NURS 120 | Introduction to Medical-Surgical Nursing | Actual Exam 2
2026 |WCU
1. A patient’s arterial blood gas (ABG) results show: pH 7.31, PaCO2 55 mmHg,
and HCO3 28 mEq/L. How should the nurse interpret these findings?
A. Fully compensated respiratory acidosis
B. Uncompensated metabolic acidosis
C. Partially compensated respiratory acidosis
D. Partially compensated metabolic alkalosis
Answer: C
Rationale: The pH is low (acidosis), the PaCO2 is high (respiratory cause), and the HCO3 is
high (compensatory response). Since the pH is not within the normal range, it is partially
compensated.
2. During surgery, a patient develops tachycardia, muscle rigidity, and a rapidly
rising temperature. Which medication should the nurse prepare for immediate
administration?
A. Epinephrine
B. Naloxone
C. Dantrolene sodium
D. Atropine sulfate
Answer: C
Rationale: These are classic signs of malignant hyperthermia, a pharmacogenetic disorder.
Dantrolene is the primary skeletal muscle relaxant used to treat this life-threatening
emergency.
,3. A patient with a serum potassium level of 2.8 mEq/L is prescribed intravenous
potassium chloride. Which nursing action is essential during administration?
A. Administer the dose via rapid IV push to restore levels quickly
B. Dilute the potassium and ensure the rate does not exceed 10 mEq/hr in a peripheral line
C. Restrict fluid intake to prevent hemodilution of electrolytes
D. Monitor for T-wave peaking on the electrocardiogram
Answer: B
Rationale: Potassium should never be given IV push due to the risk of cardiac arrest. It
must be diluted and infused slowly, typically not exceeding 10-20 mEq/hr depending on
the facility and access type.
4. A nurse is caring for a patient who is 2 days postoperative. The patient
reports a sudden ‘popping’ sensation at the abdominal incision site, and the
nurse observes bowel loops protruding. What is the priority intervention?
A. Push the organs back into the abdominal cavity gently
B. Cover the site with sterile dressings moistened with warm sterile saline
C. Place the patient in a High-Fowler’s position to reduce pressure
D. Apply a tight abdominal binder to secure the wound
Answer: B
Rationale: This is an evisceration. The nurse should cover the protruding organs with
sterile, saline-soaked dressings to keep them moist and call the surgeon immediately. The
patient should be kept in a low-Fowler’s position with knees flexed.
, 5. When assessing a patient for hypocalcemia, the nurse inflates a blood
pressure cuff on the upper arm and observes carpal spasms. How should the
nurse document this finding?
A. Positive Chvostek’s sign
B. Positive Babinski reflex
C. Negative Homans’ sign
D. Positive Trousseau’s sign
Answer: D
Rationale: Trousseau’s sign is the induction of carpopedal spasm by inflating a blood
pressure cuff above systolic pressure. Chvostek’s sign involves tapping the facial nerve to
elicit a twitch.
6. Which assessment finding in a patient receiving total parenteral nutrition
(TPN) suggests the complication of fluid volume excess?
A. Crackles heard upon lung auscultation
B. Flattened neck veins when supine
C. Poor skin turgor and tenting
D. Decreased central venous pressure
Answer: A
Rationale: TPN is hypertonic and can pull fluid into the vascular space, leading to fluid
overload. Crackles in the lungs indicate pulmonary edema associated with fluid volume
excess.
2026 |WCU
1. A patient’s arterial blood gas (ABG) results show: pH 7.31, PaCO2 55 mmHg,
and HCO3 28 mEq/L. How should the nurse interpret these findings?
A. Fully compensated respiratory acidosis
B. Uncompensated metabolic acidosis
C. Partially compensated respiratory acidosis
D. Partially compensated metabolic alkalosis
Answer: C
Rationale: The pH is low (acidosis), the PaCO2 is high (respiratory cause), and the HCO3 is
high (compensatory response). Since the pH is not within the normal range, it is partially
compensated.
2. During surgery, a patient develops tachycardia, muscle rigidity, and a rapidly
rising temperature. Which medication should the nurse prepare for immediate
administration?
A. Epinephrine
B. Naloxone
C. Dantrolene sodium
D. Atropine sulfate
Answer: C
Rationale: These are classic signs of malignant hyperthermia, a pharmacogenetic disorder.
Dantrolene is the primary skeletal muscle relaxant used to treat this life-threatening
emergency.
,3. A patient with a serum potassium level of 2.8 mEq/L is prescribed intravenous
potassium chloride. Which nursing action is essential during administration?
A. Administer the dose via rapid IV push to restore levels quickly
B. Dilute the potassium and ensure the rate does not exceed 10 mEq/hr in a peripheral line
C. Restrict fluid intake to prevent hemodilution of electrolytes
D. Monitor for T-wave peaking on the electrocardiogram
Answer: B
Rationale: Potassium should never be given IV push due to the risk of cardiac arrest. It
must be diluted and infused slowly, typically not exceeding 10-20 mEq/hr depending on
the facility and access type.
4. A nurse is caring for a patient who is 2 days postoperative. The patient
reports a sudden ‘popping’ sensation at the abdominal incision site, and the
nurse observes bowel loops protruding. What is the priority intervention?
A. Push the organs back into the abdominal cavity gently
B. Cover the site with sterile dressings moistened with warm sterile saline
C. Place the patient in a High-Fowler’s position to reduce pressure
D. Apply a tight abdominal binder to secure the wound
Answer: B
Rationale: This is an evisceration. The nurse should cover the protruding organs with
sterile, saline-soaked dressings to keep them moist and call the surgeon immediately. The
patient should be kept in a low-Fowler’s position with knees flexed.
, 5. When assessing a patient for hypocalcemia, the nurse inflates a blood
pressure cuff on the upper arm and observes carpal spasms. How should the
nurse document this finding?
A. Positive Chvostek’s sign
B. Positive Babinski reflex
C. Negative Homans’ sign
D. Positive Trousseau’s sign
Answer: D
Rationale: Trousseau’s sign is the induction of carpopedal spasm by inflating a blood
pressure cuff above systolic pressure. Chvostek’s sign involves tapping the facial nerve to
elicit a twitch.
6. Which assessment finding in a patient receiving total parenteral nutrition
(TPN) suggests the complication of fluid volume excess?
A. Crackles heard upon lung auscultation
B. Flattened neck veins when supine
C. Poor skin turgor and tenting
D. Decreased central venous pressure
Answer: A
Rationale: TPN is hypertonic and can pull fluid into the vascular space, leading to fluid
overload. Crackles in the lungs indicate pulmonary edema associated with fluid volume
excess.
