NU 157 Exam 3 V3 | 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 potassium level of 3.2 mEq/L. Which of the following
findings should the nurse expect? (Select All That Apply)
A. Muscle weakness
B. Abdominal distention
C. Peaked T waves on ECG
D. Inverted T waves
E. Hyperactive bowel sounds
F. Weak, irregular pulse
Correct Answer: A, B, D, F
Explanation: Hypokalemia (potassium less than 3.5 mEq/L) typically presents with
muscle weakness, decreased gastrointestinal motility leading to distention, and
cardiovascular changes such as inverted T waves and dysrhythmias. Peaked T waves are
associated with hyperkalemia, not hypokalemia. Nurses must monitor these patients
closely for life-threatening cardiac complications and prioritize potassium replacement as
ordered.
,2. A client is admitted with a pH of 7.25, PaCO2 of 50 mmHg, and HCO3 of 24 mEq/L. Which
acid-base imbalance is the client experiencing?
A. Metabolic Acidosis
B. Metabolic Alkalosis
C. Respiratory Alkalosis
D. Respiratory Acidosis
Correct Answer: D
Explanation: The pH of 7.25 indicates acidosis, and the PaCO2 of 50 mmHg is elevated,
which points to a respiratory cause for the low pH. The bicarbonate level is within the
normal range, indicating that compensation has not yet occurred. This clinical picture is
classic for respiratory acidosis, often caused by hypoventilation or obstructive lung
diseases.
3. The nurse is preparing a client for an elective surgery. Which action is the nurse’s primary
responsibility regarding informed consent?
A. Explaining the risks and benefits of the procedure to the client
B. Obtaining the signature from the next of kin
C. Witnessing the client’s signature on the consent form
D. Deciding if the client needs the surgery
Correct Answer: C
, Explanation: The nurse’s role in informed consent is limited to witnessing the client sign
the form and verifying that the client appears competent to provide consent. It is the
surgeon’s legal responsibility to explain the procedure, risks, and benefits. If the client has
further questions about the procedure, the nurse must notify the surgeon to return and
provide more information.
4. A postoperative client is 24 hours out from abdominal surgery. Which assessment finding
should the nurse report immediately to the surgeon?
A. Serosanguineous drainage on the dressing
B. Absence of bowel sounds
C. Pain level of 5 on a 0-10 scale
D. A blood pressure of 88/50 mmHg
Correct Answer: D
Explanation: A blood pressure of 88/50 mmHg indicates hypotension, which could be a
sign of hemorrhage or shock in a postoperative patient. Serosanguineous drainage and
absent bowel sounds are common findings in the first 24 hours after abdominal surgery.
While pain management is important, hemodynamic instability is the highest priority for
immediate intervention.
5. The nurse is caring for a client with a serum sodium level of 128 mEq/L. Which of the
following are potential causes of this imbalance? (Select All That Apply)
A. Excessive water intake
Surgical Nursing I-A | NCLEX (NGN) Q&A
with Rationale (NU157 Exam 3) | Galen
1. A nurse is assessing a client with a potassium level of 3.2 mEq/L. Which of the following
findings should the nurse expect? (Select All That Apply)
A. Muscle weakness
B. Abdominal distention
C. Peaked T waves on ECG
D. Inverted T waves
E. Hyperactive bowel sounds
F. Weak, irregular pulse
Correct Answer: A, B, D, F
Explanation: Hypokalemia (potassium less than 3.5 mEq/L) typically presents with
muscle weakness, decreased gastrointestinal motility leading to distention, and
cardiovascular changes such as inverted T waves and dysrhythmias. Peaked T waves are
associated with hyperkalemia, not hypokalemia. Nurses must monitor these patients
closely for life-threatening cardiac complications and prioritize potassium replacement as
ordered.
,2. A client is admitted with a pH of 7.25, PaCO2 of 50 mmHg, and HCO3 of 24 mEq/L. Which
acid-base imbalance is the client experiencing?
A. Metabolic Acidosis
B. Metabolic Alkalosis
C. Respiratory Alkalosis
D. Respiratory Acidosis
Correct Answer: D
Explanation: The pH of 7.25 indicates acidosis, and the PaCO2 of 50 mmHg is elevated,
which points to a respiratory cause for the low pH. The bicarbonate level is within the
normal range, indicating that compensation has not yet occurred. This clinical picture is
classic for respiratory acidosis, often caused by hypoventilation or obstructive lung
diseases.
3. The nurse is preparing a client for an elective surgery. Which action is the nurse’s primary
responsibility regarding informed consent?
A. Explaining the risks and benefits of the procedure to the client
B. Obtaining the signature from the next of kin
C. Witnessing the client’s signature on the consent form
D. Deciding if the client needs the surgery
Correct Answer: C
, Explanation: The nurse’s role in informed consent is limited to witnessing the client sign
the form and verifying that the client appears competent to provide consent. It is the
surgeon’s legal responsibility to explain the procedure, risks, and benefits. If the client has
further questions about the procedure, the nurse must notify the surgeon to return and
provide more information.
4. A postoperative client is 24 hours out from abdominal surgery. Which assessment finding
should the nurse report immediately to the surgeon?
A. Serosanguineous drainage on the dressing
B. Absence of bowel sounds
C. Pain level of 5 on a 0-10 scale
D. A blood pressure of 88/50 mmHg
Correct Answer: D
Explanation: A blood pressure of 88/50 mmHg indicates hypotension, which could be a
sign of hemorrhage or shock in a postoperative patient. Serosanguineous drainage and
absent bowel sounds are common findings in the first 24 hours after abdominal surgery.
While pain management is important, hemodynamic instability is the highest priority for
immediate intervention.
5. The nurse is caring for a client with a serum sodium level of 128 mEq/L. Which of the
following are potential causes of this imbalance? (Select All That Apply)
A. Excessive water intake
