NU 186 Exam 1 V3 | NU 186 Medical-
Surgical Nursing II-A | NCLEX (NGN) Q&A
with Rationale (NU186 Exam 1) | Galen
1. A nurse is caring for a client with an arterial blood gas (ABG) result of pH 7.30, PaCO2 52
mmHg, and HCO3 26 mEq/L. Which clinical manifestation should the nurse anticipate?
A. Hyperventilation and tachypnea
B. Muscle twitching and tetany
C. Confusion, lethargy, and headache
D. Cardiac dysrhythmias and tachycardia
Correct Answer: C
Explanation; The ABG results indicate uncompensated respiratory acidosis, which is
caused by the retention of CO2. As CO2 levels rise, it causes cerebral vasodilation, leading
to clinical manifestations such as headache and altered mental status. The nurse must
monitor for worsening respiratory depression and potential airway compromise in these
clients.
2. The nurse is assessing a client in the intensive care unit who is on a mechanical ventilator.
The high-pressure alarm begins to sound. Which actions should the nurse take? (Select All
That Apply)
A. Check for kinks in the ventilator tubing.
,B. Assess the client for the need for suctioning.
C. Check for a disconnected oxygen sensor.
D. Auscultate breath sounds for potential pneumothorax.
E. Determine if the client is biting the endotracheal tube.
F. Evaluate the client for a cuff leak in the ET tube.
Correct Answer: A, B, D, E
Explanation; A high-pressure alarm indicates that the ventilator is meeting resistance
while trying to deliver a breath. Common causes include kinks in the tubing, secretions
blocking the airway, the client biting the tube, or physiological changes like a
pneumothorax or bronchospasm. A disconnected sensor or a cuff leak would typically
trigger a low-pressure alarm rather than a high-pressure alarm.
3. A client is admitted to the telemetry unit with a diagnosis of Acute Myocardial Infarction.
The nurse notes the following rhythm on the monitor: a rapid rate of 160 bpm, no discernible
P waves, and wide, bizarre QRS complexes. What is the priority nursing action?
A. Assess the client’s pulse and blood pressure.
B. Perform immediate synchronized cardioversion.
C. Administer a bolus of Amiodarone.
D. Prepare for defibrillation at 200 Joules.
Correct Answer: A
,Explanation; The rhythm described is Ventricular Tachycardia (VT). The nurse’s first
action must be to assess the client’s hemodynamic stability by checking for a pulse and
blood pressure. Management of VT varies significantly depending on whether the client is
stable, unstable but pulsing, or pulseless.
4. A nurse is providing discharge teaching to a client with chronic heart failure who is
prescribed Furosemide and Digoxin. Which statement by the client indicates an
understanding of the teaching?
A. ‘I will take my medication with a large glass of orange juice every morning.’
B. ‘I should limit my intake of potassium-rich foods like bananas.’
C. ‘I will call my doctor if I notice I am seeing yellow halos around lights.’
D. ‘I will stop taking the diuretic if I feel dizzy when standing up.’
Correct Answer: C
Explanation; Seeing yellow halos around lights is a classic sign of Digoxin toxicity, which
requires immediate medical attention. Because Furosemide is a loop diuretic that wastes
potassium, hypokalemia can increase the risk of Digoxin toxicity. The client should be
encouraged to maintain adequate potassium intake, not limit it, unless otherwise directed.
5. The nurse is caring for a client with Acute Respiratory Distress Syndrome (ARDS) who is
being treated with prone positioning. Which finding indicates that the positioning is
effective?
A. Improvement in oxygenation and PaO2 levels.
, B. Decrease in the PaO2/FiO2 ratio.
C. Increase in peak inspiratory pressures.
D. Resolution of bilateral pulmonary infiltrates.
Correct Answer: A
Explanation; Prone positioning in ARDS helps to recruit collapsed alveoli in the posterior
lung segments and improves ventilation-perfusion matching. An improvement in PaO2 and
oxygen saturation is the primary indicator that this intervention is successful. This
technique helps reduce the shunt fraction and improves the overall efficiency of gas
exchange.
6. A client with Diabetic Ketoacidosis (DKA) is receiving an intravenous insulin infusion. The
nurse notes the client’s blood glucose has dropped from 450 mg/dL to 230 mg/dL over the
last 3 hours. Which action should the nurse take next?
A. Stop the insulin infusion immediately.
B. Increase the insulin infusion rate to clear ketones.
C. Administer 50% Dextrose IV push.
D. Switch the IV fluids to 5% Dextrose in 0.45% Normal Saline.
Correct Answer: D
Explanation; When blood glucose levels reach approximately 250 mg/dL in a client with
DKA, dextrose should be added to the IV fluids. This prevents a rapid drop in glucose that
Surgical Nursing II-A | NCLEX (NGN) Q&A
with Rationale (NU186 Exam 1) | Galen
1. A nurse is caring for a client with an arterial blood gas (ABG) result of pH 7.30, PaCO2 52
mmHg, and HCO3 26 mEq/L. Which clinical manifestation should the nurse anticipate?
