NURS 120 | Introduction to Medical-Surgical Nursing | Week 11 Final
Review 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 dyspnea. Which
action should the nurse take first?
A. Administer the prescribed PRN analgesic for pain
B. Place the patient in a high-Fowler’s position and apply oxygen
C. Encourage the patient to perform incentive spirometry
D. Check the surgical incision site for signs of evisceration
Answer: B
Rationale: The symptoms suggest a pulmonary embolism, a common post-op
complication. The priority is to optimize oxygenation and gas exchange by elevating the
head of the bed and providing oxygen.
2. A client with chronic kidney disease (CKD) has a serum potassium level of 6.8
mEq/L. Which of the following cardiac rhythm changes should the nurse
monitor for?
A. Prominent U waves
B. Tall, peaked T waves
C. ST-segment depression
D. Shortened PR interval
Answer: B
Rationale: Hyperkalemia (K+ > 5.0) causes tall, peaked T waves, widened QRS complexes,
and potentially cardiac arrest.
,3. Which clinical manifestation should a nurse expect to find in a patient
experiencing Fluid Volume Deficit (Dehydration)?
A. Distended neck veins
B. Bounding peripheral pulses
C. Orthostatic hypotension
D. Increased central venous pressure
Answer: C
Rationale: Fluid volume deficit leads to decreased circulating volume, causing low blood
pressure (especially when changing positions), tachycardia, and poor skin turgor.
4. An arterial blood gas (ABG) report shows: pH 7.28, PaCO2 50 mmHg, and
HCO3 24 mEq/L. How should the nurse interpret these results?
A. Metabolic acidosis
B. Respiratory alkalosis
C. Metabolic alkalosis
D. Respiratory acidosis
Answer: D
Rationale: A pH below 7.35 indicates acidosis. An elevated PaCO2 (>45) indicates a
respiratory cause, while the normal HCO3 indicates no compensation yet.
5. A nurse is assessing a patient with a chest tube. The nurse notices continuous
bubbling in the water-seal chamber. What does this finding indicate?
A. An air leak is present in the system
B. The system is functioning normally
C. The lung has fully re-expanded
D. The suction pressure is set too high
Answer: A
Rationale: Intermittent bubbling in the water-seal chamber is normal with respirations,
but continuous bubbling indicates a leak in the chest tube system.
, 6. A patient is being treated for Deep Vein Thrombosis (DVT) with a continuous
IV heparin infusion. The nurse should monitor which lab value to adjust the
dosage?
A. Prothrombin time (PT)
B. Activated partial thromboplastin time (aPTT)
C. International Normalized Ratio (INR)
D. Platelet count
Answer: B
Rationale: aPTT is the standard lab test used to monitor the effectiveness of heparin.
PT/INR is used for Warfarin.
7. When providing discharge teaching to a client with a new diagnosis of Type 1
Diabetes Mellitus, what is the most important topic to cover to prevent
immediate life-threatening complications?
A. Proper foot care and inspection
B. The importance of annual eye exams
C. Signs and symptoms of hypoglycemia
D. How to count carbohydrates accurately
Answer: C
Rationale: Hypoglycemia is an acute, life-threatening complication that requires
immediate recognition and treatment. The others are important for long-term health.
Review 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 dyspnea. Which
action should the nurse take first?
A. Administer the prescribed PRN analgesic for pain
B. Place the patient in a high-Fowler’s position and apply oxygen
C. Encourage the patient to perform incentive spirometry
D. Check the surgical incision site for signs of evisceration
Answer: B
Rationale: The symptoms suggest a pulmonary embolism, a common post-op
complication. The priority is to optimize oxygenation and gas exchange by elevating the
head of the bed and providing oxygen.
2. A client with chronic kidney disease (CKD) has a serum potassium level of 6.8
mEq/L. Which of the following cardiac rhythm changes should the nurse
monitor for?
A. Prominent U waves
B. Tall, peaked T waves
C. ST-segment depression
D. Shortened PR interval
Answer: B
Rationale: Hyperkalemia (K+ > 5.0) causes tall, peaked T waves, widened QRS complexes,
and potentially cardiac arrest.
,3. Which clinical manifestation should a nurse expect to find in a patient
experiencing Fluid Volume Deficit (Dehydration)?
A. Distended neck veins
B. Bounding peripheral pulses
C. Orthostatic hypotension
D. Increased central venous pressure
Answer: C
Rationale: Fluid volume deficit leads to decreased circulating volume, causing low blood
pressure (especially when changing positions), tachycardia, and poor skin turgor.
4. An arterial blood gas (ABG) report shows: pH 7.28, PaCO2 50 mmHg, and
HCO3 24 mEq/L. How should the nurse interpret these results?
A. Metabolic acidosis
B. Respiratory alkalosis
C. Metabolic alkalosis
D. Respiratory acidosis
Answer: D
Rationale: A pH below 7.35 indicates acidosis. An elevated PaCO2 (>45) indicates a
respiratory cause, while the normal HCO3 indicates no compensation yet.
5. A nurse is assessing a patient with a chest tube. The nurse notices continuous
bubbling in the water-seal chamber. What does this finding indicate?
A. An air leak is present in the system
B. The system is functioning normally
C. The lung has fully re-expanded
D. The suction pressure is set too high
Answer: A
Rationale: Intermittent bubbling in the water-seal chamber is normal with respirations,
but continuous bubbling indicates a leak in the chest tube system.
, 6. A patient is being treated for Deep Vein Thrombosis (DVT) with a continuous
IV heparin infusion. The nurse should monitor which lab value to adjust the
dosage?
A. Prothrombin time (PT)
B. Activated partial thromboplastin time (aPTT)
C. International Normalized Ratio (INR)
D. Platelet count
Answer: B
Rationale: aPTT is the standard lab test used to monitor the effectiveness of heparin.
PT/INR is used for Warfarin.
7. When providing discharge teaching to a client with a new diagnosis of Type 1
Diabetes Mellitus, what is the most important topic to cover to prevent
immediate life-threatening complications?
A. Proper foot care and inspection
B. The importance of annual eye exams
C. Signs and symptoms of hypoglycemia
D. How to count carbohydrates accurately
Answer: C
Rationale: Hypoglycemia is an acute, life-threatening complication that requires
immediate recognition and treatment. The others are important for long-term health.
