NURS 120 Introduction to Medical-Surgical Nursing - Actual Exam 4
2026 |WCU
1. A nurse is assessing a patient who is 6 hours post-operative following an
abdominal hysterectomy. Which of the following findings should the nurse
report to the provider immediately?
A. Serosanguinous drainage on the abdominal dressing
B. A temperature of 37.5 C (99.5 F)
C. A urinary output of 20 mL/hr over the last 2 hours
D. Absent bowel sounds in all four quadrants
Answer: C
Rationale: Urinary output less than 30 mL/hr can indicate hypovolemia or acute kidney
injury and must be reported immediately. The other findings are common post-operative
observations.
2. A patient has a potassium level of 6.2 mEq/L. Which of the following ECG
changes should the nurse expect to see?
A. Presence of U waves
B. Tall, peaked T waves
C. ST-segment depression
D. Shortened PR interval
Answer: B
Rationale: Hyperkalemia (potassium > 5.0) causes tall, peaked T waves and potentially
widened QRS complexes. U waves and ST depression are associated with hypokalemia.
,3. A nurse is preparing a patient for surgery. The patient states, ‘I am not sure I
want to have this procedure anymore.’ Which of the following actions should
the nurse take?
A. Tell the patient that the surgeon is highly skilled
B. Notify the surgeon that the patient has questions or second thoughts
C. Have the patient sign the consent form quickly before they change their mind
D. Ask the family to convince the patient to proceed
Answer: B
Rationale: It is the nurse’s responsibility to advocate for the patient and ensure the
surgeon provides further clarification if the patient expresses doubt or lack of
understanding regarding the procedure.
4. Which of the following patients is at the highest risk for developing
respiratory acidosis?
A. A patient with a massive pulmonary embolism
B. A patient who has been vomiting for 24 hours
C. A patient experiencing a panic attack with hyperventilation
D. A patient with chronic obstructive pulmonary disease (COPD)
Answer: D
Rationale: COPD causes chronic CO2 retention, leading to respiratory acidosis. Vomiting
causes metabolic alkalosis, and hyperventilation causes respiratory alkalosis.
5. A nurse is caring for a patient who is post-operative and reports sudden chest
pain and shortness of breath. What is the nurse’s priority action?
A. Obtain an ECG
B. Administer pain medication
C. Auscultate the patient’s lung sounds
D. Apply oxygen via nasal cannula
Answer: D
, Rationale: Applying oxygen is the priority action (Airway/Breathing) for a patient
exhibiting signs of a pulmonary embolism or acute respiratory distress before proceeding
with further diagnostics.
6. A patient’s arterial blood gas (ABG) results are: pH 7.31, PaCO2 50 mmHg,
HCO3 24 mEq/L. How should the nurse interpret these results?
A. Respiratory Acidosis
B. Metabolic Acidosis
C. Metabolic Alkalosis
D. Respiratory Alkalosis
Answer: A
Rationale: The low pH (<7.35) indicates acidosis. The high PaCO2 (>45) indicates a
respiratory cause, while the normal HCO3 shows no compensation yet.
7. During a pre-operative assessment, a patient reports an allergy to avocados
and bananas. For which of the following is the patient at higher risk?
A. Latex allergy
B. Penicillin allergy
C. Iodine sensitivity
D. Propofol intolerance
Answer: A
Rationale: Cross-sensitivity exists between certain fruits (avocados, bananas, kiwi) and
latex due to similar proteins.
2026 |WCU
1. A nurse is assessing a patient who is 6 hours post-operative following an
abdominal hysterectomy. Which of the following findings should the nurse
report to the provider immediately?
A. Serosanguinous drainage on the abdominal dressing
B. A temperature of 37.5 C (99.5 F)
C. A urinary output of 20 mL/hr over the last 2 hours
D. Absent bowel sounds in all four quadrants
Answer: C
Rationale: Urinary output less than 30 mL/hr can indicate hypovolemia or acute kidney
injury and must be reported immediately. The other findings are common post-operative
observations.
2. A patient has a potassium level of 6.2 mEq/L. Which of the following ECG
changes should the nurse expect to see?
A. Presence of U waves
B. Tall, peaked T waves
C. ST-segment depression
D. Shortened PR interval
Answer: B
Rationale: Hyperkalemia (potassium > 5.0) causes tall, peaked T waves and potentially
widened QRS complexes. U waves and ST depression are associated with hypokalemia.
,3. A nurse is preparing a patient for surgery. The patient states, ‘I am not sure I
want to have this procedure anymore.’ Which of the following actions should
the nurse take?
A. Tell the patient that the surgeon is highly skilled
B. Notify the surgeon that the patient has questions or second thoughts
C. Have the patient sign the consent form quickly before they change their mind
D. Ask the family to convince the patient to proceed
Answer: B
Rationale: It is the nurse’s responsibility to advocate for the patient and ensure the
surgeon provides further clarification if the patient expresses doubt or lack of
understanding regarding the procedure.
4. Which of the following patients is at the highest risk for developing
respiratory acidosis?
A. A patient with a massive pulmonary embolism
B. A patient who has been vomiting for 24 hours
C. A patient experiencing a panic attack with hyperventilation
D. A patient with chronic obstructive pulmonary disease (COPD)
Answer: D
Rationale: COPD causes chronic CO2 retention, leading to respiratory acidosis. Vomiting
causes metabolic alkalosis, and hyperventilation causes respiratory alkalosis.
5. A nurse is caring for a patient who is post-operative and reports sudden chest
pain and shortness of breath. What is the nurse’s priority action?
A. Obtain an ECG
B. Administer pain medication
C. Auscultate the patient’s lung sounds
D. Apply oxygen via nasal cannula
Answer: D
, Rationale: Applying oxygen is the priority action (Airway/Breathing) for a patient
exhibiting signs of a pulmonary embolism or acute respiratory distress before proceeding
with further diagnostics.
6. A patient’s arterial blood gas (ABG) results are: pH 7.31, PaCO2 50 mmHg,
HCO3 24 mEq/L. How should the nurse interpret these results?
A. Respiratory Acidosis
B. Metabolic Acidosis
C. Metabolic Alkalosis
D. Respiratory Alkalosis
Answer: A
Rationale: The low pH (<7.35) indicates acidosis. The high PaCO2 (>45) indicates a
respiratory cause, while the normal HCO3 shows no compensation yet.
7. During a pre-operative assessment, a patient reports an allergy to avocados
and bananas. For which of the following is the patient at higher risk?
A. Latex allergy
B. Penicillin allergy
C. Iodine sensitivity
D. Propofol intolerance
Answer: A
Rationale: Cross-sensitivity exists between certain fruits (avocados, bananas, kiwi) and
latex due to similar proteins.
