NURS 121L-B Medical-Surgical Nursing Module Exam 2 2026 |WCU
1. A nurse is caring for a client who is 24 hours postoperative following a total
hip arthroplasty. Which of the following findings should the nurse prioritize?
A. Pain level of 4 on a scale of 0 to 10
B. Redness and warmth in the calf area
C. Serosanguinous drainage on the dressing
D. Urinary output of 40 mL/hr
Answer: B
Rationale: Redness and warmth in the calf area are indicative of deep vein thrombosis
(DVT), a serious postoperative complication that requires immediate intervention to
prevent pulmonary embolism.
2. A client with chronic obstructive pulmonary disease (COPD) is receiving
oxygen at 2 L/min via nasal cannula. The nurse notes the client’s SaO2 is 89%.
Which action should the nurse take?
A. Increase the oxygen flow rate to 6 L/min
B. Switch the client to a non-rebreather mask
C. Continue to monitor the client’s respiratory status
D. Prepare for immediate endotracheal intubation
Answer: C
Rationale: For clients with COPD, an oxygen saturation (SaO2) between 88% and 92% is
often the target range to avoid suppressing the hypoxic drive to breathe.
,3. Which laboratory value is the most critical for a nurse to monitor in a client
receiving heparin for a pulmonary embolism?
A. Prothrombin time (PT)
B. International Normalized Ratio (INR)
C. Activated partial thromboplastin time (aPTT)
D. Platelet count
Answer: C
Rationale: The aPTT is used to monitor the effectiveness and safety of heparin therapy. PT
and INR are used for warfarin.
4. A nurse is preparing to administer potassium chloride 20 mEq IV to a client
with hypokalemia. What is the maximum recommended infusion rate for
peripheral IV administration?
A. 5 mEq/hr
B. 20 mEq/hr
C. 10 mEq/hr
D. 40 mEq/hr
Answer: C
Rationale: Potassium should generally not be infused faster than 10 mEq/hr through a
peripheral vein to prevent vein irritation and cardiac risks.
5. A client presents with a blood gas result of pH 7.30, PaCO2 52 mmHg, and
HCO3 26 mEq/L. How should the nurse interpret these results?
A. Metabolic Acidosis
B. Metabolic Alkalosis
C. Respiratory Alkalosis
D. Respiratory Acidosis
Answer: D
, Rationale: The low pH (<7.35) indicates acidosis, and the high PaCO2 (>45) indicates the
cause is respiratory.
6. During the preoperative assessment, a client reports an allergy to bananas
and avocados. Which risk should the nurse identify?
A. Allergy to iodine-based contrast
B. Malignant hyperthermia risk
C. Propofol intolerance
D. Latex allergy sensitivity
Answer: D
Rationale: There is a known cross-reactivity between certain fruits like bananas, avocados,
and kiwi with latex allergy.
7. A nurse is assessing a client with left-sided heart failure. Which clinical
manifestation should the nurse expect to find?
A. Jugular venous distention
B. Crackles in the lungs
C. Peripheral edema
D. Hepatomegaly
Answer: B
Rationale: Left-sided heart failure leads to pulmonary congestion, resulting in crackles,
dyspnea, and orthopnea.
8. A client with a history of hypertension is prescribed lisinopril. Which side
effect should the nurse instruct the client to report immediately?
A. A persistent dry cough
B. Increased urinary frequency
C. Occasional dizziness when standing
D. Swelling of the face and lips
Answer: D
1. A nurse is caring for a client who is 24 hours postoperative following a total
hip arthroplasty. Which of the following findings should the nurse prioritize?
A. Pain level of 4 on a scale of 0 to 10
B. Redness and warmth in the calf area
C. Serosanguinous drainage on the dressing
D. Urinary output of 40 mL/hr
Answer: B
Rationale: Redness and warmth in the calf area are indicative of deep vein thrombosis
(DVT), a serious postoperative complication that requires immediate intervention to
prevent pulmonary embolism.
2. A client with chronic obstructive pulmonary disease (COPD) is receiving
oxygen at 2 L/min via nasal cannula. The nurse notes the client’s SaO2 is 89%.
Which action should the nurse take?
A. Increase the oxygen flow rate to 6 L/min
B. Switch the client to a non-rebreather mask
C. Continue to monitor the client’s respiratory status
D. Prepare for immediate endotracheal intubation
Answer: C
Rationale: For clients with COPD, an oxygen saturation (SaO2) between 88% and 92% is
often the target range to avoid suppressing the hypoxic drive to breathe.
,3. Which laboratory value is the most critical for a nurse to monitor in a client
receiving heparin for a pulmonary embolism?
A. Prothrombin time (PT)
B. International Normalized Ratio (INR)
C. Activated partial thromboplastin time (aPTT)
D. Platelet count
Answer: C
Rationale: The aPTT is used to monitor the effectiveness and safety of heparin therapy. PT
and INR are used for warfarin.
4. A nurse is preparing to administer potassium chloride 20 mEq IV to a client
with hypokalemia. What is the maximum recommended infusion rate for
peripheral IV administration?
A. 5 mEq/hr
B. 20 mEq/hr
C. 10 mEq/hr
D. 40 mEq/hr
Answer: C
Rationale: Potassium should generally not be infused faster than 10 mEq/hr through a
peripheral vein to prevent vein irritation and cardiac risks.
5. A client presents with a blood gas result of pH 7.30, PaCO2 52 mmHg, and
HCO3 26 mEq/L. How should the nurse interpret these results?
A. Metabolic Acidosis
B. Metabolic Alkalosis
C. Respiratory Alkalosis
D. Respiratory Acidosis
Answer: D
, Rationale: The low pH (<7.35) indicates acidosis, and the high PaCO2 (>45) indicates the
cause is respiratory.
6. During the preoperative assessment, a client reports an allergy to bananas
and avocados. Which risk should the nurse identify?
A. Allergy to iodine-based contrast
B. Malignant hyperthermia risk
C. Propofol intolerance
D. Latex allergy sensitivity
Answer: D
Rationale: There is a known cross-reactivity between certain fruits like bananas, avocados,
and kiwi with latex allergy.
7. A nurse is assessing a client with left-sided heart failure. Which clinical
manifestation should the nurse expect to find?
A. Jugular venous distention
B. Crackles in the lungs
C. Peripheral edema
D. Hepatomegaly
Answer: B
Rationale: Left-sided heart failure leads to pulmonary congestion, resulting in crackles,
dyspnea, and orthopnea.
8. A client with a history of hypertension is prescribed lisinopril. Which side
effect should the nurse instruct the client to report immediately?
A. A persistent dry cough
B. Increased urinary frequency
C. Occasional dizziness when standing
D. Swelling of the face and lips
Answer: D
