packs to the axillae
C. Administer chilled intravenous saline solution
D. Notify the surgeon and anesthesia provider immediately
Answer: A
Rationale: While all actions are important, dantrolene sodium is the specific
pharmacological treatment for malignant hyperthermia as it inhibits calcium release from
the sarcoplasmic reticulum. Administering it is the priority to stop the metabolic crisis.
2. The nurse is caring for a patient with a potassium level of 2.8 mEq/L. Which
ECG change should the nurse monitor for most closely?
A. Peaked T waves
B. Presence of U waves
C. Widened QRS complex
D. Shortened PR interval
Answer: B
Rationale: Hypokalemia (potassium < 3.5 mEq/L) typically manifests on an ECG as
flattened T waves, ST-segment depression, and the appearance of U waves. Peaked T waves
and widened QRS are associated with hyperkalemia.
,3. Which statement correctly identifies the nurse’s primary responsibility
regarding informed consent for a surgical procedure?
A. The nurse’s signature serves as a witness that the patient signed the form voluntarily.
B. The nurse must ensure that the patient has a full understanding of the surgical alternatives.
C. The nurse must explain the risks and benefits of the procedure to the patient.
D. The nurse is responsible for determining the patient’s competency to consent.
Answer: A
Rationale: The surgeon is responsible for explaining the procedure, risks, and benefits.
The nurse acts as a witness to the patient’s signature, confirming that the patient is who
they say they are and signed it voluntarily and while competent.
4. A patient’s arterial blood gas (ABG) results are: pH 7.28, PaCO2 55 mmHg,
HCO3 26 mEq/L. How should the nurse interpret these findings?
A. Metabolic acidosis
B. Respiratory alkalosis
C. Respiratory acidosis
D. Metabolic alkalosis
Answer: C
Rationale: A pH below 7.35 indicates acidosis. A PaCO2 above 45 mmHg indicates a
respiratory cause. Since the pH and CO2 move in opposite directions and the bicarbonate is
within normal limits, it is uncompensated respiratory acidosis.
5. Following abdominal surgery, a patient experiences wound evisceration.
Which action should the nurse take first?
A. Instruct the patient to remain still and not cough
B. Cover the protruding organs with sterile gauze moistened with sterile saline
C. Place the patient in a low-Fowler’s position with knees flexed
D. Notify the surgeon and the Rapid Response Team
Answer: B
, Rationale: Evisceration is a surgical emergency. The first priority is to protect the exposed
organs from drying out and infection by covering them with sterile, saline-soaked
dressings. Other actions follow immediately after.
6. A patient with chronic obstructive pulmonary disease (COPD) is receiving
oxygen via a nasal cannula at 2 L/min. Which assessment finding is most
concerning to the nurse?
A. Oxygen saturation of 90%
B. Productive cough with clear sputum
C. Barrel chest appearance
D. Respiratory rate of 10 breaths/min
Answer: D
Rationale: In some patients with chronic hypercapnia, high levels of oxygen can suppress
the hypoxic drive, leading to respiratory depression. A respiratory rate of 10 is too low and
may indicate oxygen-induced hypoventilation.
7. Which clinical manifestation should the nurse expect in a patient with fluid
volume deficit?
A. Bounding peripheral pulses
B. Distended neck veins
C. Orthostatic hypotension
D. Crackles upon lung auscultation
Answer: C
Rationale: Fluid volume deficit (dehydration) leads to decreased circulating blood volume,
which causes orthostatic hypotension, weak/thready pulses, and poor skin turgor. The
other options are signs of fluid volume excess.
Exam 2 2026 |WCU
1. A patient in the PACU exhibits tachycardia, tachypnea, and a rapidly rising
body temperature of 103°F (39.4°C). The nurse suspects malignant
hyperthermia. What is the priority nursing intervention?
A. Prepare for the administration of intravenous dantrolene sodium
B. Initiate cooling blankets and ice packs to the axillae
C. Administer chilled intravenous saline solution
D. Notify the surgeon and anesthesia provider immediately
Answer: A
Rationale: While all actions are important, dantrolene sodium is the specific
pharmacological treatment for malignant hyperthermia as it inhibits calcium release from
the sarcoplasmic reticulum. Administering it is the priority to stop the metabolic crisis.
2. The nurse is caring for a patient with a potassium level of 2.8 mEq/L. Which
ECG change should the nurse monitor for most closely?
A. Peaked T waves
B. Presence of U waves
C. Widened QRS complex
D. Shortened PR interval
Answer: B
Rationale: Hypokalemia (potassium < 3.5 mEq/L) typically manifests on an ECG as
flattened T waves, ST-segment depression, and the appearance of U waves. Peaked T waves
and widened QRS are associated with hyperkalemia.
,3. Which statement correctly identifies the nurse’s primary responsibility
regarding informed consent for a surgical procedure?
A. The nurse’s signature serves as a witness that the patient signed the form voluntarily.
B. The nurse must ensure that the patient has a full understanding of the surgical alternatives.
C. The nurse must explain the risks and benefits of the procedure to the patient.
D. The nurse is responsible for determining the patient’s competency to consent.
Answer: A
Rationale: The surgeon is responsible for explaining the procedure, risks, and benefits.
The nurse acts as a witness to the patient’s signature, confirming that the patient is who
they say they are and signed it voluntarily and while competent.
4. A patient’s arterial blood gas (ABG) results are: pH 7.28, PaCO2 55 mmHg,
HCO3 26 mEq/L. How should the nurse interpret these findings?
A. Metabolic acidosis
B. Respiratory alkalosis
C. Respiratory acidosis
D. Metabolic alkalosis
Answer: C
Rationale: A pH below 7.35 indicates acidosis. A PaCO2 above 45 mmHg indicates a
respiratory cause. Since the pH and CO2 move in opposite directions and the bicarbonate is
within normal limits, it is uncompensated respiratory acidosis.
5. Following abdominal surgery, a patient experiences wound evisceration.
Which action should the nurse take first?
A. Instruct the patient to remain still and not cough
B. Cover the protruding organs with sterile gauze moistened with sterile saline
C. Place the patient in a low-Fowler’s position with knees flexed
D. Notify the surgeon and the Rapid Response Team
Answer: B
, Rationale: Evisceration is a surgical emergency. The first priority is to protect the exposed
organs from drying out and infection by covering them with sterile, saline-soaked
dressings. Other actions follow immediately after.
6. A patient with chronic obstructive pulmonary disease (COPD) is receiving
oxygen via a nasal cannula at 2 L/min. Which assessment finding is most
concerning to the nurse?
A. Oxygen saturation of 90%
B. Productive cough with clear sputum
C. Barrel chest appearance
D. Respiratory rate of 10 breaths/min
Answer: D
Rationale: In some patients with chronic hypercapnia, high levels of oxygen can suppress
the hypoxic drive, leading to respiratory depression. A respiratory rate of 10 is too low and
may indicate oxygen-induced hypoventilation.
7. Which clinical manifestation should the nurse expect in a patient with fluid
volume deficit?
A. Bounding peripheral pulses
B. Distended neck veins
C. Orthostatic hypotension
D. Crackles upon lung auscultation
Answer: C
Rationale: Fluid volume deficit (dehydration) leads to decreased circulating blood volume,
which causes orthostatic hypotension, weak/thready pulses, and poor skin turgor. The
other options are signs of fluid volume excess.
