NU 157 Exam 1 V3 | NU 157 Medical-
Surgical Nursing I-A | NCLEX (NGN) Q&A
with Rationale (NU157 Exam 1) | Galen
1. A nurse is assessing a client with a serum potassium level of 6.2 mEq/L. Which of the
following clinical manifestations should the nurse expect to find? Select all that apply.
A. Tall, peaked T waves
B. Muscle weakness in the lower extremities
C. Hyperactive bowel sounds and diarrhea
D. Hypotension and bradycardia
E. Paresthesia of the hands and feet
F. Flat or inverted T waves
Correct Answer: ABCDE
Explanation: Hyperkalemia is defined as a serum potassium level exceeding 5.0 mEq/L,
which can lead to life-threatening cardiac dysrhythmias. Tall, peaked T waves are a
hallmark ECG change associated with this electrolyte imbalance. The elevation of
potassium also increases neuromuscular irritability, leading to muscle weakness, diarrhea,
and tingling sensations in the extremities.
,2. A client is diagnosed with respiratory acidosis. Which of the following arterial blood gas
(ABG) results is consistent with this diagnosis?
A. pH 7.30; PaCO2 52 mmHg; HCO3 24 mEq/L
B. pH 7.50; PaCO2 30 mmHg; HCO3 22 mEq/L
C. pH 7.32; PaCO2 38 mmHg; HCO3 18 mEq/L
D. pH 7.48; PaCO2 45 mmHg; HCO3 30 mEq/L
Correct Answer: A
Explanation: Respiratory acidosis is characterized by a pH lower than 7.35 and a PaCO2
greater than 45 mmHg. In this case, the pH of 7.30 indicates acidosis, and the elevated CO2
confirms the respiratory origin. The bicarbonate level is within normal range, suggesting
that renal compensation has not yet occurred.
3. The nurse is preparing a client for an elective cholecystectomy. Which statement by the
nurse best describes the primary purpose of obtaining informed consent?
A. To protect the surgeon and hospital from legal liability.
B. To verify that the client is mentally competent to undergo surgery.
C. To document that the client has been given the opportunity to ask questions.
D. To ensure the client understands the risks, benefits, and alternatives of the procedure.
Correct Answer: D
,Explanation: Informed consent is a legal and ethical requirement that ensures the client is
a participant in their own healthcare decisions. It involves providing the client with all
necessary information regarding the procedure, its risks, and possible alternatives. While
documentation is important, the core purpose is the client’s comprehension of the surgery
they are agreeing to.
4. During the intraoperative phase, the nurse notes that the client is experiencing muscle
rigidity, a rapidly rising temperature, and tachycardia. What is the priority nursing action?
A. Notify the anesthesiologist and surgeon immediately.
B. Apply cooling blankets to the client’s body.
C. Administer chilled intravenous fluids as ordered.
D. Prepare to administer dantrolene sodium intravenously.
Correct Answer: A
Explanation: These symptoms are classic indicators of malignant hyperthermia, which is a
life-threatening complication of general anesthesia. Immediate communication with the
surgical team is essential to stop the triggering agent and begin emergency protocols.
Following notification, dantrolene and cooling measures will be implemented as part of the
rapid response.
5. A nurse is evaluating a client for signs of fluid volume deficit. Which clinical findings should
the nurse identify as consistent with this diagnosis? Select all that apply.
A. Poor skin turgor
, B. Decreased urine output (oliguria)
C. Distended neck veins
D. Dry mucous membranes
E. Tachycardia and weak pulse
Correct Answer: ABDE
Explanation: Fluid volume deficit (dehydration) results in decreased vascular volume and
interstitial fluid. This manifests as poor skin turgor, decreased urine production as the
kidneys try to conserve water, and dry membranes. Tachycardia occurs as a compensatory
mechanism to maintain cardiac output despite the low volume, whereas distended neck
veins are a sign of fluid volume overload.
6. A client is 2 days postoperative and complains of sudden pain at the surgical site. The nurse
observes that the wound has separated and internal organs are protruding. Which action
should the nurse take first?
