NUR 170 Exam 1 V3 | NUR 170 Medical-Surgical Nursing | Actual Q&A
with Rationale (NUR 170 Exam 1) | Galen
1. A 65-year-old male patient is admitted with a potassium level of 6.2 mEq/L. The nurse
notes tall, peaked T-waves on the ECG. Which medication should the nurse anticipate
administering first to protect the heart from the effects of hyperkalemia?
A. Calcium Gluconate
B. Sodium Polystyrene Sulfonate (Kayexalate)
C. Furosemide (Lasix)
D. Regular Insulin and 50% Dextrose
Answer: A
Rationale: Calcium gluconate is administered in emergency hyperkalemia to stabilize the
myocardial cell membrane and prevent life-threatening arrhythmias. While insulin and
Kayexalate help lower potassium levels, they do not provide immediate cardiac protection.
The nurse must prioritize stabilizing the heart before focusing on lowering the serum
potassium concentration.
2. A patient is 12 hours postoperative following an abdominal hysterectomy. The nurse notes
that the patient’s heart rate has increased to 110 bpm and their blood pressure has dropped
from 130/80 to 98/60 mmHg. What is the nurse’s priority action?
A. Increase the IV fluid rate according to standing orders.
B. Re-evaluate the vital signs in 30 minutes.
C. Administer a PRN dose of pain medication.
D. Check the surgical dressing and hemovac drain for excessive drainage.
Answer: D
Rationale: Tachycardia and hypotension are early clinical manifestations of hypovolemic
shock, which may indicate internal or external postoperative hemorrhage. The nurse
should immediately assess the surgical site and drains to identify the source of bleeding.
Timely assessment allows the nurse to provide objective data when notifying the surgeon
of a potential complication.
3. An arterial blood gas (ABG) report for a patient with chronic obstructive pulmonary disease
(COPD) shows: pH 7.31, PaCO2 58 mmHg, and HCO3 26 mEq/L. How should the nurse
interpret these findings?
A. Respiratory Acidosis
B. Respiratory Alkalosis
,C. Metabolic Acidosis
D. Metabolic Alkalosis
Answer: A
Rationale: The pH of 7.31 is below the normal range (7.35-7.45), indicating acidosis. The
PaCO2 is elevated at 58 mmHg (normal 35-45), which corresponds with the acidic pH,
defining the condition as respiratory acidosis. The bicarbonate level is within normal limits,
suggesting that renal compensation has not yet occurred or is incomplete.
4. The nurse is providing education to a client with a new diagnosis of HIV. The client asks
what a CD4+ T-cell count of 180 cells/mm3 means. Which response by the nurse is most
accurate?
A. You are currently in the asymptomatic stage of HIV infection.
B. This count indicates that you have progressed to Stage 3 (AIDS).
C. Your immune system is functioning well enough to fight most infections.
D. This count suggests you are experiencing a temporary viral surge.
Answer: B
Rationale: According to the CDC classification, an individual with HIV infection is
considered to have progressed to Stage 3 (AIDS) when the CD4+ T-cell count drops below
200 cells/mm3. At this stage, the client is at significant risk for opportunistic infections and
requires aggressive medical management. The nurse must provide support while
emphasizing the importance of antiretroviral therapy (ART) adherence.
5. A nurse is preparing a patient for elective surgery. The patient states, ‘I still don’t really
understand why they need to remove my gallbladder.’ What is the most appropriate nursing
action?
A. Explain the surgical procedure and the benefits of the surgery to the patient.
B. Ask the patient to sign the consent form and then call the surgeon.
C. Notify the surgeon that the patient needs further clarification before signing the consent.
D. Reassure the patient that the surgeon is highly skilled and there is nothing to worry
about.
Answer: C
Rationale: It is the surgeon’s legal responsibility to provide informed consent, which
includes explaining the procedure, risks, and benefits. The nurse’s role is to witness the
signature and advocate for the patient if they demonstrate a lack of understanding. If the
patient expresses confusion, the nurse must halt the process and ensure the surgeon
speaks with the patient again.
, 6. A patient is admitted with severe vomiting and diarrhea for three days. The nurse notes
poor skin turgor, dry mucous membranes, and a heart rate of 105 bpm. Which IV fluid does
the nurse anticipate the provider will order initially?
A. 0.45% Sodium Chloride
B. 3% Sodium Chloride
C. 0.9% Sodium Chloride
D. Dextrose 5% in Water (D5W)
Answer: C
Rationale: The patient is exhibiting signs of isotonic fluid volume deficit (hypovolemia).
0.9% Sodium Chloride (Normal Saline) is an isotonic crystalloid that stays within the
intravascular space to expand volume and improve blood pressure. Initial resuscitation in
hypovolemia requires isotonic solutions to restore perfusion quickly.
7. The nurse is assessing a patient with a history of chronic alcoholism who presents with
muscle tremors and a positive Chvostek’s sign. Which electrolyte imbalance should the nurse
suspect?
A. Hypercalcemia
B. Hypokalemia
C. Hypernatremia
D. Hypomagnesemia
Answer: D
Rationale: Hypomagnesemia is common in chronic alcoholism due to poor dietary intake
and increased renal excretion. Clinical manifestations include neuromuscular irritability,
such as tremors, tetany, and positive Chvostek’s or Trousseau’s signs. Because magnesium
and calcium levels often follow each other, hypomagnesemia can also lead to secondary
hypocalcemia.
8. During a pre-operative assessment, a patient reports an allergy to bananas and avocados.
Which action is most important for the nurse to take?