A. Hyperventilation and tachypnea
B. Muscle twitching and tetany
C. Confusion, lethargy, and headache
D. Cardiac dysrhythmias and tachycardia
Correct Answer: C
Explanation; The ABG results indicate uncompensated respiratory acidosis, which is
caused by the retention of CO2. As CO2 levels rise, it causes cerebral vasodilation, leading
to clinical manifestations such as headache and altered mental status. The nurse must
monitor for worsening respiratory depression and potential airway compromise in these
clients.
2. The nurse is assessing a client in the intensive care unit who is on a mechanical ventilator.
The high-pressure alarm begins to sound. Which actions should the nurse take? (Select All
That Apply)
A. Check for kinks in the ventilator tubing.
,B. Assess the client for the need for suctioning.
C. Check for a disconnected oxygen sensor.
D. Auscultate breath sounds for potential pneumothorax.
E. Determine if the client is biting the endotracheal tube.
F. Evaluate the client for a cuff leak in the ET tube.
Correct Answer: A, B, D, E
Explanation; A high-pressure alarm indicates that the ventilator is meeting resistance
while trying to deliver a breath. Common causes include kinks in the tubing, secretions
blocking the airway, the client biting the tube, or physiological changes like a
pneumothorax or bronchospasm. A disconnected sensor or a cuff leak would typically
trigger a low-pressure alarm rather than a high-pressure alarm.
3. A client is admitted to the telemetry unit with a diagnosis of Acute Myocardial Infarction.
The nurse notes the following rhythm on the monitor: a rapid rate of 160 bpm, no discernible
P waves, and wide, bizarre QRS complexes. What is the priority nursing action?
A. Assess the client’s pulse and blood pressure.
B. Perform immediate synchronized cardioversion.
C. Administer a bolus of Amiodarone.
D. Prepare for defibrillation at 200 Joules.
Correct Answer: A
,Explanation; The rhythm described is Ventricular Tachycardia (VT). The nurse’s first
action must be to assess the client’s hemodynamic stability by checking for a pulse and
blood pressure. Management of VT varies significantly depending on whether the client is
stable, unstable but pulsing, or pulseless.
4. A nurse is providing discharge teaching to a client with chronic heart failure who is
prescribed Furosemide and Digoxin. Which statement by the client indicates an
understanding of the teaching?
A. ‘I will take my medication with a large glass of orange juice every morning.’
B. ‘I should limit my intake of potassium-rich foods like bananas.’
C. ‘I will call my doctor if I notice I am seeing yellow halos around lights.’
D. ‘I will stop taking the diuretic if I feel dizzy when standing up.’
Correct Answer: C
Explanation; Seeing yellow halos around lights is a classic sign of Digoxin toxicity, which
requires immediate medical attention. Because Furosemide is a loop diuretic that wastes
potassium, hypokalemia can increase the risk of Digoxin toxicity. The client should be
encouraged to maintain adequate potassium intake, not limit it, unless otherwise directed.
5. The nurse is caring for a client with Acute Respiratory Distress Syndrome (ARDS) who is
being treated with prone positioning. Which finding indicates that the positioning is
effective?
A. Improvement in oxygenation and PaO2 levels.
, B. Decrease in the PaO2/FiO2 ratio.
C. Increase in peak inspiratory pressures.
D. Resolution of bilateral pulmonary infiltrates.
Correct Answer: A
Explanation; Prone positioning in ARDS helps to recruit collapsed alveoli in the posterior
lung segments and improves ventilation-perfusion matching. An improvement in PaO2 and
oxygen saturation is the primary indicator that this intervention is successful. This
technique helps reduce the shunt fraction and improves the overall efficiency of gas
exchange.
6. A client with Diabetic Ketoacidosis (DKA) is receiving an intravenous insulin infusion. The
nurse notes the client’s blood glucose has dropped from 450 mg/dL to 230 mg/dL over the
last 3 hours. Which action should the nurse take next?
A. Stop the insulin infusion immediately.
B. Increase the insulin infusion rate to clear ketones.
C. Administer 50% Dextrose IV push.
D. Switch the IV fluids to 5% Dextrose in 0.45% Normal Saline.
Correct Answer: D
Explanation; When blood glucose levels reach approximately 250 mg/dL in a client with
DKA, dextrose should be added to the IV fluids. This prevents a rapid drop in glucose that