A. Call the healthcare provider immediately.
B. Position the client in low Fowler’s with knees bent.
C. Stay with the client and monitor vital signs.
D. Cover the wound with sterile gauze soaked in normal saline.
Correct Answer: D
Surgical Nursing I-A | NCLEX (NGN) Q&A
with Rationale (NU157 Exam 1) | Galen
1. A nurse is assessing a client with a serum potassium level of 6.2 mEq/L. Which of the
following clinical manifestations should the nurse expect to find? Select all that apply.
A. Tall, peaked T waves
B. Muscle weakness in the lower extremities
C. Hyperactive bowel sounds and diarrhea
D. Hypotension and bradycardia
E. Paresthesia of the hands and feet
F. Flat or inverted T waves
Correct Answer: ABCDE
Explanation: Hyperkalemia is defined as a serum potassium level exceeding 5.0 mEq/L,
which can lead to life-threatening cardiac dysrhythmias. Tall, peaked T waves are a
hallmark ECG change associated with this electrolyte imbalance. The elevation of
potassium also increases neuromuscular irritability, leading to muscle weakness, diarrhea,
and tingling sensations in the extremities.
,2. A client is diagnosed with respiratory acidosis. Which of the following arterial blood gas
(ABG) results is consistent with this diagnosis?
A. pH 7.30; PaCO2 52 mmHg; HCO3 24 mEq/L
B. pH 7.50; PaCO2 30 mmHg; HCO3 22 mEq/L
C. pH 7.32; PaCO2 38 mmHg; HCO3 18 mEq/L
D. pH 7.48; PaCO2 45 mmHg; HCO3 30 mEq/L
Correct Answer: A
Explanation: Respiratory acidosis is characterized by a pH lower than 7.35 and a PaCO2
greater than 45 mmHg. In this case, the pH of 7.30 indicates acidosis, and the elevated CO2
confirms the respiratory origin. The bicarbonate level is within normal range, suggesting
that renal compensation has not yet occurred.
3. The nurse is preparing a client for an elective cholecystectomy. Which statement by the
nurse best describes the primary purpose of obtaining informed consent?
A. To protect the surgeon and hospital from legal liability.
B. To verify that the client is mentally competent to undergo surgery.
C. To document that the client has been given the opportunity to ask questions.
D. To ensure the client understands the risks, benefits, and alternatives of the procedure.
Correct Answer: D
,Explanation: Informed consent is a legal and ethical requirement that ensures the client is
a participant in their own healthcare decisions. It involves providing the client with all
necessary information regarding the procedure, its risks, and possible alternatives. While
documentation is important, the core purpose is the client’s comprehension of the surgery
they are agreeing to.
4. During the intraoperative phase, the nurse notes that the client is experiencing muscle
rigidity, a rapidly rising temperature, and tachycardia. What is the priority nursing action?
A. Notify the anesthesiologist and surgeon immediately.
B. Apply cooling blankets to the client’s body.
C. Administer chilled intravenous fluids as ordered.
D. Prepare to administer dantrolene sodium intravenously.
Correct Answer: A
Explanation: These symptoms are classic indicators of malignant hyperthermia, which is a
life-threatening complication of general anesthesia. Immediate communication with the
surgical team is essential to stop the triggering agent and begin emergency protocols.
Following notification, dantrolene and cooling measures will be implemented as part of the
rapid response.
5. A nurse is evaluating a client for signs of fluid volume deficit. Which clinical findings should
the nurse identify as consistent with this diagnosis? Select all that apply.
A. Poor skin turgor
, B. Decreased urine output (oliguria)
C. Distended neck veins
D. Dry mucous membranes
E. Tachycardia and weak pulse
Correct Answer: ABDE
Explanation: Fluid volume deficit (dehydration) results in decreased vascular volume and
interstitial fluid. This manifests as poor skin turgor, decreased urine production as the
kidneys try to conserve water, and dry membranes. Tachycardia occurs as a compensatory
mechanism to maintain cardiac output despite the low volume, whereas distended neck
veins are a sign of fluid volume overload.
6. A client is 2 days postoperative and complains of sudden pain at the surgical site. The nurse
observes that the wound has separated and internal organs are protruding. Which action
should the nurse take first?
A. Call the healthcare provider immediately.
B. Position the client in low Fowler’s with knees bent.
C. Stay with the client and monitor vital signs.
D. Cover the wound with sterile gauze soaked in normal saline.
Correct Answer: D
