NURS 120 Medical-Surgical Nursing Study Guide Exam 1 2026 |WCU
1. A nurse is caring for a client with a serum potassium level of 6.2 mEq/L.
Which intervention is the priority?
A. Administer sodium polystyrene sulfonate
B. Initiate continuous cardiac monitoring
C. Encourage increased fluid intake
D. Perform a detailed neurological assessment
Answer: B
Rationale: Hyperkalemia (potassium > 5.0 mEq/L) can cause life-threatening cardiac
dysrhythmias; therefore, cardiac monitoring is the immediate priority to detect changes
like peaked T waves or a widened QRS.
2. When interpreting arterial blood gas (ABG) results, the nurse notes: pH 7.28,
PaCO2 55 mmHg, and HCO3 26 mEq/L. Which condition is the client
experiencing?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis
Answer: A
Rationale: A pH below 7.35 indicates acidosis. A PaCO2 above 45 mmHg indicates a
respiratory cause. Since the HCO3 is normal, this is uncompensated respiratory acidosis.
,3. The nurse is preparing a client for surgery. Which role is the nurse’s primary
responsibility regarding informed consent?
A. Witnessing the client’s signature on the consent form
B. Explaining the risks and benefits of the procedure
C. Deciding if the surgery is necessary for the client
D. Obtaining the signature after the surgeon leaves
Answer: A
Rationale: The surgeon is responsible for explaining the procedure and risks. The nurse’s
role is to witness the signature and ensure the client is competent and signed voluntarily.
4. A client is diagnosed with hypocalcemia. Which clinical manifestation should
the nurse expect to find?
A. Diminished deep tendon reflexes
B. Hypoactive bowel sounds
C. Shortened QT interval
D. Positive Trousseau’s sign
Answer: D
Rationale: Hypocalcemia increases neuromuscular excitability, leading to signs like
Trousseau’s (carpal spasm with BP cuff inflation) and Chvostek’s sign.
5. Which assessment finding is most indicative of fluid volume deficit in an older
adult?
A. Pitting edema in the lower extremities
B. Tenting of the skin on the back of the hand
C. Increased blood pressure and bounding pulse
D. Longitudinal furrows on the tongue
Answer: D
, Rationale: In older adults, skin turgor is unreliable due to loss of elasticity. Tongue
furrows, dry mucous membranes, and confusion are more reliable indicators of
dehydration.
6. During the intraoperative phase, the ‘Time-Out’ procedure is performed to:
A. Verify the correct patient, site, and procedure
B. Document the start time of the anesthesia
C. Allow the surgeon to take a break
D. Introduce the nursing staff to the family
Answer: A
Rationale: The ‘Time-Out’ is a safety protocol mandated to prevent ‘wrong site, wrong
procedure, wrong person’ surgery.
7. A client’s ABG results are pH 7.50, PaCO2 30 mmHg, and HCO3 24 mEq/L. The
nurse identifies the cause as:
A. Hypoventilation
B. Renal failure
C. Excessive diarrhea
D. Hyperventilation
Answer: D
Rationale: The pH is alkaline (>7.45) and the PaCO2 is low (<35), indicating respiratory
alkalosis, commonly caused by hyperventilation and loss of CO2.
8. The nurse monitors a client for malignant hyperthermia. What is the earliest
sign of this condition?
A. Temperature of 104 F (40 C)
B. Tachycardia
C. Muscle rigidity
D. Cyanosis
Answer: B
1. A nurse is caring for a client with a serum potassium level of 6.2 mEq/L.
Which intervention is the priority?
A. Administer sodium polystyrene sulfonate
B. Initiate continuous cardiac monitoring
C. Encourage increased fluid intake
D. Perform a detailed neurological assessment
Answer: B
Rationale: Hyperkalemia (potassium > 5.0 mEq/L) can cause life-threatening cardiac
dysrhythmias; therefore, cardiac monitoring is the immediate priority to detect changes
like peaked T waves or a widened QRS.
2. When interpreting arterial blood gas (ABG) results, the nurse notes: pH 7.28,
PaCO2 55 mmHg, and HCO3 26 mEq/L. Which condition is the client
experiencing?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis
Answer: A
Rationale: A pH below 7.35 indicates acidosis. A PaCO2 above 45 mmHg indicates a
respiratory cause. Since the HCO3 is normal, this is uncompensated respiratory acidosis.
,3. The nurse is preparing a client for surgery. Which role is the nurse’s primary
responsibility regarding informed consent?
A. Witnessing the client’s signature on the consent form
B. Explaining the risks and benefits of the procedure
C. Deciding if the surgery is necessary for the client
D. Obtaining the signature after the surgeon leaves
Answer: A
Rationale: The surgeon is responsible for explaining the procedure and risks. The nurse’s
role is to witness the signature and ensure the client is competent and signed voluntarily.
4. A client is diagnosed with hypocalcemia. Which clinical manifestation should
the nurse expect to find?
A. Diminished deep tendon reflexes
B. Hypoactive bowel sounds
C. Shortened QT interval
D. Positive Trousseau’s sign
Answer: D
Rationale: Hypocalcemia increases neuromuscular excitability, leading to signs like
Trousseau’s (carpal spasm with BP cuff inflation) and Chvostek’s sign.
5. Which assessment finding is most indicative of fluid volume deficit in an older
adult?
A. Pitting edema in the lower extremities
B. Tenting of the skin on the back of the hand
C. Increased blood pressure and bounding pulse
D. Longitudinal furrows on the tongue
Answer: D
, Rationale: In older adults, skin turgor is unreliable due to loss of elasticity. Tongue
furrows, dry mucous membranes, and confusion are more reliable indicators of
dehydration.
6. During the intraoperative phase, the ‘Time-Out’ procedure is performed to:
A. Verify the correct patient, site, and procedure
B. Document the start time of the anesthesia
C. Allow the surgeon to take a break
D. Introduce the nursing staff to the family
Answer: A
Rationale: The ‘Time-Out’ is a safety protocol mandated to prevent ‘wrong site, wrong
procedure, wrong person’ surgery.
7. A client’s ABG results are pH 7.50, PaCO2 30 mmHg, and HCO3 24 mEq/L. The
nurse identifies the cause as:
A. Hypoventilation
B. Renal failure
C. Excessive diarrhea
D. Hyperventilation
Answer: D
Rationale: The pH is alkaline (>7.45) and the PaCO2 is low (<35), indicating respiratory
alkalosis, commonly caused by hyperventilation and loss of CO2.
8. The nurse monitors a client for malignant hyperthermia. What is the earliest
sign of this condition?
A. Temperature of 104 F (40 C)
B. Tachycardia
C. Muscle rigidity
D. Cyanosis
Answer: B
