NUR 170 Exam 1 V1 | NUR 170 Medical-Surgical
Nursing | Actual Q&A with Rationale (NUR 170
Exam 1) | Galen
1. Mr. Henderson, a 68-year-old patient with a history of heart failure, is admitted with
reports of increasing shortness of breath and peripheral edema. Upon assessment, the nurse
notes crackles in the lung bases and a 5-lb weight gain over two days. Which electrolyte
imbalance is most likely associated with this patient’s clinical presentation of fluid volume
excess?
A. Hyperkalemia
B. Hypocalcemia
C. Hypermagnesemia
D. Hyponatremia
Correct Answer: D
Explanation: In fluid volume excess, particularly in heart failure, the body often retains
water in excess of sodium, leading to dilutional hyponatremia. The clinical manifestations
of weight gain and crackles indicate extracellular fluid expansion. Monitoring serum
sodium levels is critical as rapid changes can lead to neurological complications.
,2. Ms. Rodriguez is scheduled for an elective laparoscopic cholecystectomy. During the
preoperative assessment, she mentions that she takes a daily aspirin for ‘heart health.’ Why
is this information significant for the surgical team?
A. Aspirin inhibits platelet aggregation and increases the risk of bleeding.
B. Aspirin can interact negatively with general anesthesia.
C. Aspirin increases the risk of postoperative infection.
D. Aspirin may lead to a sudden drop in blood pressure during induction.
Correct Answer: A
Explanation: Aspirin is an antiplatelet medication that irreversibly inhibits platelet
cyclooxygenase, increasing the risk for intraoperative and postoperative hemorrhage. The
surgeon usually requires patients to discontinue aspirin 7 to 10 days prior to surgery. This
assessment finding requires immediate communication with the surgical team to
determine if the procedure should be delayed.
3. A 45-year-old patient, Mr. Smith, is recovering in the PACU after a total hip replacement.
The nurse notes the patient is drowsy but arousable, has a respiratory rate of 8
breaths/minute, and an oxygen saturation of 88% on room air. What is the nurse’s priority
action?
A. Administer the prescribed PRN dose of naloxone (Narcan).
B. Call the surgeon to report the findings.
C. Apply supplemental oxygen and encourage deep breathing.
,D. Document the findings as a normal postoperative response.
Correct Answer: C
Explanation: The patient is showing signs of respiratory depression, likely due to
anesthesia or opioids, but is still arousable. The first step is to support oxygenation and
stimulate the patient to breathe more deeply. If the patient’s status does not improve or
worsens, pharmacological reversal with naloxone may be indicated.
4. The nurse is caring for a patient who has just returned from the operating room. The
patient has a large surgical wound closed with staples. The nurse observes that the wound
edges are slightly reddened and the patient has a low-grade fever of 100.2°F (37.9°C). How
should the nurse interpret these findings during the first 24 hours post-surgery?
A. These are early signs of a surgical site infection.
B. The patient is likely developing pneumonia.
C. These findings are typical of the normal inflammatory response.
D. These signs indicate the patient is experiencing a wound dehiscence.
Correct Answer: C
Explanation: A low-grade fever and mild redness at the incision site within the first 24 to
48 hours postoperatively are expected components of the inflammatory phase of wound
healing. Inflammation is the body’s natural response to surgical trauma and is necessary
for tissue repair. The nurse should continue to monitor for worsening signs, but these
initial findings are not indicative of infection at this stage.
, 5. Mrs. Bennett is admitted with severe vomiting for three days. Her arterial blood gas (ABG)
results are: pH 7.49, PaCO2 48 mmHg, and HCO3 30 mEq/L. Which acid-base imbalance is the
patient experiencing?
A. Respiratory Acidosis
B. Respiratory Alkalosis
C. Metabolic Alkalosis
D. Metabolic Acidosis
Correct Answer: C
Explanation: Severe vomiting leads to the loss of gastric acid (hydrochloric acid), resulting
in a high pH and elevated bicarbonate levels. The pH of 7.49 indicates alkalosis, and the
HCO3 of 30 confirms a metabolic origin. The elevated PaCO2 is a compensatory mechanism
by the lungs to retain acid to balance the high pH.
6. The nurse is reviewing the laboratory results of a patient receiving a potassium-wasting
diuretic. The potassium level is 2.8 mEq/L. Which cardiac rhythm change should the nurse
monitor for on the EKG?
