NU 192 Exam 2 V2 | NU 192 Medical-
Surgical Nursing II-B | NCLEX (NGN) Q&A
with Rationale (NU192 Exam 2) | Galen
1. A nurse is assessing a client who has just arrived in the emergency department with
suspected ischemic stroke. Which clinical manifestations should the nurse expect to observe?
(Select All That Apply)
A. Sudden facial drooping on one side
B. Unilateral arm weakness or drift
C. Expressive or receptive aphasia
D. Sudden onset of a ‘thunderclap’ headache
E. Nuchal rigidity and photophobia
F. Loss of balance or coordination
Correct Answer: A,B,C,F
Explanation: Ischemic strokes typically present with focal neurological deficits such as
facial drooping, unilateral weakness, and speech disturbances. Sudden ‘thunderclap’
headaches and nuchal rigidity are more characteristic of hemorrhagic strokes or
subarachnoid hemorrhages rather than ischemic events. Early identification of these
symptoms is critical for the timely administration of fibrinolytic therapy according to Galen
clinical protocols.
,2. A client with a head injury has an intracranial pressure (ICP) of 22 mmHg. Which prescribed
intervention should the nurse implement first?
A. Administer 100 mg of pentobarbital intravenously
B. Increase the suction frequency to clear the airway
C. Administer 0.5 g/kg of mannitol via IV bolus
D. Position the client in a side-lying Trendelenburg position
Correct Answer: C
Explanation: Mannitol is an osmotic diuretic used to reduce cerebral edema and lower
intracranial pressure in emergency situations. Normal ICP ranges from 5 to 15 mmHg, and
a level of 22 mmHg indicates intracranial hypertension requiring immediate
pharmacological intervention. The nurse must prioritize osmotic therapy to prevent brain
herniation while avoiding unnecessary suctioning which can further increase ICP.
3. The nurse is caring for a client with a T4 spinal cord injury. The client reports a severe,
throbbing headache and the nurse notes a blood pressure of 190/100 mmHg. What is the
priority nursing action?
A. Notify the healthcare provider immediately
B. Check the client’s bladder for distention or catheter kinks
C. Administer an antihypertensive medication
D. Lower the head of the bed to a flat position
,Correct Answer: B
Explanation: These symptoms indicate autonomic dysreflexia, a medical emergency
common in clients with spinal cord injuries at or above T6. The most common trigger is
bladder or bowel distention, and the primary intervention is to remove the noxious
stimulus. The nurse should first check for bladder distention or a kinked catheter to resolve
the underlying cause before escalating to pharmacological treatments.
4. A client is admitted to the intensive care unit with Diabetic Ketoacidosis (DKA). Which
laboratory findings should the nurse anticipate? (Select All That Apply)
A. Blood glucose level of 450 mg/dL
B. Serum bicarbonate level of 12 mEq/L
C. Arterial pH of 7.31
D. Positive ketones in the urine
E. Serum potassium of 2.8 mEq/L
Correct Answer: A,B,C,D
Explanation: DKA is characterized by hyperglycemia, metabolic acidosis with a low pH and
low bicarbonate, and the presence of ketones in the blood and urine. While potassium
levels can vary, they are often normal or high initially due to the shift of potassium out of
the cells during acidosis. The nurse must monitor these values closely to manage fluid
resuscitation and insulin titration effectively according to NGN standards.
, 5. A nurse is providing discharge teaching to a client with chronic kidney disease (CKD). Which
dietary instruction is most important to include?
A. Limit potassium intake by avoiding bananas and spinach
B. Increase intake of phosphorus-rich foods like dairy
C. Follow a high-protein diet to prevent muscle wasting
D. Consume at least 3 liters of fluid daily to flush the kidneys
Correct Answer: A
Explanation: In CKD, the kidneys are unable to effectively excrete potassium, leading to a
high risk of hyperkalemia which can cause lethal cardiac arrhythmias. Clients are typically
placed on a renal diet that limits potassium, phosphorus, and sodium. Fluid restriction is
often necessary in later stages of CKD to prevent fluid overload and heart failure.
6. The nurse is evaluating a client’s Glasgow Coma Scale (GCS) score. The client opens eyes to
verbal command, is disoriented to place, and withdraws from painful stimuli. What is the
client’s GCS score?
