NU 192 Exam 4 V1 | NU 192 Medical-
Surgical Nursing II-B | NCLEX (NGN) Q&A
with Rationale (NU192 Exam 4) | Galen
1. A nurse is caring for a client with a chest tube connected to a water-seal drainage system.
Which of the following findings should the nurse identify as requiring immediate
intervention? Select all that apply.
A. Continuous bubbling in the water-seal chamber
B. Tidaling in the water-seal chamber concurrent with respirations
C. Chest tube drainage output of 150 mL in the last hour
D. Crepitus palpated around the chest tube insertion site
E. Constant vigorous bubbling in the suction control chamber
F. The drainage system is kept below the level of the client’s chest
Correct Answer: A, C, D
Explanation: Continuous bubbling in the water-seal chamber suggests an air leak in the
system that requires immediate troubleshooting. Drainage exceeding 100 mL per hour is
considered excessive and may indicate active hemorrhage or a significant shift in status.
Crepitus indicates subcutaneous emphysema, implying that air is leaking into the
surrounding tissue and the insertion site may not be airtight.
,2. A client is admitted to the emergency department after being rescued from a house fire.
The nurse notes soot around the client’s nose and mouth and a hoarse voice. Which action is
the nurse’s priority?
A. Obtain arterial blood gas (ABG) levels
B. Administer 100% oxygen via a non-rebreather mask
C. Prepare for prophylactic endotracheal intubation
D. Inspect the oropharynx for redness and edema
Correct Answer: C
Explanation: Assessment findings of soot and hoarseness strongly suggest an inhalation
injury, which can lead to rapid airway edema and obstruction. Prophylactic intubation is
prioritized to secure the airway before swelling makes it impossible to insert a tube. While
oxygen and diagnostics are important, maintaining airway patency is the primary nursing
concern in trauma and burn scenarios.
3. The nurse is analyzing the arterial blood gas (ABG) results for a client with a history of
chronic obstructive pulmonary disease (COPD): pH 7.32, PaCO2 58 mm Hg, HCO3 30 mEq/L,
and PaO2 65 mm Hg. How should the nurse interpret these results?
A. Partially compensated respiratory acidosis with hypoxemia
B. Fully compensated metabolic alkalosis
C. Uncompensated respiratory acidosis with hypoxemia
D. Normal findings for a client with end-stage COPD
,Correct Answer: A
Explanation: The pH is below 7.35, indicating acidosis, while the PaCO2 is elevated,
pointing to a respiratory cause. The HCO3 is also elevated, which indicates the kidneys are
attempting to compensate for the acidic state. Because the pH has not yet returned to the
normal range, the condition is classified as partially compensated.
4. A client with a T4 spinal cord injury suddenly reports a severe, throbbing headache and
blurred vision. The nurse notes the client is diaphoretic and the blood pressure is 210/110
mm Hg. What is the nurse’s initial action?
A. Notify the healthcare provider immediately
B. Administer an ordered PRN antihypertensive medication
C. Check the client’s bladder for distension or a kinked catheter
D. Place the client in a high-Fowler’s position
Correct Answer: D
Explanation: The client is exhibiting classic signs of autonomic dysreflexia, a medical
emergency triggered by noxious stimuli in patients with injuries above T6. Elevating the
head of the bed is the first priority to help lower blood pressure via orthostatic effects.
After positioning, the nurse should then assess for and remove the trigger, such as an
overdistended bladder or impacted stool.
, 5. A client in the oliguric phase of acute kidney injury (AKI) has a potassium level of 6.8
mEq/L. Which of the following ECG changes should the nurse expect to see?
A. Tall, peaked T waves
B. Prominent U waves
C. ST-segment depression
D. Shortened PR interval
Correct Answer: A
Explanation: Hyperkalemia is a life-threatening complication of AKI that specifically
affects cardiac conduction. Tall, peaked T waves are one of the earliest signs seen on an
ECG when potassium levels rise significantly. If untreated, this can progress to widened
QRS complexes and eventually ventricular fibrillation or asystole.
6. The nurse is triage officer at a mass casualty incident involving a bus accident. Which client
should be assigned a Red tag?
