NU 157 Exam 1 V2 | NU 157 Medical-
Surgical Nursing I-A | NCLEX (NGN) Q&A
with Rationale (NU157 Exam 1) | Galen
1. A nurse is caring for a client with a potassium level of 2.8 mEq/L. Which assessment finding
should the nurse prioritize?
A. Hyperactive bowel sounds
B. Tall peaked T waves on ECG
C. Increased muscle strength
D. Cardiac dysrhythmias
Correct Answer: D
Explanation: Hypokalemia, defined as a serum potassium level below 3.5 mEq/L, can
cause significant electrical instability in the myocardium. Cardiac dysrhythmias are a life-
threatening complication that requires immediate nursing intervention and cardiac
monitoring. The nurse must also monitor for signs such as U waves or flat T waves, which
are characteristic of low potassium levels rather than peaked T waves.
2. The nurse is reviewing the arterial blood gas (ABG) results for a client with chronic
obstructive pulmonary disease (COPD): pH 7.31, PaCO2 52 mm Hg, and HCO3 28 mEq/L. How
should the nurse interpret these results?
A. Respiratory alkalosis, fully compensated
,B. Metabolic acidosis, partially compensated
C. Respiratory acidosis, partially compensated
D. Metabolic alkalosis, uncompensated
Correct Answer: C
Explanation: The pH is below 7.35, indicating acidosis, and the PaCO2 is elevated above 45
mm Hg, indicating a respiratory cause. The HCO3 is also elevated above 26 mEq/L, which
demonstrates that the kidneys are attempting to compensate by retaining base. Because
the pH has not yet returned to the normal range, the condition is considered partially
compensated respiratory acidosis.
3. A nurse is preparing a client for an elective cholecystectomy. Which actions are included in
the preoperative checklist? (Select All That Apply)
A. Ensuring the informed consent is signed and witnessed
B. Verifying the client’s NPO status
C. Administering the first dose of postoperative pain medication
D. Removing jewelry, nail polish, and dentures
E. Documenting that the ‘Time Out’ was performed in the preoperative holding area
F. Confirming the surgical site has been marked by the surgeon
Correct Answer: A, B, D, F
, Explanation: Preoperative nursing care involves several safety checks to prevent surgical
errors and complications. Ensuring informed consent is signed and the surgical site is
marked are critical safety steps performed before the procedure begins. NPO status and the
removal of physical objects like dentures or jewelry are necessary to prevent aspiration
and injury during anesthesia.
4. A client is 12 hours postoperative following abdominal surgery. The nurse notes the client
is restless, has a heart rate of 115 bpm, and a blood pressure of 88/52 mm Hg. What should
be the nurse’s first action?
A. Administer the prescribed PRN analgesic for pain
B. Increase the IV fluid rate as per protocol and notify the surgeon
C. Encourage the client to use the incentive spirometer
D. Document the findings and continue to monitor
Correct Answer: B
Explanation: Tachycardia and hypotension in a postoperative client are classic signs of
hypovolemic shock, likely due to hemorrhage or fluid loss. Immediate fluid resuscitation is
required to maintain organ perfusion while the surgical team is notified to identify the
source of the problem. Restlessness is often an early sign of hypoxia or decreased cerebral
perfusion associated with shock.
Surgical Nursing I-A | NCLEX (NGN) Q&A
with Rationale (NU157 Exam 1) | Galen
1. A nurse is caring for a client with a potassium level of 2.8 mEq/L. Which assessment finding
should the nurse prioritize?
A. Hyperactive bowel sounds
B. Tall peaked T waves on ECG
C. Increased muscle strength
D. Cardiac dysrhythmias
Correct Answer: D
Explanation: Hypokalemia, defined as a serum potassium level below 3.5 mEq/L, can
cause significant electrical instability in the myocardium. Cardiac dysrhythmias are a life-
threatening complication that requires immediate nursing intervention and cardiac
monitoring. The nurse must also monitor for signs such as U waves or flat T waves, which
are characteristic of low potassium levels rather than peaked T waves.
2. The nurse is reviewing the arterial blood gas (ABG) results for a client with chronic
obstructive pulmonary disease (COPD): pH 7.31, PaCO2 52 mm Hg, and HCO3 28 mEq/L. How
should the nurse interpret these results?
A. Respiratory alkalosis, fully compensated
,B. Metabolic acidosis, partially compensated
C. Respiratory acidosis, partially compensated
D. Metabolic alkalosis, uncompensated
Correct Answer: C
Explanation: The pH is below 7.35, indicating acidosis, and the PaCO2 is elevated above 45
mm Hg, indicating a respiratory cause. The HCO3 is also elevated above 26 mEq/L, which
demonstrates that the kidneys are attempting to compensate by retaining base. Because
the pH has not yet returned to the normal range, the condition is considered partially
compensated respiratory acidosis.
3. A nurse is preparing a client for an elective cholecystectomy. Which actions are included in
the preoperative checklist? (Select All That Apply)
A. Ensuring the informed consent is signed and witnessed
B. Verifying the client’s NPO status
C. Administering the first dose of postoperative pain medication
D. Removing jewelry, nail polish, and dentures
E. Documenting that the ‘Time Out’ was performed in the preoperative holding area
F. Confirming the surgical site has been marked by the surgeon
Correct Answer: A, B, D, F
, Explanation: Preoperative nursing care involves several safety checks to prevent surgical
errors and complications. Ensuring informed consent is signed and the surgical site is
marked are critical safety steps performed before the procedure begins. NPO status and the
removal of physical objects like dentures or jewelry are necessary to prevent aspiration
and injury during anesthesia.
4. A client is 12 hours postoperative following abdominal surgery. The nurse notes the client
is restless, has a heart rate of 115 bpm, and a blood pressure of 88/52 mm Hg. What should
be the nurse’s first action?
A. Administer the prescribed PRN analgesic for pain
B. Increase the IV fluid rate as per protocol and notify the surgeon
C. Encourage the client to use the incentive spirometer
D. Document the findings and continue to monitor
Correct Answer: B
Explanation: Tachycardia and hypotension in a postoperative client are classic signs of
hypovolemic shock, likely due to hemorrhage or fluid loss. Immediate fluid resuscitation is
required to maintain organ perfusion while the surgical team is notified to identify the
source of the problem. Restlessness is often an early sign of hypoxia or decreased cerebral
perfusion associated with shock.