A. GCS 9
B. GCS 10
C. GCS 12
D. GCS 11
Correct Answer: D
Surgical Nursing II-B | NCLEX (NGN) Q&A
with Rationale (NU192 Exam 2) | Galen
1. A nurse is assessing a client who has just arrived in the emergency department with
suspected ischemic stroke. Which clinical manifestations should the nurse expect to observe?
(Select All That Apply)
A. Sudden facial drooping on one side
B. Unilateral arm weakness or drift
C. Expressive or receptive aphasia
D. Sudden onset of a ‘thunderclap’ headache
E. Nuchal rigidity and photophobia
F. Loss of balance or coordination
Correct Answer: A,B,C,F
Explanation: Ischemic strokes typically present with focal neurological deficits such as
facial drooping, unilateral weakness, and speech disturbances. Sudden ‘thunderclap’
headaches and nuchal rigidity are more characteristic of hemorrhagic strokes or
subarachnoid hemorrhages rather than ischemic events. Early identification of these
symptoms is critical for the timely administration of fibrinolytic therapy according to Galen
clinical protocols.
,2. A client with a head injury has an intracranial pressure (ICP) of 22 mmHg. Which prescribed
intervention should the nurse implement first?
A. Administer 100 mg of pentobarbital intravenously
B. Increase the suction frequency to clear the airway
C. Administer 0.5 g/kg of mannitol via IV bolus
D. Position the client in a side-lying Trendelenburg position
Correct Answer: C
Explanation: Mannitol is an osmotic diuretic used to reduce cerebral edema and lower
intracranial pressure in emergency situations. Normal ICP ranges from 5 to 15 mmHg, and
a level of 22 mmHg indicates intracranial hypertension requiring immediate
pharmacological intervention. The nurse must prioritize osmotic therapy to prevent brain
herniation while avoiding unnecessary suctioning which can further increase ICP.
3. The nurse is caring for a client with a T4 spinal cord injury. The client reports a severe,
throbbing headache and the nurse notes a blood pressure of 190/100 mmHg. What is the
priority nursing action?
A. Notify the healthcare provider immediately
B. Check the client’s bladder for distention or catheter kinks
C. Administer an antihypertensive medication
D. Lower the head of the bed to a flat position
,Correct Answer: B
Explanation: These symptoms indicate autonomic dysreflexia, a medical emergency
common in clients with spinal cord injuries at or above T6. The most common trigger is
bladder or bowel distention, and the primary intervention is to remove the noxious
stimulus. The nurse should first check for bladder distention or a kinked catheter to resolve
the underlying cause before escalating to pharmacological treatments.
4. A client is admitted to the intensive care unit with Diabetic Ketoacidosis (DKA). Which
laboratory findings should the nurse anticipate? (Select All That Apply)
A. Blood glucose level of 450 mg/dL
B. Serum bicarbonate level of 12 mEq/L
C. Arterial pH of 7.31
D. Positive ketones in the urine
E. Serum potassium of 2.8 mEq/L
Correct Answer: A,B,C,D
Explanation: DKA is characterized by hyperglycemia, metabolic acidosis with a low pH and
low bicarbonate, and the presence of ketones in the blood and urine. While potassium
levels can vary, they are often normal or high initially due to the shift of potassium out of
the cells during acidosis. The nurse must monitor these values closely to manage fluid
resuscitation and insulin titration effectively according to NGN standards.
, 5. A nurse is providing discharge teaching to a client with chronic kidney disease (CKD). Which
dietary instruction is most important to include?
A. Limit potassium intake by avoiding bananas and spinach
B. Increase intake of phosphorus-rich foods like dairy
C. Follow a high-protein diet to prevent muscle wasting
D. Consume at least 3 liters of fluid daily to flush the kidneys
Correct Answer: A
Explanation: In CKD, the kidneys are unable to effectively excrete potassium, leading to a
high risk of hyperkalemia which can cause lethal cardiac arrhythmias. Clients are typically
placed on a renal diet that limits potassium, phosphorus, and sodium. Fluid restriction is
often necessary in later stages of CKD to prevent fluid overload and heart failure.
6. The nurse is evaluating a client’s Glasgow Coma Scale (GCS) score. The client opens eyes to
verbal command, is disoriented to place, and withdraws from painful stimuli. What is the
client’s GCS score?
A. GCS 9
B. GCS 10
C. GCS 12
D. GCS 11
Correct Answer: D
