NU 157 Final Exam V3 | NU 157 Medical-
Surgical Nursing I-A | NCLEX (NGN) Q&A
with Rationale (NU157 Final Exam) | Galen
1. A nurse is providing preoperative teaching for a client scheduled for an elective surgery.
Which of the following statements by the client indicates a need for further teaching?
A. I will be able to drive myself home once the anesthesia wears off.
B. I can drink a small glass of water with my morning medications on the day of surgery.
C. I should keep my hearing aids in until I reach the operating room door.
D. I will need to stop taking my aspirin one week before the surgery.
Correct Answer: A
Explanation: Clients undergoing anesthesia or sedation are strictly prohibited from
driving themselves home due to the lingering effects of medication on cognitive and motor
functions. The nurse must ensure that a responsible adult is available to provide
transportation and monitoring post-discharge. This safety protocol is essential to prevent
accidents and ensure the client’s well-being following a surgical procedure.
2. A nurse is caring for a postoperative client who reports sudden sharp chest pain and
dyspnea. Which of the following actions should the nurse take first?
A. Apply oxygen and elevate the head of the bed.
B. Administer the prescribed PRN analgesic for pain.
,C. Assess the client’s surgical incision for dehiscence.
D. Check the client’s calves for redness or swelling.
Correct Answer: A
Explanation: The client’s symptoms are highly suggestive of a pulmonary embolism, which
is a life-threatening postoperative complication. Elevating the head of the bed and
providing oxygen are the immediate priorities to improve gas exchange and reduce
respiratory distress. The nurse should then notify the rapid response team or the primary
healthcare provider for further diagnostic testing and intervention.
3. A nurse is reviewing the lab results of a client receiving potent diuretics and notes a
potassium level of 3.2 mEq/L. Which clinical manifestation should the nurse monitor for?
A. Peaked T waves on the EKG
B. Hyperactive bowel sounds
C. Muscle weakness and leg cramps
D. Positive Trousseau’s sign
Correct Answer: C
Explanation: A potassium level of 3.2 mEq/L indicates hypokalemia, which can lead to
neuromuscular irritability and muscle weakness. Clients may also experience cardiac
dysrhythmias and decreased deep tendon reflexes. Monitoring the client’s heart rhythm
and muscle strength is crucial to prevent further complications associated with electrolyte
imbalances.
,4. A nurse is assessing a client for signs of fluid volume deficit (hypovolemia). Which of the
following findings should the nurse expect? (Select All That Apply)
A. Decreased skin turgor
B. Jugular venous distention
C. Orthostatic hypotension
D. Increased heart rate
E. Concentrated urine with high specific gravity
F. Pitting edema in the lower extremities
Correct Answer: A, C, D, E
Explanation: Hypovolemia results in a decrease in circulating blood volume, leading to
physiological compensations such as tachycardia to maintain cardiac output. Physical signs
include poor skin turgor due to tissue dehydration and orthostatic hypotension when the
client changes position. Concentrated urine indicates the kidneys are attempting to
conserve water by increasing reabsorption.
5. A nurse is preparing to administer a unit of packed red blood cells (PRBCs). Which action is
the priority to ensure client safety?
A. Warming the blood to room temperature before administration.
B. Verifying the client’s identity and blood type with another RN.
C. Starting the infusion at a rate of 150 mL per hour.
, D. Administering diphenhydramine before starting the transfusion.
Correct Answer: B
Explanation: Double-checking the blood product against the client’s identification and the
medical order with another registered nurse is the most critical step in preventing a
hemolytic transfusion reaction. This verification process must occur at the bedside to
ensure the right blood is given to the right client. Failure to follow this protocol can result
in life-threatening incompatibility errors.
6. A client with Type 1 Diabetes Mellitus is found unconscious and clammy. The nurse should
immediately perform which action?
A. Administer prescribed glucagon intramuscularly.
B. Check the client’s capillary blood glucose level.
C. Provide 15 grams of oral carbohydrates.
D. Administer 10 units of regular insulin subcutaneously.
Correct Answer: A
Explanation: In an unconscious client who is suspected of being hypoglycemic, the priority
is to elevate the blood glucose safely without the risk of aspiration. Glucagon is the
appropriate emergency treatment when the client cannot safely swallow oral glucose. The
nurse should also contact emergency services and monitor the client’s response to the
medication.
