NUR 170 Exam 1 V1 | NUR 170 Medical-Surgical Nursing | Actual Q&A
with Rationale (NUR 170 Exam 1) | Galen
1. A 65-year-old male patient with a history of COPD is admitted to the medical unit. His
arterial blood gas (ABG) results are: pH 7.31, PaCO2 55 mm Hg, and HCO3 26 mEq/L. The
nurse interprets these findings as which of the following?
A. Respiratory acidosis, uncompensated
B. Metabolic acidosis, partially compensated
C. Respiratory alkalosis, uncompensated
D. Metabolic alkalosis, fully compensated
Answer: A
Rationale: The pH is 7.31, which is below the normal range of 7.35 to 7.45, indicating
acidosis. The PaCO2 is 55 mm Hg, which is above the normal range of 35 to 45 mm Hg,
identifying the cause as respiratory. Because the HCO3 is within the normal range, the
kidneys have not yet begun to compensate for the respiratory imbalance.
2. Mr. Thompson, a 72-year-old patient, is receiving IV furosemide for heart failure. He
reports new onset of muscle weakness and leg cramps. The nurse should prioritize assessing
for which electrolyte imbalance?
A. Hypokalemia
B. Hyperkalemia
C. Hypernatremia
D. Hypocalcemia
Answer: A
Rationale: Furosemide is a loop diuretic that promotes the excretion of potassium in the
urine, leading to potential hypokalemia. Muscle weakness and leg cramps are classic
clinical manifestations of low potassium levels. The nurse must monitor the patient’s
potassium levels and cardiac rhythm, as hypokalemia can lead to lethal dysrhythmias.
3. A nurse is caring for a postoperative patient who has just returned from a total hip
arthroplasty. Which assessment finding would be most indicative of an early sign of
hypovolemic shock?
A. Decreased urine output to 20 mL/hr
B. Increased heart rate and restlessness
C. Bradycardia and hypertension
,D. Warm, flushed skin and bounding pulses
Answer: B
Rationale: In the early stages of hypovolemic shock, the body attempts to compensate for
decreased circulating volume by increasing the heart rate (tachycardia). Restlessness and
agitation are also early signs of decreased cerebral perfusion. Later signs include
hypotension and significantly decreased urine output as the body’s compensatory
mechanisms fail.
4. While assessing a patient with a history of alcohol abuse, the nurse notes a positive
Chvostek’s sign. Which laboratory value should the nurse expect to find?
A. Calcium 10.5 mg/dL
B. Magnesium 1.2 mg/dL
C. Potassium 5.2 mEq/L
D. Sodium 130 mEq/L
Answer: B
Rationale: A positive Chvostek’s sign, which is a contraction of facial muscles in response
to tapping the facial nerve, is a classic sign of hypocalcemia or hypomagnesemia. Alcohol
abuse is a common cause of hypomagnesemia due to poor intake and increased renal
excretion. Low magnesium levels often occur concurrently with low calcium levels, both of
which increase neuromuscular excitability.
5. A patient is scheduled for an elective cholecystectomy. The nurse is verifying the informed
consent. Which of the following best describes the nurse’s primary responsibility in this
process?
A. Explaining the risks and benefits of the surgical procedure
B. Ensuring the patient has been informed and witnessing the signature
C. Determining if the patient understands all surgical alternatives
D. Obtaining the signature when the surgeon is unavailable
Answer: B
Rationale: The nurse’s role in informed consent is to act as a witness to the patient’s
signature and to ensure the patient appears competent to provide consent. The primary
responsibility for explaining the procedure, risks, and alternatives lies solely with the
surgeon. If the nurse discovers the patient does not understand the procedure, the surgeon
must be notified to provide further education before the surgery proceeds.
6. A patient with chronic kidney disease presents with a potassium level of 6.4 mEq/L. Which
EKG change is most characteristic of this condition?
A. Prominent U waves
, B. Tall, peaked T waves
C. Prolonged ST segment
D. Shortened PR interval
Answer: B
Rationale: Hyperkalemia, defined as a potassium level above 5.0 mEq/L, significantly
affects cardiac conduction and can lead to dangerous arrhythmias. Tall, peaked T waves are
one of the earliest and most diagnostic EKG changes seen in patients with elevated
potassium. As levels continue to rise, the QRS complex widens and the P wave may flatten
or disappear, potentially leading to ventricular fibrillation.
7. The nurse is assessing a surgical wound that is healing by secondary intention. Which
description best characterizes this type of wound healing?
A. The wound edges are neatly approximated with sutures.
B. The wound is closed several days after the initial injury due to infection.
C. The wound is left open to heal from the bottom up with granulation tissue.
D. Healing occurs rapidly with minimal scarring and no tissue loss.
Answer: C
Rationale: Secondary intention occurs when a wound has significant tissue loss or is
contaminated, preventing the edges from being approximated. The wound is left open and
fills with granulation tissue, which eventually forms a larger scar than primary intention.
This process takes longer and carries a higher risk of infection compared to primary
closure.
8. A 45-year-old patient is 2 hours postoperative from abdominal surgery. The nurse notes
that the patient’s respiratory rate is 10 breaths per minute and they are difficult to arouse.
Which medication should the nurse anticipate administering?
A. Flumazenil
B. Protamine sulfate
C. Naloxone
D. Vitamin K
Answer: C
Rationale: Postoperative respiratory depression is a frequent complication of opioid
administration during and after surgery. Naloxone is a short-acting opioid antagonist used
to reverse the effects of narcotics such as morphine or fentanyl. The nurse must monitor
the patient closely after administration because the half-life of naloxone is often shorter
than the opioid being reversed, potentially leading to recurrent depression.
with Rationale (NUR 170 Exam 1) | Galen
1. A 65-year-old male patient with a history of COPD is admitted to the medical unit. His
arterial blood gas (ABG) results are: pH 7.31, PaCO2 55 mm Hg, and HCO3 26 mEq/L. The
nurse interprets these findings as which of the following?
