NU 157 Final Exam V2 | NU 157 Medical-
Surgical Nursing I-A | NCLEX (NGN) Q&A
with Rationale (NU157 Final Exam) | Galen
1. A nurse is caring for a postoperative patient who suddenly reports a ‘popping’ sensation in
the abdominal incision. Upon assessment, the nurse notes that the wound has opened and
internal organs are protruding. What is the nurse’s priority action?
A. Attempt to push the organs back into the abdominal cavity gently.
B. Place the patient in a high-Fowler’s position to assist with breathing.
C. Cover the protruding organs with sterile dressings moistened with sterile normal saline.
D. Leave the patient to call the surgeon immediately from the nurses’ station.
Correct Answer: C
Explanation: This scenario describes wound evisceration, which is a surgical emergency.
The nurse should immediately cover the site with sterile, saline-soaked dressings to keep
the organs moist and prevent infection. The patient should be placed in a low-Fowler’s
position with knees bent to reduce abdominal tension, and the nurse must remain with the
patient while another staff member notifies the surgeon.
2. A nurse is assessing a patient for clinical manifestations of hypokalemia. Which of the
following findings should the nurse expect? (Select All That Apply)
A. Muscle weakness
,B. Cardiac dysrhythmias
C. Hypoactive bowel sounds
D. Hyperactive deep tendon reflexes
E. Flat or inverted T-waves on ECG
F. Numbness and tingling around the mouth
Correct Answer: A, B, C, E
Explanation: Hypokalemia affects neuromuscular and cardiac function by lowering the
resting membrane potential. Common signs include muscle weakness, decreased bowel
motility leading to constipation or ileus, and significant ECG changes like flat T-waves.
Hyperactive reflexes and circumoral paresthesia are more commonly associated with
hypocalcemia rather than hypokalemia.
3. A patient’s arterial blood gas (ABG) results are: pH 7.31, PaCO2 52 mmHg, and HCO3 26
mEq/L. How should the nurse interpret these findings?
A. Metabolic Acidosis
B. Respiratory Alkalosis
C. Metabolic Alkalosis
D. Respiratory Acidosis
Correct Answer: D
,Explanation: The pH of 7.31 indicates acidosis since it is below the normal range of 7.35 to
7.45. The PaCO2 of 52 mmHg is elevated, indicating CO2 retention, which is the cause of the
respiratory acidosis. The HCO3 is within the normal range, suggesting that compensation
has not yet occurred or is just beginning.
4. The nurse is preparing a patient for surgery. Which statement by the patient indicates a
need for further teaching regarding informed consent?
A. I can change my mind and cancel the surgery even after I sign this form.
B. The surgeon will explain the risks and benefits of the procedure to me.
C. Since I signed the paper, the nurse is responsible for explaining the whole procedure to
me.
D. I understand that there are alternative treatments to this surgery.
Correct Answer: C
Explanation: It is the surgeon’s responsibility, not the nurse’s, to explain the surgical
procedure, risks, and benefits to the patient. The nurse’s role is to witness the patient’s
signature and ensure the patient is competent to provide consent. If the patient expresses
confusion about the procedure, the nurse must contact the surgeon to provide further
clarification before the surgery proceeds.
, 5. A nurse is caring for a patient with Chronic Obstructive Pulmonary Disease (COPD). The
patient is receiving oxygen at 2 L/min via nasal cannula. Why is it important to avoid high
concentrations of oxygen in this patient?
A. In chronic CO2 retainers, high oxygen levels can suppress the hypoxic drive to breathe.
B. It may increase the risk of spontaneous pneumothorax in patients with blebs.
C. High oxygen levels can lead to oxygen toxicity and permanent lung damage.
D. High flow oxygen causes excessive drying of the mucous membranes and crusting.
Correct Answer: A
Explanation: Some patients with chronic hypercapnia (high CO2 levels) rely on a low
oxygen level (hypoxic drive) to stimulate their respiratory center. If supplemental oxygen
is provided at too high a concentration, their PaO2 rises, which may signal the brain to slow
or stop respirations. The nurse must carefully titrate oxygen to maintain an SpO2 between
88% and 92% for these specific patients.
