NURS 121L-B | Introduction to Medical-Surgical Nursing Practicum -
Week 13 Comprehensive Quiz 2026 |WCU
1. A nurse is caring for a postoperative client who reports sudden shortness of
breath and chest pain. Which action should the nurse take first?
A. Elevate the head of the bed
B. Obtain an apical pulse rate
C. Administer the prescribed analgesic
D. Initiate a rapid response team call
Answer: A
Rationale: Elevating the head of the bed is the immediate priority intervention to improve
gas exchange and reduce the work of breathing in a client experiencing acute respiratory
distress.
2. A client with chronic kidney disease has a serum potassium level of 6.2
mEq/L. Which ECG change should the nurse expect to observe?
A. Tall, peaked T waves
B. Prominent U waves
C. Prolonged ST segment
D. Shortened PR interval
Answer: A
Rationale: Hyperkalemia (potassium > 5.0 mEq/L) typically manifests on an ECG as tall,
peaked T waves and widened QRS complexes.
,3. A client is 24 hours postoperative following an abdominal surgery. Which
finding most urgently requires notification of the provider?
A. A urine output of 20 mL/hr for the past two hours
B. Serosanguineous drainage on the dressing
C. Hypoactive bowel sounds in all four quadrants
D. A temperature of 37.6°C (99.7°F)
Answer: A
Rationale: Urine output less than 30 mL/hr can indicate hypovolemia or acute kidney
injury and requires immediate assessment and intervention.
4. Which arterial blood gas (ABG) result is consistent with a client experiencing
metabolic acidosis?
A. pH 7.50, PaCO2 42, HCO3 30
B. pH 7.48, PaCO2 30, HCO3 23
C. pH 7.30, PaCO2 50, HCO3 28
D. pH 7.32, PaCO2 36, HCO3 18
Answer: D
Rationale: Metabolic acidosis is characterized by a low pH (<7.35) and a low bicarbonate
level (<22 mEq/L).
5. A nurse is teaching a client about the use of an incentive spirometer. Which
instruction is correct?
A. Exhale forcefully into the device
B. Inhale slowly and deeply through the mouthpiece
C. Hold your breath for at least 15 seconds
D. Use the device only when feeling short of breath
Answer: B
Rationale: Incentive spirometry requires slow, deep inhalations to expand the lungs and
prevent atelectasis.
, 6. A client is receiving a blood transfusion and develops hives and itching. What
is the nurse’s first action?
A. Slow the rate of the transfusion
B. Administer diphenhydramine as ordered
C. Notify the blood bank
D. Stop the transfusion immediately
Answer: D
Rationale: At the first sign of a transfusion reaction, the nurse must stop the infusion to
prevent further exposure to the allergen.
7. Which clinical manifestation is a hallmark sign of a stage 2 pressure injury?
A. Partial-thickness loss of dermis presenting as a shallow open ulcer
B. Non-blanchable erythema of intact skin
C. Full-thickness tissue loss with visible subcutaneous fat
D. Full-thickness skin loss with exposed bone or muscle
Answer: A
Rationale: Stage 2 pressure injuries involve partial-thickness loss of the dermis and may
present as an intact or ruptured blister.
8. A client with type 1 diabetes mellitus is found unconscious and diaphoretic.
What should be the nurse’s first intervention?
A. Check the client’s blood glucose level
B. Administer intramuscular glucagon
C. Administer 15g of simple carbohydrates orally
D. Call the provider for an insulin order
Answer: B
Rationale: For an unconscious client with suspected hypoglycemia, glucagon or IV
dextrose should be administered since oral intake is unsafe.
Week 13 Comprehensive Quiz 2026 |WCU
1. A nurse is caring for a postoperative client who reports sudden shortness of
breath and chest pain. Which action should the nurse take first?
A. Elevate the head of the bed
B. Obtain an apical pulse rate
C. Administer the prescribed analgesic
D. Initiate a rapid response team call
Answer: A
Rationale: Elevating the head of the bed is the immediate priority intervention to improve
gas exchange and reduce the work of breathing in a client experiencing acute respiratory
distress.
2. A client with chronic kidney disease has a serum potassium level of 6.2
mEq/L. Which ECG change should the nurse expect to observe?
A. Tall, peaked T waves
B. Prominent U waves
C. Prolonged ST segment
D. Shortened PR interval
Answer: A
Rationale: Hyperkalemia (potassium > 5.0 mEq/L) typically manifests on an ECG as tall,
peaked T waves and widened QRS complexes.
,3. A client is 24 hours postoperative following an abdominal surgery. Which
finding most urgently requires notification of the provider?
A. A urine output of 20 mL/hr for the past two hours
B. Serosanguineous drainage on the dressing
C. Hypoactive bowel sounds in all four quadrants
D. A temperature of 37.6°C (99.7°F)
Answer: A
Rationale: Urine output less than 30 mL/hr can indicate hypovolemia or acute kidney
injury and requires immediate assessment and intervention.
4. Which arterial blood gas (ABG) result is consistent with a client experiencing
metabolic acidosis?
A. pH 7.50, PaCO2 42, HCO3 30
B. pH 7.48, PaCO2 30, HCO3 23
C. pH 7.30, PaCO2 50, HCO3 28
D. pH 7.32, PaCO2 36, HCO3 18
Answer: D
Rationale: Metabolic acidosis is characterized by a low pH (<7.35) and a low bicarbonate
level (<22 mEq/L).
5. A nurse is teaching a client about the use of an incentive spirometer. Which
instruction is correct?
A. Exhale forcefully into the device
B. Inhale slowly and deeply through the mouthpiece
C. Hold your breath for at least 15 seconds
D. Use the device only when feeling short of breath
Answer: B
Rationale: Incentive spirometry requires slow, deep inhalations to expand the lungs and
prevent atelectasis.
, 6. A client is receiving a blood transfusion and develops hives and itching. What
is the nurse’s first action?
A. Slow the rate of the transfusion
B. Administer diphenhydramine as ordered
C. Notify the blood bank
D. Stop the transfusion immediately
Answer: D
Rationale: At the first sign of a transfusion reaction, the nurse must stop the infusion to
prevent further exposure to the allergen.
7. Which clinical manifestation is a hallmark sign of a stage 2 pressure injury?
A. Partial-thickness loss of dermis presenting as a shallow open ulcer
B. Non-blanchable erythema of intact skin
C. Full-thickness tissue loss with visible subcutaneous fat
D. Full-thickness skin loss with exposed bone or muscle
Answer: A
Rationale: Stage 2 pressure injuries involve partial-thickness loss of the dermis and may
present as an intact or ruptured blister.
8. A client with type 1 diabetes mellitus is found unconscious and diaphoretic.
What should be the nurse’s first intervention?
A. Check the client’s blood glucose level
B. Administer intramuscular glucagon
C. Administer 15g of simple carbohydrates orally
D. Call the provider for an insulin order
Answer: B
Rationale: For an unconscious client with suspected hypoglycemia, glucagon or IV
dextrose should be administered since oral intake is unsafe.
