NURS 120 | Medical-Surgical Nursing Exam 3 2026 |WCU
1. A nurse is preparing a client for surgery. Which of the following is the primary
role of the nurse regarding informed consent?
A. Obtaining the client’s signature and witnessing that the signature is authentic
B. Explaining the risks and benefits of the procedure to the client
C. Evaluating the client’s understanding of alternative treatment options
D. Determining the legal competence of the client for the surgeon
Answer: A
Rationale: The nurse’s role in informed consent is to witness the client’s signature,
ensuring it is authentic and that the client appears competent and gave consent voluntarily.
The provider is responsible for explaining the procedure, risks, and benefits.
2. A client is diagnosed with hypokalemia. Which of the following findings
should the nurse expect on the client’s electrocardiogram (ECG)?
A. Presence of U waves and ST-segment depression
B. Shortened QT interval
C. Tall, peaked T waves
D. Widened QRS complex
Answer: A
Rationale: Hypokalemia often presents with U waves, flat or inverted T waves, and ST-
segment depression. Peaked T waves and widened QRS complexes are characteristic of
hyperkalemia.
,3. A client in the PACU is experiencing malignant hyperthermia. Which
medication should the nurse anticipate administering immediately?
A. Atropine sulfate
B. Succinylcholine
C. Calcium gluconate
D. Dantrolene sodium
Answer: D
Rationale: Dantrolene sodium is a skeletal muscle relaxant used specifically to treat
malignant hyperthermia by inhibiting the release of calcium from the sarcoplasmic
reticulum.
4. A nurse is assessing a client with fluid volume excess. Which of the following
clinical manifestations is most likely to be present?
A. Flattened neck veins
B. Increased hematocrit levels
C. Poor skin turgor
D. Bounding peripheral pulses
Answer: D
Rationale: Fluid volume excess leads to hypervolemia, which causes bounding pulses,
distended neck veins, and decreased hematocrit due to hemodilution.
5. Which of the following ABG results indicates metabolic acidosis?
A. pH 7.48, PaCO2 30 mmHg, HCO3 23 mEq/L
B. pH 7.32, PaCO2 50 mmHg, HCO3 28 mEq/L
C. pH 7.30, PaCO2 40 mmHg, HCO3 18 mEq/L
D. pH 7.50, PaCO2 45 mmHg, HCO3 34 mEq/L
Answer: C
Rationale: Metabolic acidosis is characterized by a low pH (below 7.35) and a low
bicarbonate (HCO3) level (below 22 mEq/L), with a normal or low PaCO2 if compensating.
, 6. A client post-op day 2 reports sudden abdominal pain and a ‘popping’
sensation while coughing. The nurse observes loops of bowel protruding
through the incision. What is the priority action?
A. Push the bowel back into the abdominal cavity gently
B. Cover the protruding organs with sterile dressings moistened with sterile normal saline
C. Instruct the client to remain NPO and prepare for immediate surgery
D. Call the rapid response team and elevate the client’s head 45 degrees
Answer: B
Rationale: This is an evisceration. The immediate nursing priority is to protect the organs
from drying and infection by covering them with sterile, saline-soaked dressings while
keeping the client in a low-Fowler’s position with knees flexed.
7. Which electrolyte imbalance is associated with a positive Chvostek’s sign?
A. Hypercalcemia and Hypokalemia
B. Hyperkalemia and Hyponatremia
C. Hypomagnesemia and Hypocalcemia
D. Hypophosphatemia and Hypermagnesemia
Answer: C
Rationale: Chvostek’s sign (facial twitching) and Trousseau’s sign (carpal spasm) are
indicative of increased neuromuscular excitability caused by low calcium or low
magnesium levels.
8. A nurse is caring for a client with respiratory alkalosis. Which of the following
is a common cause of this acid-base imbalance?
A. Chronic Obstructive Pulmonary Disease (COPD)
B. Hyperventilation due to anxiety or pain
C. Excessive nasogastric suctioning
D. Severe diarrhea
Answer: B
1. A nurse is preparing a client for surgery. Which of the following is the primary
role of the nurse regarding informed consent?
