NURS 120 Introduction to Medical-Surgical Nursing - Module Exam 1
2026 |WCU
1. A patient presents with a serum potassium level of 6.5 mEq/L. Which of the
following electrocardiogram (ECG) changes is the most critical for the nurse to
monitor?
A. ST-segment depression
B. Prominent U waves
C. Shortened PR interval
D. Tall, peaked T waves
Answer: D
Rationale: Hyperkalemia (K+ > 5.0 mEq/L) typically causes tall, peaked T waves,
prolonged PR intervals, and wide QRS complexes. ST depression and U waves are
associated with hypokalemia.
2. When assessing a patient for Trousseau’s sign, which action should the nurse
take?
A. Tap the facial nerve in front of the ear.
B. Observe for carpal spasm after a sharp tap on the radial nerve.
C. Inflate a blood pressure cuff above systolic pressure for 3 minutes.
D. Ask the patient to hyperventilate for one minute.
Answer: C
Rationale: Trousseau’s sign is an indicator of hypocalcemia; it involves inflating a BP cuff
on the upper arm, which triggers a carpal spasm due to ischemia-induced irritability of the
nerves.
,3. An elderly patient is admitted with dehydration. Which physiological change
associated with aging increases this patient’s risk for fluid volume deficit?
A. Increased thirst sensation
B. Reduced total body water percentage
C. Decreased glomerular filtration rate (GFR)
D. Enhanced ability to concentrate urine
Answer: B
Rationale: Older adults have a lower percentage of total body water, a decreased thirst
mechanism, and reduced renal ability to concentrate urine, making them highly susceptible
to dehydration.
4. A patient’s arterial blood gas (ABG) results are: pH 7.28, PaCO2 50 mmHg,
HCO3 24 mEq/L. How should the nurse interpret these results?
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 with a normal
HCO3 indicates that the cause is respiratory in nature.
5. The nurse is caring for a patient with a serum sodium level of 120 mEq/L.
Which nursing intervention is the highest priority?
A. Encouraging oral fluid intake
B. Assessing for peripheral edema
C. Administering hypotonic IV fluids
D. Initiating seizure precautions
Answer: D
, Rationale: Severe hyponatremia (below 125 mEq/L) puts the patient at high risk for
cerebral edema, seizures, and coma. Safety via seizure precautions is the priority.
6. During the preoperative assessment, a patient reports an allergy to bananas
and avocados. Which action is most important for the nurse to take?
A. Notify the dietary department immediately.
B. Alert the surgical team about a possible latex allergy.
C. Document the need for a low-potassium diet.
D. Reassure the patient these allergies are common.
Answer: B
Rationale: There is a known cross-reactivity between certain foods (bananas, avocados,
kiwi, chestnuts) and latex allergy. The surgical team must be notified to provide a latex-free
environment.
7. Which member of the surgical team is responsible for maintaining the sterile
field and passing instruments to the surgeon?
A. Scrub Nurse
B. Anesthesiologist
C. Circulating Nurse
D. Holding Area Nurse
Answer: A
Rationale: The scrub nurse or surgical technologist works within the sterile field, handles
instruments, and ensures sterile technique is maintained. The circulating nurse works
outside the sterile field.
2026 |WCU
1. A patient presents with a serum potassium level of 6.5 mEq/L. Which of the
following electrocardiogram (ECG) changes is the most critical for the nurse to
monitor?
A. ST-segment depression
B. Prominent U waves
C. Shortened PR interval
D. Tall, peaked T waves
Answer: D
Rationale: Hyperkalemia (K+ > 5.0 mEq/L) typically causes tall, peaked T waves,
prolonged PR intervals, and wide QRS complexes. ST depression and U waves are
associated with hypokalemia.
2. When assessing a patient for Trousseau’s sign, which action should the nurse
take?
A. Tap the facial nerve in front of the ear.
B. Observe for carpal spasm after a sharp tap on the radial nerve.
C. Inflate a blood pressure cuff above systolic pressure for 3 minutes.
D. Ask the patient to hyperventilate for one minute.
Answer: C
Rationale: Trousseau’s sign is an indicator of hypocalcemia; it involves inflating a BP cuff
on the upper arm, which triggers a carpal spasm due to ischemia-induced irritability of the
nerves.
,3. An elderly patient is admitted with dehydration. Which physiological change
associated with aging increases this patient’s risk for fluid volume deficit?
A. Increased thirst sensation
B. Reduced total body water percentage
C. Decreased glomerular filtration rate (GFR)
D. Enhanced ability to concentrate urine
Answer: B
Rationale: Older adults have a lower percentage of total body water, a decreased thirst
mechanism, and reduced renal ability to concentrate urine, making them highly susceptible
to dehydration.
4. A patient’s arterial blood gas (ABG) results are: pH 7.28, PaCO2 50 mmHg,
HCO3 24 mEq/L. How should the nurse interpret these results?
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 with a normal
HCO3 indicates that the cause is respiratory in nature.
5. The nurse is caring for a patient with a serum sodium level of 120 mEq/L.
Which nursing intervention is the highest priority?
A. Encouraging oral fluid intake
B. Assessing for peripheral edema
C. Administering hypotonic IV fluids
D. Initiating seizure precautions
Answer: D
, Rationale: Severe hyponatremia (below 125 mEq/L) puts the patient at high risk for
cerebral edema, seizures, and coma. Safety via seizure precautions is the priority.
6. During the preoperative assessment, a patient reports an allergy to bananas
and avocados. Which action is most important for the nurse to take?
A. Notify the dietary department immediately.
B. Alert the surgical team about a possible latex allergy.
C. Document the need for a low-potassium diet.
D. Reassure the patient these allergies are common.
Answer: B
Rationale: There is a known cross-reactivity between certain foods (bananas, avocados,
kiwi, chestnuts) and latex allergy. The surgical team must be notified to provide a latex-free
environment.
7. Which member of the surgical team is responsible for maintaining the sterile
field and passing instruments to the surgeon?
A. Scrub Nurse
B. Anesthesiologist
C. Circulating Nurse
D. Holding Area Nurse
Answer: A
Rationale: The scrub nurse or surgical technologist works within the sterile field, handles
instruments, and ensures sterile technique is maintained. The circulating nurse works
outside the sterile field.
