NU 157 Exam 3 V1 | NU 157 Medical-
Surgical Nursing I-A | NCLEX (NGN) Q&A
with Rationale (NU157 Exam 3) | Galen
1. A nurse is assessing a client with a fluid volume excess. Which of the following clinical
manifestations should the nurse expect to find? Select all that apply.
A. Distended neck veins
B. Dependent edema
C. Crackles upon auscultation
D. Tachycardia
E. Flat neck veins when supine
F. Increased blood pressure
Correct Answer: A, B, C, D, F
Explanation: Fluid volume excess often leads to increased venous pressure which
manifests as jugular vein distension and hypertension. Crackles occur when fluid leaks into
the alveoli due to hydrostatic pressure changes. Tachycardia is a compensatory mechanism
to pump the excess fluid volume through the systemic circulation.
2. A client is admitted with a potassium level of 2.8 mEq/L. Which of the following
assessment findings is a priority for the nurse to address?
A. Cardiac dysrhythmias and prominent U waves
,B. Abdominal distension and hypoactive bowel sounds
C. Muscle weakness and fatigue
D. Increased urinary output
Correct Answer: A
Explanation: Hypokalemia significantly affects cardiac electrical conduction, potentially
leading to lethal arrhythmias. Prominent U waves are a classic ECG indicator of low
potassium levels. While muscle weakness and decreased bowel motility are signs of
hypokalemia, the cardiovascular system is the highest priority due to the risk of cardiac
arrest.
3. The nurse is caring for a client who is scheduled for surgery. Which of the following actions
is the most essential for the nurse to perform during the preoperative phase?
A. Administering post-operative pain medication
B. Teaching the client how to use a PCA pump
C. Ensuring the informed consent form is signed and on the chart
D. Assessing the surgical site for drainage
Correct Answer: C
Explanation: The nurse is responsible for verifying that the surgeon has explained the
procedure and that the client has signed the consent form voluntarily. Legal and ethical
standards require that the consent be present before any anesthesia or procedure begins.
, The nurse’s signature witnesses that the client was the one who signed and appeared
competent to do so.
4. A client’s arterial blood gas (ABG) results are: pH 7.30, PaCO2 52 mmHg, and HCO3 26
mEq/L. How should the nurse interpret these findings?
A. Metabolic acidosis
B. Respiratory acidosis
C. Metabolic alkalosis
D. Respiratory alkalosis
Correct Answer: B
Explanation: A pH below 7.35 indicates acidosis, and a PaCO2 above 45 mmHg indicates a
respiratory cause. The normal bicarbonate (HCO3) level suggests that the body has not yet
compensated for the respiratory imbalance. This condition is commonly seen in patients
with hypoventilation or COPD.
5. A nurse is providing discharge instructions to a client who had a laparoscopic
cholecystectomy. Which statement by the client indicates a need for further teaching?
A. I will call the doctor if I develop a fever over 101 degrees.
B. I can remove my Steri-Strips tomorrow when I take a shower.
C. I will avoid lifting heavy objects for the next few weeks.
D. I may feel some pain in my right shoulder due to the gas used in surgery.
Surgical Nursing I-A | NCLEX (NGN) Q&A
with Rationale (NU157 Exam 3) | Galen
1. A nurse is assessing a client with a fluid volume excess. Which of the following clinical
manifestations should the nurse expect to find? Select all that apply.
A. Distended neck veins
B. Dependent edema
C. Crackles upon auscultation
D. Tachycardia
E. Flat neck veins when supine
F. Increased blood pressure
Correct Answer: A, B, C, D, F
Explanation: Fluid volume excess often leads to increased venous pressure which
manifests as jugular vein distension and hypertension. Crackles occur when fluid leaks into
the alveoli due to hydrostatic pressure changes. Tachycardia is a compensatory mechanism
to pump the excess fluid volume through the systemic circulation.
2. A client is admitted with a potassium level of 2.8 mEq/L. Which of the following
assessment findings is a priority for the nurse to address?
A. Cardiac dysrhythmias and prominent U waves
,B. Abdominal distension and hypoactive bowel sounds
C. Muscle weakness and fatigue
D. Increased urinary output
Correct Answer: A
Explanation: Hypokalemia significantly affects cardiac electrical conduction, potentially
leading to lethal arrhythmias. Prominent U waves are a classic ECG indicator of low
potassium levels. While muscle weakness and decreased bowel motility are signs of
hypokalemia, the cardiovascular system is the highest priority due to the risk of cardiac
arrest.
3. The nurse is caring for a client who is scheduled for surgery. Which of the following actions
is the most essential for the nurse to perform during the preoperative phase?
A. Administering post-operative pain medication
B. Teaching the client how to use a PCA pump
C. Ensuring the informed consent form is signed and on the chart
D. Assessing the surgical site for drainage
Correct Answer: C
Explanation: The nurse is responsible for verifying that the surgeon has explained the
procedure and that the client has signed the consent form voluntarily. Legal and ethical
standards require that the consent be present before any anesthesia or procedure begins.
, The nurse’s signature witnesses that the client was the one who signed and appeared
competent to do so.
4. A client’s arterial blood gas (ABG) results are: pH 7.30, PaCO2 52 mmHg, and HCO3 26
mEq/L. How should the nurse interpret these findings?
A. Metabolic acidosis
B. Respiratory acidosis
C. Metabolic alkalosis
D. Respiratory alkalosis
Correct Answer: B
Explanation: A pH below 7.35 indicates acidosis, and a PaCO2 above 45 mmHg indicates a
respiratory cause. The normal bicarbonate (HCO3) level suggests that the body has not yet
compensated for the respiratory imbalance. This condition is commonly seen in patients
with hypoventilation or COPD.
5. A nurse is providing discharge instructions to a client who had a laparoscopic
cholecystectomy. Which statement by the client indicates a need for further teaching?
A. I will call the doctor if I develop a fever over 101 degrees.
B. I can remove my Steri-Strips tomorrow when I take a shower.
C. I will avoid lifting heavy objects for the next few weeks.
D. I may feel some pain in my right shoulder due to the gas used in surgery.