A. Obtaining the client’s signature and witnessing that the signature is authentic
B. Explaining the risks and benefits of the procedure to the client
C. Evaluating the client’s understanding of alternative treatment options
D. Determining the legal competence of the client for the surgeon
Answer: A
Rationale: The nurse’s role in informed consent is to witness the client’s signature,
ensuring it is authentic and that the client appears competent and gave consent voluntarily.
The provider is responsible for explaining the procedure, risks, and benefits.
2. A client is diagnosed with hypokalemia. Which of the following findings
should the nurse expect on the client’s electrocardiogram (ECG)?
A. Presence of U waves and ST-segment depression
B. Shortened QT interval
C. Tall, peaked T waves
D. Widened QRS complex
Answer: A
Rationale: Hypokalemia often presents with U waves, flat or inverted T waves, and ST-
segment depression. Peaked T waves and widened QRS complexes are characteristic of
hyperkalemia.
,3. A client in the PACU is experiencing malignant hyperthermia. Which
medication should the nurse anticipate administering immediately?
A. Atropine sulfate
B. Succinylcholine
C. Calcium gluconate
D. Dantrolene sodium
Answer: D
Rationale: Dantrolene sodium is a skeletal muscle relaxant used specifically to treat
malignant hyperthermia by inhibiting the release of calcium from the sarcoplasmic
reticulum.
4. A nurse is assessing a client with fluid volume excess. Which of the following
clinical manifestations is most likely to be present?
A. Flattened neck veins
B. Increased hematocrit levels
C. Poor skin turgor
D. Bounding peripheral pulses
Answer: D
Rationale: Fluid volume excess leads to hypervolemia, which causes bounding pulses,
distended neck veins, and decreased hematocrit due to hemodilution.
5. Which of the following ABG results indicates metabolic acidosis?
A. pH 7.48, PaCO2 30 mmHg, HCO3 23 mEq/L
B. pH 7.32, PaCO2 50 mmHg, HCO3 28 mEq/L
C. pH 7.30, PaCO2 40 mmHg, HCO3 18 mEq/L
D. pH 7.50, PaCO2 45 mmHg, HCO3 34 mEq/L
Answer: C
Rationale: Metabolic acidosis is characterized by a low pH (below 7.35) and a low
bicarbonate (HCO3) level (below 22 mEq/L), with a normal or low PaCO2 if compensating.
, 6. A client post-op day 2 reports sudden abdominal pain and a ‘popping’
sensation while coughing. The nurse observes loops of bowel protruding
through the incision. What is the priority action?
A. Push the bowel back into the abdominal cavity gently
B. Cover the protruding organs with sterile dressings moistened with sterile normal saline
C. Instruct the client to remain NPO and prepare for immediate surgery
D. Call the rapid response team and elevate the client’s head 45 degrees
Answer: B
Rationale: This is an evisceration. The immediate nursing priority is to protect the organs
from drying and infection by covering them with sterile, saline-soaked dressings while
keeping the client in a low-Fowler’s position with knees flexed.
7. Which electrolyte imbalance is associated with a positive Chvostek’s sign?
A. Hypercalcemia and Hypokalemia
B. Hyperkalemia and Hyponatremia
C. Hypomagnesemia and Hypocalcemia
D. Hypophosphatemia and Hypermagnesemia
Answer: C
Rationale: Chvostek’s sign (facial twitching) and Trousseau’s sign (carpal spasm) are
indicative of increased neuromuscular excitability caused by low calcium or low
magnesium levels.
8. A nurse is caring for a client with respiratory alkalosis. Which of the following
is a common cause of this acid-base imbalance?
A. Chronic Obstructive Pulmonary Disease (COPD)
B. Hyperventilation due to anxiety or pain
C. Excessive nasogastric suctioning
D. Severe diarrhea
Answer: B