Surgical Nursing I-A | NCLEX (NGN) Q&A
with Rationale (NU157 Final Exam) | Galen
1. A nurse is providing preoperative teaching for a client scheduled for an elective surgery.
Which of the following statements by the client indicates a need for further teaching?
A. I will be able to drive myself home once the anesthesia wears off.
B. I can drink a small glass of water with my morning medications on the day of surgery.
C. I should keep my hearing aids in until I reach the operating room door.
D. I will need to stop taking my aspirin one week before the surgery.
Correct Answer: A
Explanation: Clients undergoing anesthesia or sedation are strictly prohibited from
driving themselves home due to the lingering effects of medication on cognitive and motor
functions. The nurse must ensure that a responsible adult is available to provide
transportation and monitoring post-discharge. This safety protocol is essential to prevent
accidents and ensure the client’s well-being following a surgical procedure.
2. A nurse is caring for a postoperative client who reports sudden sharp chest pain and
dyspnea. Which of the following actions should the nurse take first?
A. Apply oxygen and elevate the head of the bed.
B. Administer the prescribed PRN analgesic for pain.
,C. Assess the client’s surgical incision for dehiscence.
D. Check the client’s calves for redness or swelling.
Correct Answer: A
Explanation: The client’s symptoms are highly suggestive of a pulmonary embolism, which
is a life-threatening postoperative complication. Elevating the head of the bed and
providing oxygen are the immediate priorities to improve gas exchange and reduce
respiratory distress. The nurse should then notify the rapid response team or the primary
healthcare provider for further diagnostic testing and intervention.
3. A nurse is reviewing the lab results of a client receiving potent diuretics and notes a
potassium level of 3.2 mEq/L. Which clinical manifestation should the nurse monitor for?
A. Peaked T waves on the EKG
B. Hyperactive bowel sounds
C. Muscle weakness and leg cramps
D. Positive Trousseau’s sign
Correct Answer: C
Explanation: A potassium level of 3.2 mEq/L indicates hypokalemia, which can lead to
neuromuscular irritability and muscle weakness. Clients may also experience cardiac
dysrhythmias and decreased deep tendon reflexes. Monitoring the client’s heart rhythm
and muscle strength is crucial to prevent further complications associated with electrolyte
imbalances.
,4. A nurse is assessing a client for signs of fluid volume deficit (hypovolemia). Which of the
following findings should the nurse expect? (Select All That Apply)
A. Decreased skin turgor
B. Jugular venous distention
C. Orthostatic hypotension
D. Increased heart rate
E. Concentrated urine with high specific gravity
F. Pitting edema in the lower extremities
Correct Answer: A, C, D, E
Explanation: Hypovolemia results in a decrease in circulating blood volume, leading to
physiological compensations such as tachycardia to maintain cardiac output. Physical signs
include poor skin turgor due to tissue dehydration and orthostatic hypotension when the
client changes position. Concentrated urine indicates the kidneys are attempting to
conserve water by increasing reabsorption.
5. A nurse is preparing to administer a unit of packed red blood cells (PRBCs). Which action is
the priority to ensure client safety?
A. Warming the blood to room temperature before administration.
B. Verifying the client’s identity and blood type with another RN.
C. Starting the infusion at a rate of 150 mL per hour.
, D. Administering diphenhydramine before starting the transfusion.
Correct Answer: B
Explanation: Double-checking the blood product against the client’s identification and the
medical order with another registered nurse is the most critical step in preventing a
hemolytic transfusion reaction. This verification process must occur at the bedside to
ensure the right blood is given to the right client. Failure to follow this protocol can result
in life-threatening incompatibility errors.
6. A client with Type 1 Diabetes Mellitus is found unconscious and clammy. The nurse should
immediately perform which action?
A. Administer prescribed glucagon intramuscularly.
B. Check the client’s capillary blood glucose level.
C. Provide 15 grams of oral carbohydrates.
D. Administer 10 units of regular insulin subcutaneously.
Correct Answer: A
Explanation: In an unconscious client who is suspected of being hypoglycemic, the priority
is to elevate the blood glucose safely without the risk of aspiration. Glucagon is the
appropriate emergency treatment when the client cannot safely swallow oral glucose. The
nurse should also contact emergency services and monitor the client’s response to the
medication.
