NURS 120 Introduction to Medical-Surgical Nursing - Exam 3 Study
Guide 2026 |WCU
1. A nurse is caring for a client who is 24 hours postoperative following
abdominal surgery. The client reports sudden chest pain and dyspnea. Which of
the following actions should the nurse take first?
A. Apply oxygen and notify the Rapid Response Team
B. Perform an incentive spirometry check
C. Administer the prescribed analgesic
D. Encourage the client to cough and deep breathe
Answer: A
Rationale: Sudden chest pain and dyspnea in a postoperative patient are classic signs of a
pulmonary embolism. Applying oxygen and seeking immediate assistance are priority
actions following the ABC (Airway, Breathing, Circulation) framework.
2. Which of the following electrolyte imbalances is most likely to occur in a
client with prolonged nasogastric suctioning?
A. Hypermagnesemia
B. Hypokalemia
C. Hypernatremia
D. Hypercalcemia
Answer: B
Rationale: Nasogastric suctioning removes gastric secretions, which are rich in potassium,
chloride, and hydrogen ions, leading to hypokalemia and metabolic alkalosis.
,3. A client is diagnosed with respiratory acidosis. Which of the following arterial
blood gas (ABG) results is consistent with this diagnosis?
A. pH 7.48, PaCO2 32 mmHg, HCO3 24 mEq/L
B. pH 7.25, PaCO2 38 mmHg, HCO3 18 mEq/L
C. pH 7.30, PaCO2 55 mmHg, HCO3 26 mEq/L
D. pH 7.50, PaCO2 40 mmHg, HCO3 30 mEq/L
Answer: C
Rationale: Respiratory acidosis is characterized by a low pH (<7.35) and an elevated
PaCO2 (>45 mmHg).
4. The nurse is reviewing the preoperative checklist for a client scheduled for
surgery. Which of the following is the nurse’s primary responsibility regarding
informed consent?
A. Witnessing the client’s signature on the consent form
B. Describing the alternative treatments available
C. Explaining the risks and benefits of the procedure
D. Ensuring the surgeon has discussed the prognosis
Answer: A
Rationale: The nurse’s role is to witness the signature and ensure the client is competent
to sign. The surgeon is responsible for explaining the procedure, risks, and benefits.
5. A client is receiving a blood transfusion and develops chills, fever, and lower
back pain. Which of the following actions should the nurse take first?
A. Slow the infusion rate
B. Stop the transfusion immediately
C. Notify the provider
D. Administer diphenhydramine
Answer: B
, Rationale: These symptoms indicate a possible hemolytic reaction. The immediate priority
is to stop the transfusion to prevent further exposure to the incompatible blood.
6. Which medication is considered the antidote for malignant hyperthermia
during surgery?
A. Atropine
B. Protamine sulfate
C. Naloxone
D. Dantrolene sodium
Answer: D
Rationale: Dantrolene is a muscle relaxant that specifically treats malignant hyperthermia
by inhibiting calcium release from the sarcoplasmic reticulum.
7. A nurse is teaching a client about the use of an incentive spirometer. Which
instruction should the nurse include?
A. Exhale forcefully into the mouthpiece
B. Inhale slowly and deeply to raise the indicator
C. Use the device once every 4 hours
D. Hold your breath for 15 seconds after inhalation
Answer: B
Rationale: Incentive spirometry requires slow, deep inhalations to expand the alveoli and
prevent atelectasis.
8. A client has a potassium level of 6.2 mEq/L. Which of the following ECG
changes should the nurse monitor for?
A. Prominent U waves
B. ST-segment depression
C. Shortened PR interval
D. Tall, peaked T waves
Answer: D
Guide 2026 |WCU
1. A nurse is caring for a client who is 24 hours postoperative following
abdominal surgery. The client reports sudden chest pain and dyspnea. Which of
the following actions should the nurse take first?
A. Apply oxygen and notify the Rapid Response Team
B. Perform an incentive spirometry check
C. Administer the prescribed analgesic
D. Encourage the client to cough and deep breathe
Answer: A
Rationale: Sudden chest pain and dyspnea in a postoperative patient are classic signs of a
pulmonary embolism. Applying oxygen and seeking immediate assistance are priority
actions following the ABC (Airway, Breathing, Circulation) framework.
2. Which of the following electrolyte imbalances is most likely to occur in a
client with prolonged nasogastric suctioning?
A. Hypermagnesemia
B. Hypokalemia
C. Hypernatremia
D. Hypercalcemia
Answer: B
Rationale: Nasogastric suctioning removes gastric secretions, which are rich in potassium,
chloride, and hydrogen ions, leading to hypokalemia and metabolic alkalosis.
,3. A client is diagnosed with respiratory acidosis. Which of the following arterial
blood gas (ABG) results is consistent with this diagnosis?
A. pH 7.48, PaCO2 32 mmHg, HCO3 24 mEq/L
B. pH 7.25, PaCO2 38 mmHg, HCO3 18 mEq/L
C. pH 7.30, PaCO2 55 mmHg, HCO3 26 mEq/L
D. pH 7.50, PaCO2 40 mmHg, HCO3 30 mEq/L
Answer: C
Rationale: Respiratory acidosis is characterized by a low pH (<7.35) and an elevated
PaCO2 (>45 mmHg).
4. The nurse is reviewing the preoperative checklist for a client scheduled for
surgery. Which of the following is the nurse’s primary responsibility regarding
informed consent?
A. Witnessing the client’s signature on the consent form
B. Describing the alternative treatments available
C. Explaining the risks and benefits of the procedure
D. Ensuring the surgeon has discussed the prognosis
Answer: A
Rationale: The nurse’s role is to witness the signature and ensure the client is competent
to sign. The surgeon is responsible for explaining the procedure, risks, and benefits.
5. A client is receiving a blood transfusion and develops chills, fever, and lower
back pain. Which of the following actions should the nurse take first?
A. Slow the infusion rate
B. Stop the transfusion immediately
C. Notify the provider
D. Administer diphenhydramine
Answer: B
, Rationale: These symptoms indicate a possible hemolytic reaction. The immediate priority
is to stop the transfusion to prevent further exposure to the incompatible blood.
6. Which medication is considered the antidote for malignant hyperthermia
during surgery?
A. Atropine
B. Protamine sulfate
C. Naloxone
D. Dantrolene sodium
Answer: D
Rationale: Dantrolene is a muscle relaxant that specifically treats malignant hyperthermia
by inhibiting calcium release from the sarcoplasmic reticulum.
7. A nurse is teaching a client about the use of an incentive spirometer. Which
instruction should the nurse include?
A. Exhale forcefully into the mouthpiece
B. Inhale slowly and deeply to raise the indicator
C. Use the device once every 4 hours
D. Hold your breath for 15 seconds after inhalation
Answer: B
Rationale: Incentive spirometry requires slow, deep inhalations to expand the alveoli and
prevent atelectasis.
8. A client has a potassium level of 6.2 mEq/L. Which of the following ECG
changes should the nurse monitor for?
A. Prominent U waves
B. ST-segment depression
C. Shortened PR interval
D. Tall, peaked T waves
Answer: D
