NURS 120 | Introduction to Medical-Surgical Nursing |
Comprehensive Exam 1 2026 |WCU
1. A patient presents with a serum potassium level of 6.2 mEq/L. Which of the
following is the priority nursing intervention?
A. Monitor the patient’s EKG for tall, peaked T-waves.
B. Administer an oral potassium supplement as prescribed.
C. Encourage the intake of bananas and orange juice.
D. Assess the patient for signs of Chvostek’s sign.
Answer: A
Rationale: Hyperkalemia (potassium > 5.0 mEq/L) can cause life-threatening cardiac
dysrhythmias, characterized by tall peaked T-waves and widened QRS complexes.
2. When assessing a patient with suspected hypovolemia, which clinical finding
should the nurse anticipate?
A. Distended neck veins
B. Increased heart rate and decreased blood pressure
C. Bounding peripheral pulses
D. Crackles on lung auscultation
Answer: B
Rationale: Hypovolemia results in reduced circulating volume, leading to tachycardia as a
compensatory mechanism and hypotension once compensation fails.
,3. The nurse is preparing a patient for surgery. Which of the following is the
nurse’s primary responsibility regarding informed consent?
A. Explaining the risks and benefits of the procedure.
B. Determining the patient’s understanding of the surgery.
C. Providing alternative treatment options.
D. Witnessing the patient’s signature on the consent form.
Answer: D
Rationale: The surgeon is responsible for explaining the procedure. The nurse acts as a
witness to the signature and ensures the signature is authentic.
4. A patient has an arterial blood gas (ABG) result of pH 7.28, PaCO2 50 mmHg,
and HCO3 24 mEq/L. How should the nurse interpret this result?
A. Metabolic Acidosis
B. Respiratory Acidosis
C. Respiratory Alkalosis
D. Metabolic Alkalosis
Answer: B
Rationale: A pH below 7.35 indicates acidosis. A PaCO2 above 45 mmHg with a normal
HCO3 indicates the cause is respiratory.
5. Which electrolyte imbalance is most commonly associated with a positive
Trousseau’s sign?
A. Hypermagnesemia
B. Hypokalemia
C. Hypernatremia
D. Hypocalcemia
Answer: D
Rationale: Hypocalcemia increases neuromuscular excitability, leading to Trousseau’s sign
(carpal spasm induced by inflating a BP cuff).
, 6. A patient is 2 hours postoperative following abdominal surgery. The nurse
notes the surgical dressing is saturated with bright red blood. What is the
priority nursing action?
A. Document the findings and re-evaluate in one hour.
B. Change the dressing to a sterile one.
C. Reinforce the dressing and notify the surgeon.
D. Apply a heating pad to the site to promote vasoconstriction.
Answer: C
Rationale: Bright red blood (sanguineous) indicates active bleeding. The nurse should
reinforce the dressing (never remove the original post-op dressing) and call the surgeon.
7. The nurse is caring for an elderly patient with dehydration. Which assessment
finding is the most reliable indicator of fluid status in this population?
A. Skin turgor on the back of the hand.
B. Dryness of the mucous membranes.
C. Presence of a coating on the tongue.
D. Peripheral edema.
Answer: B
Rationale: Skin turgor is less reliable in the elderly due to loss of elasticity. Moistness of
mucous membranes and mental status are better indicators of hydration.
8. Which type of isolation precaution should the nurse implement for a patient
diagnosed with Pulmonary Tuberculosis?
A. Airborne Precautions
B. Contact Precautions
C. Droplet Precautions
D. Standard Precautions only
Answer: A
Comprehensive Exam 1 2026 |WCU
1. A patient presents with a serum potassium level of 6.2 mEq/L. Which of the
following is the priority nursing intervention?
A. Monitor the patient’s EKG for tall, peaked T-waves.
B. Administer an oral potassium supplement as prescribed.
C. Encourage the intake of bananas and orange juice.
D. Assess the patient for signs of Chvostek’s sign.
Answer: A
Rationale: Hyperkalemia (potassium > 5.0 mEq/L) can cause life-threatening cardiac
dysrhythmias, characterized by tall peaked T-waves and widened QRS complexes.
2. When assessing a patient with suspected hypovolemia, which clinical finding
should the nurse anticipate?
A. Distended neck veins
B. Increased heart rate and decreased blood pressure
C. Bounding peripheral pulses
D. Crackles on lung auscultation
Answer: B
Rationale: Hypovolemia results in reduced circulating volume, leading to tachycardia as a
compensatory mechanism and hypotension once compensation fails.
,3. The nurse is preparing a patient for surgery. Which of the following is the
nurse’s primary responsibility regarding informed consent?
A. Explaining the risks and benefits of the procedure.
B. Determining the patient’s understanding of the surgery.
C. Providing alternative treatment options.
D. Witnessing the patient’s signature on the consent form.
Answer: D
Rationale: The surgeon is responsible for explaining the procedure. The nurse acts as a
witness to the signature and ensures the signature is authentic.
4. A patient has an arterial blood gas (ABG) result of pH 7.28, PaCO2 50 mmHg,
and HCO3 24 mEq/L. How should the nurse interpret this result?
A. Metabolic Acidosis
B. Respiratory Acidosis
C. Respiratory Alkalosis
D. Metabolic Alkalosis
Answer: B
Rationale: A pH below 7.35 indicates acidosis. A PaCO2 above 45 mmHg with a normal
HCO3 indicates the cause is respiratory.
5. Which electrolyte imbalance is most commonly associated with a positive
Trousseau’s sign?
A. Hypermagnesemia
B. Hypokalemia
C. Hypernatremia
D. Hypocalcemia
Answer: D
Rationale: Hypocalcemia increases neuromuscular excitability, leading to Trousseau’s sign
(carpal spasm induced by inflating a BP cuff).
, 6. A patient is 2 hours postoperative following abdominal surgery. The nurse
notes the surgical dressing is saturated with bright red blood. What is the
priority nursing action?
A. Document the findings and re-evaluate in one hour.
B. Change the dressing to a sterile one.
C. Reinforce the dressing and notify the surgeon.
D. Apply a heating pad to the site to promote vasoconstriction.
Answer: C
Rationale: Bright red blood (sanguineous) indicates active bleeding. The nurse should
reinforce the dressing (never remove the original post-op dressing) and call the surgeon.
7. The nurse is caring for an elderly patient with dehydration. Which assessment
finding is the most reliable indicator of fluid status in this population?
A. Skin turgor on the back of the hand.
B. Dryness of the mucous membranes.
C. Presence of a coating on the tongue.
D. Peripheral edema.
Answer: B
Rationale: Skin turgor is less reliable in the elderly due to loss of elasticity. Moistness of
mucous membranes and mental status are better indicators of hydration.
8. Which type of isolation precaution should the nurse implement for a patient
diagnosed with Pulmonary Tuberculosis?
A. Airborne Precautions
B. Contact Precautions
C. Droplet Precautions
D. Standard Precautions only
Answer: A