A. Respiratory acidosis, uncompensated
B. Metabolic acidosis, partially compensated
C. Respiratory alkalosis, uncompensated
D. Metabolic alkalosis, fully compensated
Answer: A
Rationale: The pH is 7.31, which is below the normal range of 7.35 to 7.45, indicating
acidosis. The PaCO2 is 55 mm Hg, which is above the normal range of 35 to 45 mm Hg,
identifying the cause as respiratory. Because the HCO3 is within the normal range, the
kidneys have not yet begun to compensate for the respiratory imbalance.
2. Mr. Thompson, a 72-year-old patient, is receiving IV furosemide for heart failure. He
reports new onset of muscle weakness and leg cramps. The nurse should prioritize assessing
for which electrolyte imbalance?
A. Hypokalemia
B. Hyperkalemia
C. Hypernatremia
D. Hypocalcemia
Answer: A
Rationale: Furosemide is a loop diuretic that promotes the excretion of potassium in the
urine, leading to potential hypokalemia. Muscle weakness and leg cramps are classic
clinical manifestations of low potassium levels. The nurse must monitor the patient’s
potassium levels and cardiac rhythm, as hypokalemia can lead to lethal dysrhythmias.
3. A nurse is caring for a postoperative patient who has just returned from a total hip
arthroplasty. Which assessment finding would be most indicative of an early sign of
hypovolemic shock?
A. Decreased urine output to 20 mL/hr
B. Increased heart rate and restlessness
C. Bradycardia and hypertension
,D. Warm, flushed skin and bounding pulses
Answer: B
Rationale: In the early stages of hypovolemic shock, the body attempts to compensate for
decreased circulating volume by increasing the heart rate (tachycardia). Restlessness and
agitation are also early signs of decreased cerebral perfusion. Later signs include
hypotension and significantly decreased urine output as the body’s compensatory
mechanisms fail.
4. While assessing a patient with a history of alcohol abuse, the nurse notes a positive
Chvostek’s sign. Which laboratory value should the nurse expect to find?
A. Calcium 10.5 mg/dL
B. Magnesium 1.2 mg/dL
C. Potassium 5.2 mEq/L
D. Sodium 130 mEq/L
Answer: B
Rationale: A positive Chvostek’s sign, which is a contraction of facial muscles in response
to tapping the facial nerve, is a classic sign of hypocalcemia or hypomagnesemia. Alcohol
abuse is a common cause of hypomagnesemia due to poor intake and increased renal
excretion. Low magnesium levels often occur concurrently with low calcium levels, both of
which increase neuromuscular excitability.
5. A patient is scheduled for an elective cholecystectomy. The nurse is verifying the informed
consent. Which of the following best describes the nurse’s primary responsibility in this
process?
A. Explaining the risks and benefits of the surgical procedure
B. Ensuring the patient has been informed and witnessing the signature
C. Determining if the patient understands all surgical alternatives
D. Obtaining the signature when the surgeon is unavailable
Answer: B
Rationale: The nurse’s role in informed consent is to act as a witness to the patient’s
signature and to ensure the patient appears competent to provide consent. The primary
responsibility for explaining the procedure, risks, and alternatives lies solely with the
surgeon. If the nurse discovers the patient does not understand the procedure, the surgeon
must be notified to provide further education before the surgery proceeds.
6. A patient with chronic kidney disease presents with a potassium level of 6.4 mEq/L. Which
EKG change is most characteristic of this condition?
A. Prominent U waves
, B. Tall, peaked T waves
C. Prolonged ST segment
D. Shortened PR interval
Answer: B
Rationale: Hyperkalemia, defined as a potassium level above 5.0 mEq/L, significantly
affects cardiac conduction and can lead to dangerous arrhythmias. Tall, peaked T waves are
one of the earliest and most diagnostic EKG changes seen in patients with elevated
potassium. As levels continue to rise, the QRS complex widens and the P wave may flatten
or disappear, potentially leading to ventricular fibrillation.
7. The nurse is assessing a surgical wound that is healing by secondary intention. Which
description best characterizes this type of wound healing?
A. The wound edges are neatly approximated with sutures.
B. The wound is closed several days after the initial injury due to infection.
C. The wound is left open to heal from the bottom up with granulation tissue.
D. Healing occurs rapidly with minimal scarring and no tissue loss.
Answer: C
Rationale: Secondary intention occurs when a wound has significant tissue loss or is
contaminated, preventing the edges from being approximated. The wound is left open and
fills with granulation tissue, which eventually forms a larger scar than primary intention.
This process takes longer and carries a higher risk of infection compared to primary
closure.
8. A 45-year-old patient is 2 hours postoperative from abdominal surgery. The nurse notes
that the patient’s respiratory rate is 10 breaths per minute and they are difficult to arouse.
Which medication should the nurse anticipate administering?
A. Flumazenil
B. Protamine sulfate
C. Naloxone
D. Vitamin K
Answer: C
Rationale: Postoperative respiratory depression is a frequent complication of opioid
administration during and after surgery. Naloxone is a short-acting opioid antagonist used
to reverse the effects of narcotics such as morphine or fentanyl. The nurse must monitor
the patient closely after administration because the half-life of naloxone is often shorter
than the opioid being reversed, potentially leading to recurrent depression.