A. Presence of U waves
B. Widened QRS complex
C. Peaked T waves
D. Shortened PR interval
Nursing | Actual Q&A with Rationale (NUR 170
Exam 1) | Galen
1. Mr. Henderson, a 68-year-old patient with a history of heart failure, is admitted with
reports of increasing shortness of breath and peripheral edema. Upon assessment, the nurse
notes crackles in the lung bases and a 5-lb weight gain over two days. Which electrolyte
imbalance is most likely associated with this patient’s clinical presentation of fluid volume
excess?
A. Hyperkalemia
B. Hypocalcemia
C. Hypermagnesemia
D. Hyponatremia
Correct Answer: D
Explanation: In fluid volume excess, particularly in heart failure, the body often retains
water in excess of sodium, leading to dilutional hyponatremia. The clinical manifestations
of weight gain and crackles indicate extracellular fluid expansion. Monitoring serum
sodium levels is critical as rapid changes can lead to neurological complications.
,2. Ms. Rodriguez is scheduled for an elective laparoscopic cholecystectomy. During the
preoperative assessment, she mentions that she takes a daily aspirin for ‘heart health.’ Why
is this information significant for the surgical team?
A. Aspirin inhibits platelet aggregation and increases the risk of bleeding.
B. Aspirin can interact negatively with general anesthesia.
C. Aspirin increases the risk of postoperative infection.
D. Aspirin may lead to a sudden drop in blood pressure during induction.
Correct Answer: A
Explanation: Aspirin is an antiplatelet medication that irreversibly inhibits platelet
cyclooxygenase, increasing the risk for intraoperative and postoperative hemorrhage. The
surgeon usually requires patients to discontinue aspirin 7 to 10 days prior to surgery. This
assessment finding requires immediate communication with the surgical team to
determine if the procedure should be delayed.
3. A 45-year-old patient, Mr. Smith, is recovering in the PACU after a total hip replacement.
The nurse notes the patient is drowsy but arousable, has a respiratory rate of 8
breaths/minute, and an oxygen saturation of 88% on room air. What is the nurse’s priority
action?
A. Administer the prescribed PRN dose of naloxone (Narcan).
B. Call the surgeon to report the findings.
C. Apply supplemental oxygen and encourage deep breathing.
,D. Document the findings as a normal postoperative response.
Correct Answer: C
Explanation: The patient is showing signs of respiratory depression, likely due to
anesthesia or opioids, but is still arousable. The first step is to support oxygenation and
stimulate the patient to breathe more deeply. If the patient’s status does not improve or
worsens, pharmacological reversal with naloxone may be indicated.
4. The nurse is caring for a patient who has just returned from the operating room. The
patient has a large surgical wound closed with staples. The nurse observes that the wound
edges are slightly reddened and the patient has a low-grade fever of 100.2°F (37.9°C). How
should the nurse interpret these findings during the first 24 hours post-surgery?
A. These are early signs of a surgical site infection.
B. The patient is likely developing pneumonia.
C. These findings are typical of the normal inflammatory response.
D. These signs indicate the patient is experiencing a wound dehiscence.
Correct Answer: C
Explanation: A low-grade fever and mild redness at the incision site within the first 24 to
48 hours postoperatively are expected components of the inflammatory phase of wound
healing. Inflammation is the body’s natural response to surgical trauma and is necessary
for tissue repair. The nurse should continue to monitor for worsening signs, but these
initial findings are not indicative of infection at this stage.
, 5. Mrs. Bennett is admitted with severe vomiting for three days. Her arterial blood gas (ABG)
results are: pH 7.49, PaCO2 48 mmHg, and HCO3 30 mEq/L. Which acid-base imbalance is the
patient experiencing?
A. Respiratory Acidosis
B. Respiratory Alkalosis
C. Metabolic Alkalosis
D. Metabolic Acidosis
Correct Answer: C
Explanation: Severe vomiting leads to the loss of gastric acid (hydrochloric acid), resulting
in a high pH and elevated bicarbonate levels. The pH of 7.49 indicates alkalosis, and the
HCO3 of 30 confirms a metabolic origin. The elevated PaCO2 is a compensatory mechanism
by the lungs to retain acid to balance the high pH.
6. The nurse is reviewing the laboratory results of a patient receiving a potassium-wasting
diuretic. The potassium level is 2.8 mEq/L. Which cardiac rhythm change should the nurse
monitor for on the EKG?
A. Presence of U waves
B. Widened QRS complex
C. Peaked T waves
D. Shortened PR interval
