NURS 201 Medical-Surgical Nursing Exam 2 Study Guide 2026 |WCU
1. A patient presents with a pH of 7.28, PaCO2 of 52 mmHg, and HCO3 of 25
mEq/L. Which clinical condition should the nurse prioritize?
A. Metabolic Acidosis
B. Respiratory Acidosis
C. Metabolic Alkalosis
D. Respiratory Alkalosis
Answer: B
Rationale: The pH is below 7.35 (acidosis) and the PaCO2 is elevated (above 45),
indicating a respiratory cause with no compensation from the bicarbonate yet.
2. When caring for a patient with a potassium level of 6.2 mEq/L, which
intervention is the nurse’s immediate priority?
A. Administering sodium polystyrene sulfonate (Kayexalate)
B. Placing the patient on a continuous cardiac monitor
C. Encouraging increased fluid intake
D. Checking the patient’s urine output
Answer: B
Rationale: Hyperkalemia (K+ > 5.0) can cause life-threatening cardiac dysrhythmias;
monitoring cardiac rhythm is the first priority to ensure safety.
,3. A post-operative patient reports sudden shortness of breath and chest pain.
Which complication should the nurse suspect first?
A. Pneumonia
B. Atelectasis
C. Pulmonary Embolism
D. Myocardial Infarction
Answer: C
Rationale: Sudden onset of dyspnea and chest pain in a post-op patient is a classic sign of a
pulmonary embolism, which is a medical emergency.
4. Which assessment finding in a patient with right-sided heart failure should
the nurse document as a systemic manifestation?
A. Crackles in the lungs
B. Frothy pink-tinged sputum
C. Paroxysmal nocturnal dyspnea
D. Peripheral edema and jugular venous distention
Answer: D
Rationale: Right-sided heart failure causes blood to back up into the systemic circulation,
leading to peripheral edema, hepatomegaly, and JVD.
5. A patient with COPD is receiving oxygen at 2L/min via nasal cannula. The
nurse notes the SpO2 is 89%. What is the most appropriate action?
A. Document the finding as normal for this patient
B. Increase the oxygen flow to 6L/min immediately
C. Change the delivery device to a non-rebreather mask
D. Assess the patient for signs of respiratory distress and notify the provider
Answer: A
Rationale: For many COPD patients, a target SpO2 of 88-92% is acceptable because high
oxygen levels can suppress their hypoxic drive to breathe.
, 6. Which laboratory value is most critical for the nurse to monitor in a patient
receiving an ACE inhibitor for hypertension?
A. Serum Glucose
B. Serum Magnesium
C. Serum Calcium
D. Serum Potassium
Answer: D
Rationale: ACE inhibitors can cause potassium retention, leading to hyperkalemia;
therefore, monitoring serum potassium is essential.
7. During a blood transfusion, the patient complains of lower back pain and
chills. What is the nurse’s first action?
A. Slow the infusion rate
B. Check the patient’s temperature
C. Stop the transfusion immediately
D. Administer diphenhydramine
Answer: C
Rationale: Back pain and chills are signs of a hemolytic transfusion reaction; the infusion
must be stopped immediately to prevent further harm.
8. A nurse is preparing to administer Digoxin. Which finding would require the
nurse to withhold the medication?
A. Apical pulse of 52 beats per minute
B. Potassium level of 4.8 mEq/L
C. Blood pressure of 110/70 mmHg
D. Respiratory rate of 16 breaths per minute
Answer: A
Rationale: Digoxin should be withheld if the apical pulse is less than 60 bpm in an adult to
avoid further bradycardia.
1. A patient presents with a pH of 7.28, PaCO2 of 52 mmHg, and HCO3 of 25
mEq/L. Which clinical condition should the nurse prioritize?
A. Metabolic Acidosis
B. Respiratory Acidosis
C. Metabolic Alkalosis
D. Respiratory Alkalosis
Answer: B
Rationale: The pH is below 7.35 (acidosis) and the PaCO2 is elevated (above 45),
indicating a respiratory cause with no compensation from the bicarbonate yet.
2. When caring for a patient with a potassium level of 6.2 mEq/L, which
intervention is the nurse’s immediate priority?
A. Administering sodium polystyrene sulfonate (Kayexalate)
B. Placing the patient on a continuous cardiac monitor
C. Encouraging increased fluid intake
D. Checking the patient’s urine output
Answer: B
Rationale: Hyperkalemia (K+ > 5.0) can cause life-threatening cardiac dysrhythmias;
monitoring cardiac rhythm is the first priority to ensure safety.
,3. A post-operative patient reports sudden shortness of breath and chest pain.
Which complication should the nurse suspect first?
A. Pneumonia
B. Atelectasis
C. Pulmonary Embolism
D. Myocardial Infarction
Answer: C
Rationale: Sudden onset of dyspnea and chest pain in a post-op patient is a classic sign of a
pulmonary embolism, which is a medical emergency.
4. Which assessment finding in a patient with right-sided heart failure should
the nurse document as a systemic manifestation?
A. Crackles in the lungs
B. Frothy pink-tinged sputum
C. Paroxysmal nocturnal dyspnea
D. Peripheral edema and jugular venous distention
Answer: D
Rationale: Right-sided heart failure causes blood to back up into the systemic circulation,
leading to peripheral edema, hepatomegaly, and JVD.
5. A patient with COPD is receiving oxygen at 2L/min via nasal cannula. The
nurse notes the SpO2 is 89%. What is the most appropriate action?
A. Document the finding as normal for this patient
B. Increase the oxygen flow to 6L/min immediately
C. Change the delivery device to a non-rebreather mask
D. Assess the patient for signs of respiratory distress and notify the provider
Answer: A
Rationale: For many COPD patients, a target SpO2 of 88-92% is acceptable because high
oxygen levels can suppress their hypoxic drive to breathe.
, 6. Which laboratory value is most critical for the nurse to monitor in a patient
receiving an ACE inhibitor for hypertension?
A. Serum Glucose
B. Serum Magnesium
C. Serum Calcium
D. Serum Potassium
Answer: D
Rationale: ACE inhibitors can cause potassium retention, leading to hyperkalemia;
therefore, monitoring serum potassium is essential.
7. During a blood transfusion, the patient complains of lower back pain and
chills. What is the nurse’s first action?
A. Slow the infusion rate
B. Check the patient’s temperature
C. Stop the transfusion immediately
D. Administer diphenhydramine
Answer: C
Rationale: Back pain and chills are signs of a hemolytic transfusion reaction; the infusion
must be stopped immediately to prevent further harm.
8. A nurse is preparing to administer Digoxin. Which finding would require the
nurse to withhold the medication?
A. Apical pulse of 52 beats per minute
B. Potassium level of 4.8 mEq/L
C. Blood pressure of 110/70 mmHg
D. Respiratory rate of 16 breaths per minute
Answer: A
Rationale: Digoxin should be withheld if the apical pulse is less than 60 bpm in an adult to
avoid further bradycardia.