A. Document the food allergies in the patient’s medical record only.
B. Inform the dietitian to avoid these fruits in the patient’s meals.
C. Notify the surgical team and ensure a latex-free environment.
D. Ask the patient if they have ever had a reaction to elastic bandages.
Answer: C
with Rationale (NUR 170 Exam 1) | Galen
1. A 65-year-old male patient is admitted with a potassium level of 6.2 mEq/L. The nurse
notes tall, peaked T-waves on the ECG. Which medication should the nurse anticipate
administering first to protect the heart from the effects of hyperkalemia?
A. Calcium Gluconate
B. Sodium Polystyrene Sulfonate (Kayexalate)
C. Furosemide (Lasix)
D. Regular Insulin and 50% Dextrose
Answer: A
Rationale: Calcium gluconate is administered in emergency hyperkalemia to stabilize the
myocardial cell membrane and prevent life-threatening arrhythmias. While insulin and
Kayexalate help lower potassium levels, they do not provide immediate cardiac protection.
The nurse must prioritize stabilizing the heart before focusing on lowering the serum
potassium concentration.
2. A patient is 12 hours postoperative following an abdominal hysterectomy. The nurse notes
that the patient’s heart rate has increased to 110 bpm and their blood pressure has dropped
from 130/80 to 98/60 mmHg. What is the nurse’s priority action?
A. Increase the IV fluid rate according to standing orders.
B. Re-evaluate the vital signs in 30 minutes.
C. Administer a PRN dose of pain medication.
D. Check the surgical dressing and hemovac drain for excessive drainage.
Answer: D
Rationale: Tachycardia and hypotension are early clinical manifestations of hypovolemic
shock, which may indicate internal or external postoperative hemorrhage. The nurse
should immediately assess the surgical site and drains to identify the source of bleeding.
Timely assessment allows the nurse to provide objective data when notifying the surgeon
of a potential complication.
3. An arterial blood gas (ABG) report for a patient with chronic obstructive pulmonary disease
(COPD) shows: pH 7.31, PaCO2 58 mmHg, and HCO3 26 mEq/L. How should the nurse
interpret these findings?
A. Respiratory Acidosis
B. Respiratory Alkalosis
,C. Metabolic Acidosis
D. Metabolic Alkalosis
Answer: A
Rationale: The pH of 7.31 is below the normal range (7.35-7.45), indicating acidosis. The
PaCO2 is elevated at 58 mmHg (normal 35-45), which corresponds with the acidic pH,
defining the condition as respiratory acidosis. The bicarbonate level is within normal limits,
suggesting that renal compensation has not yet occurred or is incomplete.
4. The nurse is providing education to a client with a new diagnosis of HIV. The client asks
what a CD4+ T-cell count of 180 cells/mm3 means. Which response by the nurse is most
accurate?
A. You are currently in the asymptomatic stage of HIV infection.
B. This count indicates that you have progressed to Stage 3 (AIDS).
C. Your immune system is functioning well enough to fight most infections.
D. This count suggests you are experiencing a temporary viral surge.
Answer: B
Rationale: According to the CDC classification, an individual with HIV infection is
considered to have progressed to Stage 3 (AIDS) when the CD4+ T-cell count drops below
200 cells/mm3. At this stage, the client is at significant risk for opportunistic infections and
requires aggressive medical management. The nurse must provide support while
emphasizing the importance of antiretroviral therapy (ART) adherence.
5. A nurse is preparing a patient for elective surgery. The patient states, ‘I still don’t really
understand why they need to remove my gallbladder.’ What is the most appropriate nursing
action?
A. Explain the surgical procedure and the benefits of the surgery to the patient.
B. Ask the patient to sign the consent form and then call the surgeon.
C. Notify the surgeon that the patient needs further clarification before signing the consent.
D. Reassure the patient that the surgeon is highly skilled and there is nothing to worry
about.
Answer: C
Rationale: It is the surgeon’s legal responsibility to provide informed consent, which
includes explaining the procedure, risks, and benefits. The nurse’s role is to witness the
signature and advocate for the patient if they demonstrate a lack of understanding. If the
patient expresses confusion, the nurse must halt the process and ensure the surgeon
speaks with the patient again.
, 6. A patient is admitted with severe vomiting and diarrhea for three days. The nurse notes
poor skin turgor, dry mucous membranes, and a heart rate of 105 bpm. Which IV fluid does
the nurse anticipate the provider will order initially?
A. 0.45% Sodium Chloride
B. 3% Sodium Chloride
C. 0.9% Sodium Chloride
D. Dextrose 5% in Water (D5W)
Answer: C
Rationale: The patient is exhibiting signs of isotonic fluid volume deficit (hypovolemia).
0.9% Sodium Chloride (Normal Saline) is an isotonic crystalloid that stays within the
intravascular space to expand volume and improve blood pressure. Initial resuscitation in
hypovolemia requires isotonic solutions to restore perfusion quickly.
7. The nurse is assessing a patient with a history of chronic alcoholism who presents with
muscle tremors and a positive Chvostek’s sign. Which electrolyte imbalance should the nurse
suspect?
A. Hypercalcemia
B. Hypokalemia
C. Hypernatremia
D. Hypomagnesemia
Answer: D
Rationale: Hypomagnesemia is common in chronic alcoholism due to poor dietary intake
and increased renal excretion. Clinical manifestations include neuromuscular irritability,
such as tremors, tetany, and positive Chvostek’s or Trousseau’s signs. Because magnesium
and calcium levels often follow each other, hypomagnesemia can also lead to secondary
hypocalcemia.
8. During a pre-operative assessment, a patient reports an allergy to bananas and avocados.
Which action is most important for the nurse to take?
A. Document the food allergies in the patient’s medical record only.
B. Inform the dietitian to avoid these fruits in the patient’s meals.
C. Notify the surgical team and ensure a latex-free environment.
D. Ask the patient if they have ever had a reaction to elastic bandages.
Answer: C
