NURS 120 | Introduction to Medical-Surgical Nursing | Final Exam
2026 |WCU
1. A nurse is caring for a patient who is 24 hours post-abdominal surgery. The
patient reports a ‘popping’ sensation after coughing, and the nurse observes a
loop of bowel protruding through the incision. Which action should the nurse
take first?
A. Apply a sterile, saline-soaked dressing to the wound
B. Notify the surgeon immediately while staying with the patient
C. Place the patient in a High-Fowler’s position
D. Attempt to push the bowel back into the abdominal cavity
Answer: B
Rationale: The first action in an evisceration is to stay with the patient and call for
help/notify the surgeon. While saline dressings are applied next, notification of the
emergency takes priority.
2. A patient with chronic kidney disease presents with a potassium level of 6.4
mEq/L. Which EKG change should the nurse expect to see?
A. Prominent U waves
B. Tall, peaked T waves
C. ST-segment depression
D. Inverted T waves
Answer: B
Rationale: Hyperkalemia (K+ > 5.0) typically causes tall, peaked T waves, widened QRS
complexes, and potentially cardiac arrest if untreated.
,3. An older adult patient is admitted with dehydration. Which assessment
finding is the most reliable indicator of fluid volume deficit in this population?
A. Poor skin turgor on the back of the hand
B. Increased blood pressure
C. Dry mucous membranes
D. Bradycardia
Answer: C
Rationale: In older adults, skin turgor is unreliable due to loss of elasticity. Dry mucous
membranes and longitudinal furrows on the tongue are better indicators of dehydration.
4. The nurse is reviewing arterial blood gas (ABG) results: pH 7.30, PaCO2 52
mmHg, HCO3 26 mEq/L. How should the nurse interpret these results?
A. Metabolic Acidosis
B. Respiratory Alkalosis
C. Respiratory Acidosis
D. Metabolic Alkalosis
Answer: C
Rationale: A low pH (<7.35) indicates acidosis, and a high PaCO2 (>45) indicates a
respiratory cause. The HCO3 is normal, suggesting no compensation yet.
5. A patient is scheduled for surgery. The nurse notices the surgical consent
form is signed, but the patient states, ‘I don’t really understand what the doctor
is going to do.’ What is the nurse’s priority action?
A. Explain the procedure to the patient in simple terms
B. Proceed with preoperative medication as ordered
C. Notify the surgeon that the patient needs further clarification
D. Tell the patient not to worry because the surgeon is highly skilled
Answer: C
, Rationale: The nurse’s role in informed consent is to witness the signature and ensure the
patient understands. If the patient is confused, the surgeon must be called back to provide a
full explanation.
6. A nurse is assessing a patient with a Stage 3 pressure injury. Which
characteristic should the nurse expect to observe?
A. Full-thickness skin loss involving damage to subcutaneous tissue
B. Non-blanchable erythema of intact skin
C. Partial-thickness skin loss with exposed dermis
D. Full-thickness tissue loss with exposed bone or muscle
Answer: A
Rationale: Stage 3 involves full-thickness skin loss into the subcutaneous fat. Stage 4
involves muscle or bone exposure.
7. A patient is receiving a blood transfusion and develops chills, lower back pain,
and hypotension 15 minutes into the infusion. What is the nurse’s immediate
priority?
A. Slow the infusion rate and notify the provider
B. Administer diphenhydramine as ordered
C. Stop the transfusion and disconnect the tubing at the hub
D. Check the patient’s temperature
Answer: C
Rationale: These symptoms suggest a hemolytic reaction. The transfusion must be stopped
immediately to prevent further infusion of incompatible blood.
2026 |WCU
1. A nurse is caring for a patient who is 24 hours post-abdominal surgery. The
patient reports a ‘popping’ sensation after coughing, and the nurse observes a
loop of bowel protruding through the incision. Which action should the nurse
take first?
A. Apply a sterile, saline-soaked dressing to the wound
B. Notify the surgeon immediately while staying with the patient
C. Place the patient in a High-Fowler’s position
D. Attempt to push the bowel back into the abdominal cavity
Answer: B
Rationale: The first action in an evisceration is to stay with the patient and call for
help/notify the surgeon. While saline dressings are applied next, notification of the
emergency takes priority.
2. A patient with chronic kidney disease presents with a potassium level of 6.4
mEq/L. Which EKG change should the nurse expect to see?
A. Prominent U waves
B. Tall, peaked T waves
C. ST-segment depression
D. Inverted T waves
Answer: B
Rationale: Hyperkalemia (K+ > 5.0) typically causes tall, peaked T waves, widened QRS
complexes, and potentially cardiac arrest if untreated.
,3. An older adult patient is admitted with dehydration. Which assessment
finding is the most reliable indicator of fluid volume deficit in this population?
A. Poor skin turgor on the back of the hand
B. Increased blood pressure
C. Dry mucous membranes
D. Bradycardia
Answer: C
Rationale: In older adults, skin turgor is unreliable due to loss of elasticity. Dry mucous
membranes and longitudinal furrows on the tongue are better indicators of dehydration.
4. The nurse is reviewing arterial blood gas (ABG) results: pH 7.30, PaCO2 52
mmHg, HCO3 26 mEq/L. How should the nurse interpret these results?
A. Metabolic Acidosis
B. Respiratory Alkalosis
C. Respiratory Acidosis
D. Metabolic Alkalosis
Answer: C
Rationale: A low pH (<7.35) indicates acidosis, and a high PaCO2 (>45) indicates a
respiratory cause. The HCO3 is normal, suggesting no compensation yet.
5. A patient is scheduled for surgery. The nurse notices the surgical consent
form is signed, but the patient states, ‘I don’t really understand what the doctor
is going to do.’ What is the nurse’s priority action?
A. Explain the procedure to the patient in simple terms
B. Proceed with preoperative medication as ordered
C. Notify the surgeon that the patient needs further clarification
D. Tell the patient not to worry because the surgeon is highly skilled
Answer: C
, Rationale: The nurse’s role in informed consent is to witness the signature and ensure the
patient understands. If the patient is confused, the surgeon must be called back to provide a
full explanation.
6. A nurse is assessing a patient with a Stage 3 pressure injury. Which
characteristic should the nurse expect to observe?
A. Full-thickness skin loss involving damage to subcutaneous tissue
B. Non-blanchable erythema of intact skin
C. Partial-thickness skin loss with exposed dermis
D. Full-thickness tissue loss with exposed bone or muscle
Answer: A
Rationale: Stage 3 involves full-thickness skin loss into the subcutaneous fat. Stage 4
involves muscle or bone exposure.
7. A patient is receiving a blood transfusion and develops chills, lower back pain,
and hypotension 15 minutes into the infusion. What is the nurse’s immediate
priority?
A. Slow the infusion rate and notify the provider
B. Administer diphenhydramine as ordered
C. Stop the transfusion and disconnect the tubing at the hub
D. Check the patient’s temperature
Answer: C
Rationale: These symptoms suggest a hemolytic reaction. The transfusion must be stopped
immediately to prevent further infusion of incompatible blood.
