NU 157 Exam 1 V1 | NU 157 Medical-
Surgical Nursing I-A | NCLEX (NGN) Q&A
with Rationale (NU157 Exam 1) | Galen
1. A nurse is assessing a client who presents with a serum potassium level of 3.2 mEq/L.
Which of the following electrocardiogram (ECG) changes should the nurse expect to observe?
A. Presence of U waves and flat T waves
B. Widened QRS complex
C. Tall, peaked T waves
D. Shortened PR interval
Correct Answer: A
Explanation: Hypokalemia, defined as a potassium level below 3.5 mEq/L, alters the
repolarization phase of the cardiac cycle. This typically manifests on an ECG as flattened or
inverted T waves and the appearance of a prominent U wave. The nurse must monitor for
these changes as they can precede life-threatening ventricular arrhythmias.
2. The nurse is preparing a client for an elective cholecystectomy. The client asks, ‘Why do I
have to sign this consent form?’ Which is the best response by the nurse?
A. It confirms that the surgeon has explained the risks, benefits, and alternatives to you.
B. It proves that I have explained the entire surgical procedure to you.
C. It protects the hospital from being sued if something goes wrong during surgery.
,D. It allows the nurse to serve as the primary witness to the medical necessity of the
procedure.
Correct Answer: A
Explanation: The nurse’s role in the informed consent process is to witness the client’s
signature and ensure the client is competent to sign. The surgeon is legally responsible for
explaining the procedure, its risks, benefits, and alternatives. This document serves as legal
evidence that the client has received the necessary information and agreed to proceed
voluntarily.
3. A client is admitted with a localized inflammatory response from a wound. Which clinical
manifestations should the nurse expect to find during the assessment? (Select All That Apply)
A. Erythema (redness)
B. Edema (swelling)
C. Warmth at the site
D. Pain or tenderness
E. Fever and chills
F. Leukocytosis
Correct Answer: A, B, C, D
Explanation: Localized inflammation is characterized by redness, heat, swelling, and pain
due to vasodilation and increased capillary permeability. Fever, chills, and leukocytosis are
, systemic manifestations of inflammation rather than localized ones. Recognizing the
difference between local and systemic responses is essential for appropriate clinical
monitoring and intervention.
4. An arterial blood gas (ABG) report shows a pH of 7.30, PaCO2 of 52 mmHg, and HCO3 of 26
mEq/L. The nurse interprets these results as which of the following?
A. Respiratory Acidosis
B. Respiratory Alkalosis
C. Metabolic Acidosis
D. Metabolic Alkalosis
Correct Answer: A
Explanation: A pH below 7.35 indicates acidosis, and a PaCO2 above 45 mmHg indicates a
respiratory cause. Since the bicarbonate (HCO3) is within the normal range, the condition
is uncompensated respiratory acidosis. This state is common in clients with
hypoventilation or obstructive lung diseases where carbon dioxide is retained.
5. A nurse is caring for a client with a serum sodium level of 152 mEq/L. Which nursing
intervention is the priority for this client?
A. Restrict fluid intake to 1000 mL per day.
B. Administer 0.45% Sodium Chloride IV as ordered.
C. Encourage the consumption of canned soups and processed meats.
Surgical Nursing I-A | NCLEX (NGN) Q&A
with Rationale (NU157 Exam 1) | Galen
1. A nurse is assessing a client who presents with a serum potassium level of 3.2 mEq/L.
Which of the following electrocardiogram (ECG) changes should the nurse expect to observe?
A. Presence of U waves and flat T waves
B. Widened QRS complex
C. Tall, peaked T waves
D. Shortened PR interval
Correct Answer: A
Explanation: Hypokalemia, defined as a potassium level below 3.5 mEq/L, alters the
repolarization phase of the cardiac cycle. This typically manifests on an ECG as flattened or
inverted T waves and the appearance of a prominent U wave. The nurse must monitor for
these changes as they can precede life-threatening ventricular arrhythmias.
2. The nurse is preparing a client for an elective cholecystectomy. The client asks, ‘Why do I
have to sign this consent form?’ Which is the best response by the nurse?
A. It confirms that the surgeon has explained the risks, benefits, and alternatives to you.
B. It proves that I have explained the entire surgical procedure to you.
C. It protects the hospital from being sued if something goes wrong during surgery.
,D. It allows the nurse to serve as the primary witness to the medical necessity of the
procedure.
Correct Answer: A
Explanation: The nurse’s role in the informed consent process is to witness the client’s
signature and ensure the client is competent to sign. The surgeon is legally responsible for
explaining the procedure, its risks, benefits, and alternatives. This document serves as legal
evidence that the client has received the necessary information and agreed to proceed
voluntarily.
3. A client is admitted with a localized inflammatory response from a wound. Which clinical
manifestations should the nurse expect to find during the assessment? (Select All That Apply)
A. Erythema (redness)
B. Edema (swelling)
C. Warmth at the site
D. Pain or tenderness
E. Fever and chills
F. Leukocytosis
Correct Answer: A, B, C, D
Explanation: Localized inflammation is characterized by redness, heat, swelling, and pain
due to vasodilation and increased capillary permeability. Fever, chills, and leukocytosis are
, systemic manifestations of inflammation rather than localized ones. Recognizing the
difference between local and systemic responses is essential for appropriate clinical
monitoring and intervention.
4. An arterial blood gas (ABG) report shows a pH of 7.30, PaCO2 of 52 mmHg, and HCO3 of 26
mEq/L. The nurse interprets these results as which of the following?
A. Respiratory Acidosis
B. Respiratory Alkalosis
C. Metabolic Acidosis
D. Metabolic Alkalosis
Correct Answer: A
Explanation: A pH below 7.35 indicates acidosis, and a PaCO2 above 45 mmHg indicates a
respiratory cause. Since the bicarbonate (HCO3) is within the normal range, the condition
is uncompensated respiratory acidosis. This state is common in clients with
hypoventilation or obstructive lung diseases where carbon dioxide is retained.
5. A nurse is caring for a client with a serum sodium level of 152 mEq/L. Which nursing
intervention is the priority for this client?
A. Restrict fluid intake to 1000 mL per day.
B. Administer 0.45% Sodium Chloride IV as ordered.
C. Encourage the consumption of canned soups and processed meats.