6. A nurse is assessing a patient for fluid volume deficit (hypovolemia). Which findings
support this diagnosis? (Select All That Apply)
A. Tachycardia
B. Jugular venous distension
C. Decreased skin turgor
D. Orthostatic hypotension
Surgical Nursing I-A | NCLEX (NGN) Q&A
with Rationale (NU157 Final Exam) | Galen
1. A nurse is caring for a postoperative patient who suddenly reports a ‘popping’ sensation in
the abdominal incision. Upon assessment, the nurse notes that the wound has opened and
internal organs are protruding. What is the nurse’s priority action?
A. Attempt to push the organs back into the abdominal cavity gently.
B. Place the patient in a high-Fowler’s position to assist with breathing.
C. Cover the protruding organs with sterile dressings moistened with sterile normal saline.
D. Leave the patient to call the surgeon immediately from the nurses’ station.
Correct Answer: C
Explanation: This scenario describes wound evisceration, which is a surgical emergency.
The nurse should immediately cover the site with sterile, saline-soaked dressings to keep
the organs moist and prevent infection. The patient should be placed in a low-Fowler’s
position with knees bent to reduce abdominal tension, and the nurse must remain with the
patient while another staff member notifies the surgeon.
2. A nurse is assessing a patient for clinical manifestations of hypokalemia. Which of the
following findings should the nurse expect? (Select All That Apply)
A. Muscle weakness
,B. Cardiac dysrhythmias
C. Hypoactive bowel sounds
D. Hyperactive deep tendon reflexes
E. Flat or inverted T-waves on ECG
F. Numbness and tingling around the mouth
Correct Answer: A, B, C, E
Explanation: Hypokalemia affects neuromuscular and cardiac function by lowering the
resting membrane potential. Common signs include muscle weakness, decreased bowel
motility leading to constipation or ileus, and significant ECG changes like flat T-waves.
Hyperactive reflexes and circumoral paresthesia are more commonly associated with
hypocalcemia rather than hypokalemia.
3. A patient’s arterial blood gas (ABG) results are: pH 7.31, PaCO2 52 mmHg, and HCO3 26
mEq/L. How should the nurse interpret these findings?
A. Metabolic Acidosis
B. Respiratory Alkalosis
C. Metabolic Alkalosis
D. Respiratory Acidosis
Correct Answer: D
,Explanation: The pH of 7.31 indicates acidosis since it is below the normal range of 7.35 to
7.45. The PaCO2 of 52 mmHg is elevated, indicating CO2 retention, which is the cause of the
respiratory acidosis. The HCO3 is within the normal range, suggesting that compensation
has not yet occurred or is just beginning.
4. The nurse is preparing a patient for surgery. Which statement by the patient indicates a
need for further teaching regarding informed consent?
A. I can change my mind and cancel the surgery even after I sign this form.
B. The surgeon will explain the risks and benefits of the procedure to me.
C. Since I signed the paper, the nurse is responsible for explaining the whole procedure to
me.
D. I understand that there are alternative treatments to this surgery.
Correct Answer: C
Explanation: It is the surgeon’s responsibility, not the nurse’s, to explain the surgical
procedure, risks, and benefits to the patient. The nurse’s role is to witness the patient’s
signature and ensure the patient is competent to provide consent. If the patient expresses
confusion about the procedure, the nurse must contact the surgeon to provide further
clarification before the surgery proceeds.
, 5. A nurse is caring for a patient with Chronic Obstructive Pulmonary Disease (COPD). The
patient is receiving oxygen at 2 L/min via nasal cannula. Why is it important to avoid high
concentrations of oxygen in this patient?
A. In chronic CO2 retainers, high oxygen levels can suppress the hypoxic drive to breathe.
B. It may increase the risk of spontaneous pneumothorax in patients with blebs.
C. High oxygen levels can lead to oxygen toxicity and permanent lung damage.
D. High flow oxygen causes excessive drying of the mucous membranes and crusting.
Correct Answer: A
Explanation: Some patients with chronic hypercapnia (high CO2 levels) rely on a low
oxygen level (hypoxic drive) to stimulate their respiratory center. If supplemental oxygen
is provided at too high a concentration, their PaO2 rises, which may signal the brain to slow
or stop respirations. The nurse must carefully titrate oxygen to maintain an SpO2 between
88% and 92% for these specific patients.
6. A nurse is assessing a patient for fluid volume deficit (hypovolemia). Which findings
support this diagnosis? (Select All That Apply)
A. Tachycardia
B. Jugular venous distension
C. Decreased skin turgor
D. Orthostatic hypotension
