NURS 120 | Introduction to Medical-Surgical Nursing | Exam 3 2026
|WCU
1. A patient is scheduled for an elective surgery. During the preoperative
assessment, the nurse notes the patient is wearing a medical alert bracelet for a
severe latex allergy. Which action is the priority for the nurse?
A. Ask the patient to remove the bracelet and place it with their personal belongings.
B. Administer a prophylactic dose of antihistamines as ordered.
C. Notify the surgical team and ensure the operating room is prepared as a latex-free environment.
D. Document the allergy in the electronic health record only.
Answer: C
Rationale: Latex allergy is a critical safety concern. Preparing a latex-free environment is
the priority to prevent anaphylaxis during surgery.
2. A nurse is caring for a patient who is 24 hours postoperative following
abdominal surgery. The patient reports sudden chest pain and shortness of
breath. Which complication should the nurse suspect first?
A. Hypovolemic shock
B. Dehiscence
C. Atelectasis
D. Pulmonary embolism
Answer: D
Rationale: Sudden onset of chest pain and dyspnea in a postoperative patient are classic
signs of a pulmonary embolism, a life-threatening complication.
,3. The nurse is reviewing the arterial blood gas (ABG) results of a patient with
chronic obstructive pulmonary disease (COPD): pH 7.31, PaCO2 52 mmHg, HCO3
28 mEq/L. How should the nurse interpret these results?
A. Metabolic Acidosis
B. Partially compensated Respiratory Acidosis
C. Respiratory Alkalosis
D. Uncompensated Metabolic Alkalosis
Answer: B
Rationale: The pH is low (acidosis), PaCO2 is high (respiratory cause), and the HCO3 is
high, indicating the kidneys are attempting to compensate.
4. A patient has a serum potassium level of 2.8 mEq/L. Which assessment
finding is most concerning to the nurse?
A. Hyperactive bowel sounds
B. Increased muscle strength
C. Irregular heart rhythm and flattened T waves on ECG
D. Hyperreflexia
Answer: C
Rationale: Hypokalemia (potassium < 3.5 mEq/L) can cause life-threatening cardiac
dysrhythmias and characteristic ECG changes like flat T waves.
5. A patient who underwent a total hip replacement 2 days ago becomes
confused and agitated. The nurse notes petechiae on the patient’s chest and
neck. Which condition is most likely?
A. Myocardial infarction
B. Septic shock
C. Delirium tremens
D. Fat embolism syndrome
Answer: D
, Rationale: Confusion, agitation, and petechiae following orthopedic surgery are hallmark
signs of fat embolism syndrome.
6. When providing preoperative education for a patient having surgery the next
day, which statement by the patient indicates a need for further teaching?
A. I will stay in bed as much as possible after surgery to prevent the incision from opening.
B. I will stop taking my aspirin one week before the procedure.
C. I can drink clear liquids up until 2 hours before the surgery starts.
D. I will use my incentive spirometer every hour while I am awake.
Answer: A
Rationale: Early ambulation is encouraged to prevent complications like DVT and
atelectasis; staying in bed is not recommended.
7. A nurse is monitoring a patient receiving an IV infusion of 0.45% normal
saline. For which complication should the nurse monitor closely?
A. Fluid volume excess
B. Cerebral edema
C. Hypertension
D. Hypernatremia
Answer: B
Rationale: 0.45% NS is a hypotonic solution, which causes fluid to shift from the
intravascular space into the cells, potentially leading to cellular swelling and cerebral
edema.
|WCU
1. A patient is scheduled for an elective surgery. During the preoperative
assessment, the nurse notes the patient is wearing a medical alert bracelet for a
severe latex allergy. Which action is the priority for the nurse?
A. Ask the patient to remove the bracelet and place it with their personal belongings.
B. Administer a prophylactic dose of antihistamines as ordered.
C. Notify the surgical team and ensure the operating room is prepared as a latex-free environment.
D. Document the allergy in the electronic health record only.
Answer: C
Rationale: Latex allergy is a critical safety concern. Preparing a latex-free environment is
the priority to prevent anaphylaxis during surgery.
2. A nurse is caring for a patient who is 24 hours postoperative following
abdominal surgery. The patient reports sudden chest pain and shortness of
breath. Which complication should the nurse suspect first?
A. Hypovolemic shock
B. Dehiscence
C. Atelectasis
D. Pulmonary embolism
Answer: D
Rationale: Sudden onset of chest pain and dyspnea in a postoperative patient are classic
signs of a pulmonary embolism, a life-threatening complication.
,3. The nurse is reviewing the arterial blood gas (ABG) results of a patient with
chronic obstructive pulmonary disease (COPD): pH 7.31, PaCO2 52 mmHg, HCO3
28 mEq/L. How should the nurse interpret these results?
A. Metabolic Acidosis
B. Partially compensated Respiratory Acidosis
C. Respiratory Alkalosis
D. Uncompensated Metabolic Alkalosis
Answer: B
Rationale: The pH is low (acidosis), PaCO2 is high (respiratory cause), and the HCO3 is
high, indicating the kidneys are attempting to compensate.
4. A patient has a serum potassium level of 2.8 mEq/L. Which assessment
finding is most concerning to the nurse?
A. Hyperactive bowel sounds
B. Increased muscle strength
C. Irregular heart rhythm and flattened T waves on ECG
D. Hyperreflexia
Answer: C
Rationale: Hypokalemia (potassium < 3.5 mEq/L) can cause life-threatening cardiac
dysrhythmias and characteristic ECG changes like flat T waves.
5. A patient who underwent a total hip replacement 2 days ago becomes
confused and agitated. The nurse notes petechiae on the patient’s chest and
neck. Which condition is most likely?
A. Myocardial infarction
B. Septic shock
C. Delirium tremens
D. Fat embolism syndrome
Answer: D
, Rationale: Confusion, agitation, and petechiae following orthopedic surgery are hallmark
signs of fat embolism syndrome.
6. When providing preoperative education for a patient having surgery the next
day, which statement by the patient indicates a need for further teaching?
A. I will stay in bed as much as possible after surgery to prevent the incision from opening.
B. I will stop taking my aspirin one week before the procedure.
C. I can drink clear liquids up until 2 hours before the surgery starts.
D. I will use my incentive spirometer every hour while I am awake.
Answer: A
Rationale: Early ambulation is encouraged to prevent complications like DVT and
atelectasis; staying in bed is not recommended.
7. A nurse is monitoring a patient receiving an IV infusion of 0.45% normal
saline. For which complication should the nurse monitor closely?
A. Fluid volume excess
B. Cerebral edema
C. Hypertension
D. Hypernatremia
Answer: B
Rationale: 0.45% NS is a hypotonic solution, which causes fluid to shift from the
intravascular space into the cells, potentially leading to cellular swelling and cerebral
edema.
