NURS 120 | Introduction to Medical-Surgical Nursing | Exam 4 2026
|WCU
1. 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. Pulmonary embolism
B. Atelectasis
C. Hypovolemic shock
D. Pneumonia
Answer: A
Rationale: Sudden onset of chest pain and dyspnea in a postoperative patient are classic
signs of a pulmonary embolism, which is a medical emergency.
2. A client presents with a pH of 7.32, PaCO2 of 52 mmHg, and HCO3 of 24
mEq/L. Which acid-base imbalance does the nurse identify?
A. Metabolic Acidosis
B. Respiratory Acidosis
C. Metabolic Alkalosis
D. Respiratory Alkalosis
Answer: B
Rationale: A pH below 7.35 indicates acidosis. A PaCO2 above 45 mmHg indicates a
respiratory cause. Since the HCO3 is normal, this is uncompensated respiratory acidosis.
,3. Which of the following is the primary responsibility of the nurse regarding
informed consent for a surgical procedure?
A. Obtaining the patient’s signature and witnessing the signature.
B. Explaining the risks and benefits of the surgery to the patient.
C. Deciding if the patient is mentally competent to undergo surgery.
D. Describing alternative treatments to the patient.
Answer: A
Rationale: The nurse’s role is to witness the patient’s signature and ensure the patient
appears competent and signed voluntarily. The surgeon is responsible for explaining the
procedure, risks, and benefits.
4. A patient has a serum potassium level of 2.8 mEq/L. Which of the following
EKG changes should the nurse monitor for?
A. Presence of U waves
B. Shortened QT interval
C. Peaked T waves
D. Widened QRS complex
Answer: A
Rationale: Hypokalemia (potassium < 3.5) is associated with the presence of U waves, ST-
segment depression, and flattened T waves. Peaked T waves are seen in hyperkalemia.
5. A nurse is preparing to administer a unit of packed red blood cells. Which IV
fluid is the only one compatible for administration with blood products?
A. Lactated Ringer’s
B. 0.9% Sodium Chloride
C. 0.45% Sodium Chloride
D. 5% Dextrose in Water (D5W)
Answer: B
, Rationale: Normal Saline (0.9% NaCl) is the only fluid compatible with blood. Other fluids
can cause hemolysis or clotting.
6. During the inflammatory phase of wound healing, which of the following cells
are the first to arrive at the site of injury?
A. Neutrophils
B. Fibroblasts
C. Lymphocytes
D. Erythrocytes
Answer: A
Rationale: Neutrophils are the first leukocytes to arrive at the injury site (usually within
24 hours) to begin the process of phagocytosis.
7. A patient with a history of COPD is receiving oxygen at 2L/min via nasal
cannula. The nurse understands that for this patient, the drive to breathe is
triggered by:
A. High levels of Carbon Dioxide
B. Low levels of Carbon Dioxide
C. High levels of Bicarbonate
D. Low levels of Oxygen
Answer: D
Rationale: In chronic COPD, the body becomes desensitized to high CO2 levels. The
respiratory drive shifts to the ‘hypoxic drive,’ where low oxygen levels stimulate breathing.
|WCU
1. 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. Pulmonary embolism
B. Atelectasis
C. Hypovolemic shock
D. Pneumonia
Answer: A
Rationale: Sudden onset of chest pain and dyspnea in a postoperative patient are classic
signs of a pulmonary embolism, which is a medical emergency.
2. A client presents with a pH of 7.32, PaCO2 of 52 mmHg, and HCO3 of 24
mEq/L. Which acid-base imbalance does the nurse identify?
A. Metabolic Acidosis
B. Respiratory Acidosis
C. Metabolic Alkalosis
D. Respiratory Alkalosis
Answer: B
Rationale: A pH below 7.35 indicates acidosis. A PaCO2 above 45 mmHg indicates a
respiratory cause. Since the HCO3 is normal, this is uncompensated respiratory acidosis.
,3. Which of the following is the primary responsibility of the nurse regarding
informed consent for a surgical procedure?
A. Obtaining the patient’s signature and witnessing the signature.
B. Explaining the risks and benefits of the surgery to the patient.
C. Deciding if the patient is mentally competent to undergo surgery.
D. Describing alternative treatments to the patient.
Answer: A
Rationale: The nurse’s role is to witness the patient’s signature and ensure the patient
appears competent and signed voluntarily. The surgeon is responsible for explaining the
procedure, risks, and benefits.
4. A patient has a serum potassium level of 2.8 mEq/L. Which of the following
EKG changes should the nurse monitor for?
A. Presence of U waves
B. Shortened QT interval
C. Peaked T waves
D. Widened QRS complex
Answer: A
Rationale: Hypokalemia (potassium < 3.5) is associated with the presence of U waves, ST-
segment depression, and flattened T waves. Peaked T waves are seen in hyperkalemia.
5. A nurse is preparing to administer a unit of packed red blood cells. Which IV
fluid is the only one compatible for administration with blood products?
A. Lactated Ringer’s
B. 0.9% Sodium Chloride
C. 0.45% Sodium Chloride
D. 5% Dextrose in Water (D5W)
Answer: B
, Rationale: Normal Saline (0.9% NaCl) is the only fluid compatible with blood. Other fluids
can cause hemolysis or clotting.
6. During the inflammatory phase of wound healing, which of the following cells
are the first to arrive at the site of injury?
A. Neutrophils
B. Fibroblasts
C. Lymphocytes
D. Erythrocytes
Answer: A
Rationale: Neutrophils are the first leukocytes to arrive at the injury site (usually within
24 hours) to begin the process of phagocytosis.
7. A patient with a history of COPD is receiving oxygen at 2L/min via nasal
cannula. The nurse understands that for this patient, the drive to breathe is
triggered by:
A. High levels of Carbon Dioxide
B. Low levels of Carbon Dioxide
C. High levels of Bicarbonate
D. Low levels of Oxygen
Answer: D
Rationale: In chronic COPD, the body becomes desensitized to high CO2 levels. The
respiratory drive shifts to the ‘hypoxic drive,’ where low oxygen levels stimulate breathing.