A. A client who is crying hysterically with minor abrasions
B. A client with a closed fracture of the tibia and stable vitals
C. A client with a large head wound and no spontaneous respirations
D. A client with a sucking chest wound and labored respirations
Correct Answer: D
Surgical Nursing II-B | NCLEX (NGN) Q&A
with Rationale (NU192 Exam 4) | Galen
1. A nurse is caring for a client with a chest tube connected to a water-seal drainage system.
Which of the following findings should the nurse identify as requiring immediate
intervention? Select all that apply.
A. Continuous bubbling in the water-seal chamber
B. Tidaling in the water-seal chamber concurrent with respirations
C. Chest tube drainage output of 150 mL in the last hour
D. Crepitus palpated around the chest tube insertion site
E. Constant vigorous bubbling in the suction control chamber
F. The drainage system is kept below the level of the client’s chest
Correct Answer: A, C, D
Explanation: Continuous bubbling in the water-seal chamber suggests an air leak in the
system that requires immediate troubleshooting. Drainage exceeding 100 mL per hour is
considered excessive and may indicate active hemorrhage or a significant shift in status.
Crepitus indicates subcutaneous emphysema, implying that air is leaking into the
surrounding tissue and the insertion site may not be airtight.
,2. A client is admitted to the emergency department after being rescued from a house fire.
The nurse notes soot around the client’s nose and mouth and a hoarse voice. Which action is
the nurse’s priority?
A. Obtain arterial blood gas (ABG) levels
B. Administer 100% oxygen via a non-rebreather mask
C. Prepare for prophylactic endotracheal intubation
D. Inspect the oropharynx for redness and edema
Correct Answer: C
Explanation: Assessment findings of soot and hoarseness strongly suggest an inhalation
injury, which can lead to rapid airway edema and obstruction. Prophylactic intubation is
prioritized to secure the airway before swelling makes it impossible to insert a tube. While
oxygen and diagnostics are important, maintaining airway patency is the primary nursing
concern in trauma and burn scenarios.
3. The nurse is analyzing the arterial blood gas (ABG) results for a client with a history of
chronic obstructive pulmonary disease (COPD): pH 7.32, PaCO2 58 mm Hg, HCO3 30 mEq/L,
and PaO2 65 mm Hg. How should the nurse interpret these results?
A. Partially compensated respiratory acidosis with hypoxemia
B. Fully compensated metabolic alkalosis
C. Uncompensated respiratory acidosis with hypoxemia
D. Normal findings for a client with end-stage COPD
,Correct Answer: A
Explanation: The pH is below 7.35, indicating acidosis, while the PaCO2 is elevated,
pointing to a respiratory cause. The HCO3 is also elevated, which indicates the kidneys are
attempting to compensate for the acidic state. Because the pH has not yet returned to the
normal range, the condition is classified as partially compensated.
4. A client with a T4 spinal cord injury suddenly reports a severe, throbbing headache and
blurred vision. The nurse notes the client is diaphoretic and the blood pressure is 210/110
mm Hg. What is the nurse’s initial action?
A. Notify the healthcare provider immediately
B. Administer an ordered PRN antihypertensive medication
C. Check the client’s bladder for distension or a kinked catheter
D. Place the client in a high-Fowler’s position
Correct Answer: D
Explanation: The client is exhibiting classic signs of autonomic dysreflexia, a medical
emergency triggered by noxious stimuli in patients with injuries above T6. Elevating the
head of the bed is the first priority to help lower blood pressure via orthostatic effects.
After positioning, the nurse should then assess for and remove the trigger, such as an
overdistended bladder or impacted stool.
, 5. A client in the oliguric phase of acute kidney injury (AKI) has a potassium level of 6.8
mEq/L. Which of the following ECG changes should the nurse expect to see?
A. Tall, peaked T waves
B. Prominent U waves
C. ST-segment depression
D. Shortened PR interval
Correct Answer: A
Explanation: Hyperkalemia is a life-threatening complication of AKI that specifically
affects cardiac conduction. Tall, peaked T waves are one of the earliest signs seen on an
ECG when potassium levels rise significantly. If untreated, this can progress to widened
QRS complexes and eventually ventricular fibrillation or asystole.
6. The nurse is triage officer at a mass casualty incident involving a bus accident. Which client
should be assigned a Red tag?
A. A client who is crying hysterically with minor abrasions
B. A client with a closed fracture of the tibia and stable vitals
C. A client with a large head wound and no spontaneous respirations
D. A client with a sucking chest wound and labored respirations
Correct Answer: D
