NU 157 Exam 4 V1 | NU 157 Medical-
Surgical Nursing I-A | NCLEX (NGN) Q&A
with Rationale (NU157 Exam 4) | Galen
1. A nurse is assessing a client with a suspected fluid volume deficit. Which clinical
manifestations should the nurse expect to find? (Select all that apply.)
A. Increased heart rate
B. Poor skin turgor
C. Jugular venous distention
D. Orthostatic hypotension
E. Concentrated urine
F. Weight gain of 2 lbs in 24 hours
Correct Answer: A, B, D, E
Explanation: Fluid volume deficit, or hypovolemia, leads to compensatory mechanisms
such as tachycardia to maintain cardiac output. Loss of interstitial fluid results in poor skin
turgor and decreased vascular volume causes orthostatic hypotension. Concentrated urine
(high specific gravity) occurs as the kidneys attempt to conserve water, whereas jugular
venous distention and weight gain are signs of fluid volume excess.
,2. A client presents with the following arterial blood gas (ABG) results: pH 7.28, PaCO2 50
mmHg, and HCO3 24 mEq/L. Which acid-base imbalance does the nurse identify?
A. Respiratory Acidosis
B. Metabolic Alkalosis
C. Metabolic Acidosis
D. Respiratory Alkalosis
Correct Answer: A
Explanation: The pH of 7.28 indicates acidosis (normal range is 7.35-7.45). The PaCO2 of
50 mmHg is elevated (normal range is 35-45 mmHg), indicating a respiratory cause for the
acidosis. Since the HCO3 is within the normal range (22-26 mEq/L), there is no metabolic
compensation occurring yet.
3. A nurse is preparing a client for an elective surgery. Who is ultimately responsible for
obtaining the client’s informed consent?
A. The primary nurse
B. The nurse manager
C. The anesthesiologist
D. The surgeon
Correct Answer: D
, Explanation: It is the surgeon’s legal responsibility to explain the procedure, risks,
benefits, and alternatives to the client to obtain informed consent. The nurse’s role is to
witness the client’s signature and ensure the signed form is on the chart. If the client does
not understand the procedure, the nurse must notify the surgeon to return and provide
further clarification.
4. A nurse is caring for a client with a serum potassium level of 6.2 mEq/L. Which cardiac
monitor changes are associated with this condition? (Select all that apply.)
A. Tall, peaked T waves
B. Prolonged PR interval
C. Prominent U waves
D. Widened QRS complex
E. Flat T waves
Correct Answer: A, B, D
Explanation: Hyperkalemia (potassium > 5.0 mEq/L) affects cardiac conduction, typically
manifesting as tall peaked T waves, followed by a prolonged PR interval and eventually a
widened QRS as the level rises. These changes are critical indicators of potential cardiac
arrest. Prominent U waves and flat T waves are characteristic findings in hypokalemia, not
hyperkalemia.
Surgical Nursing I-A | NCLEX (NGN) Q&A
with Rationale (NU157 Exam 4) | Galen
1. A nurse is assessing a client with a suspected fluid volume deficit. Which clinical
manifestations should the nurse expect to find? (Select all that apply.)
A. Increased heart rate
B. Poor skin turgor
C. Jugular venous distention
D. Orthostatic hypotension
E. Concentrated urine
F. Weight gain of 2 lbs in 24 hours
Correct Answer: A, B, D, E
Explanation: Fluid volume deficit, or hypovolemia, leads to compensatory mechanisms
such as tachycardia to maintain cardiac output. Loss of interstitial fluid results in poor skin
turgor and decreased vascular volume causes orthostatic hypotension. Concentrated urine
(high specific gravity) occurs as the kidneys attempt to conserve water, whereas jugular
venous distention and weight gain are signs of fluid volume excess.
,2. A client presents with the following arterial blood gas (ABG) results: pH 7.28, PaCO2 50
mmHg, and HCO3 24 mEq/L. Which acid-base imbalance does the nurse identify?
A. Respiratory Acidosis
B. Metabolic Alkalosis
C. Metabolic Acidosis
D. Respiratory Alkalosis
Correct Answer: A
Explanation: The pH of 7.28 indicates acidosis (normal range is 7.35-7.45). The PaCO2 of
50 mmHg is elevated (normal range is 35-45 mmHg), indicating a respiratory cause for the
acidosis. Since the HCO3 is within the normal range (22-26 mEq/L), there is no metabolic
compensation occurring yet.
3. A nurse is preparing a client for an elective surgery. Who is ultimately responsible for
obtaining the client’s informed consent?
A. The primary nurse
B. The nurse manager
C. The anesthesiologist
D. The surgeon
Correct Answer: D
, Explanation: It is the surgeon’s legal responsibility to explain the procedure, risks,
benefits, and alternatives to the client to obtain informed consent. The nurse’s role is to
witness the client’s signature and ensure the signed form is on the chart. If the client does
not understand the procedure, the nurse must notify the surgeon to return and provide
further clarification.
4. A nurse is caring for a client with a serum potassium level of 6.2 mEq/L. Which cardiac
monitor changes are associated with this condition? (Select all that apply.)
A. Tall, peaked T waves
B. Prolonged PR interval
C. Prominent U waves
D. Widened QRS complex
E. Flat T waves
Correct Answer: A, B, D
Explanation: Hyperkalemia (potassium > 5.0 mEq/L) affects cardiac conduction, typically
manifesting as tall peaked T waves, followed by a prolonged PR interval and eventually a
widened QRS as the level rises. These changes are critical indicators of potential cardiac
arrest. Prominent U waves and flat T waves are characteristic findings in hypokalemia, not
hyperkalemia.
