NUR170 Med Surg Exam 1 - Comprehensive Review
Questions and Correct Answers with Rationale | Newest
Update | Galen College of Nursing
1. A patient is admitted with a serum sodium level of 118 mEq/L. Which nursing
priority is most important?
A. Encouraging increased fluid intake
B. Initiating seizure precautions
C. Monitoring for signs of dehydration
D. Administering a diuretic
Answer: B
Rationale: Severe hyponatremia (below 120 mEq/L) can cause cerebral edema and
increase the risk of seizures and coma.
2. Which clinical manifestation would the nurse expect to find in a patient with
hypocalcemia?
A. Shortened QT interval
B. Depressed deep tendon reflexes
C. Constipation
D. Positive Trousseau’s sign
Answer: D
,Rationale: Hypocalcemia causes increased neuromuscular excitability, leading to signs like
Trousseau’s and Chvostek’s signs.
3. A patient’s ABG results are: pH 7.28, PaCO2 55, HCO3 26. What is the
interpretation?
A. Metabolic Acidosis
B. Respiratory Acidosis
C. Metabolic Alkalosis
D. Respiratory Alkalosis
Answer: B
Rationale: The pH is low (acidosis) and the PaCO2 is high (respiratory cause), while the
HCO3 is normal, indicating respiratory acidosis.
4. The nurse is caring for a patient with a potassium level of 6.2 mEq/L. Which
medication should the nurse anticipate administering?
A. Spironolactone
B. Potassium chloride
C. Magnesium sulfate
D. Sodium polystyrene sulfonate (Kayexalate)
Answer: D
Rationale: Kayexalate is used to lower serum potassium levels by exchanging sodium for
potassium ions in the intestine.
, 5. What is the primary goal of the ‘time-out’ performed in the operating room?
A. To ensure the correct patient, site, and procedure
B. To allow the anesthesia to take effect
C. To count the sponges and instruments
D. To introduce the surgical team
Answer: A
Rationale: The Universal Protocol/Time-out is a safety measure to prevent wrong-site,
wrong-procedure, and wrong-person surgery.
6. A patient is 2 days post-op and reports sudden chest pain and shortness of
breath. What is the nurse’s first action?
A. Administer pain medication
B. Obtain an ECG
C. Auscultate bowel sounds
D. Apply oxygen and assess vital signs
Answer: D
Rationale: Sudden SOB and chest pain suggest pulmonary embolism; applying oxygen and
checking stability is the immediate priority.
Questions and Correct Answers with Rationale | Newest
Update | Galen College of Nursing
1. A patient is admitted with a serum sodium level of 118 mEq/L. Which nursing
priority is most important?
A. Encouraging increased fluid intake
B. Initiating seizure precautions
C. Monitoring for signs of dehydration
D. Administering a diuretic
Answer: B
Rationale: Severe hyponatremia (below 120 mEq/L) can cause cerebral edema and
increase the risk of seizures and coma.
2. Which clinical manifestation would the nurse expect to find in a patient with
hypocalcemia?
A. Shortened QT interval
B. Depressed deep tendon reflexes
C. Constipation
D. Positive Trousseau’s sign
Answer: D
,Rationale: Hypocalcemia causes increased neuromuscular excitability, leading to signs like
Trousseau’s and Chvostek’s signs.
3. A patient’s ABG results are: pH 7.28, PaCO2 55, HCO3 26. What is the
interpretation?
A. Metabolic Acidosis
B. Respiratory Acidosis
C. Metabolic Alkalosis
D. Respiratory Alkalosis
Answer: B
Rationale: The pH is low (acidosis) and the PaCO2 is high (respiratory cause), while the
HCO3 is normal, indicating respiratory acidosis.
4. The nurse is caring for a patient with a potassium level of 6.2 mEq/L. Which
medication should the nurse anticipate administering?
A. Spironolactone
B. Potassium chloride
C. Magnesium sulfate
D. Sodium polystyrene sulfonate (Kayexalate)
Answer: D
Rationale: Kayexalate is used to lower serum potassium levels by exchanging sodium for
potassium ions in the intestine.
, 5. What is the primary goal of the ‘time-out’ performed in the operating room?
A. To ensure the correct patient, site, and procedure
B. To allow the anesthesia to take effect
C. To count the sponges and instruments
D. To introduce the surgical team
Answer: A
Rationale: The Universal Protocol/Time-out is a safety measure to prevent wrong-site,
wrong-procedure, and wrong-person surgery.
6. A patient is 2 days post-op and reports sudden chest pain and shortness of
breath. What is the nurse’s first action?
A. Administer pain medication
B. Obtain an ECG
C. Auscultate bowel sounds
D. Apply oxygen and assess vital signs
Answer: D
Rationale: Sudden SOB and chest pain suggest pulmonary embolism; applying oxygen and
checking stability is the immediate priority.
