NU 157 Exam 2 V3 | NU 157 Medical-
Surgical Nursing I-A | NCLEX (NGN) Q&A
with Rationale (NU157 Exam 2) | Galen
1. A nurse is assessing a patient who is 6 hours postoperative following abdominal surgery.
Which of the following findings should the nurse prioritize as the most immediate concern?
A. Pain level of 6 on a scale of 0 to 10
B. Urine output of 20 mL over the last hour
C. Absent bowel sounds in all four quadrants
D. Serosanguineous drainage on the surgical dressing
Correct Answer: B
Explanation: A urine output of less than 30 mL/hr is a significant finding that may indicate
decreased renal perfusion or hypovolemia, necessitating immediate intervention. While
absent bowel sounds are common shortly after abdominal surgery due to paralytic ileus,
they are not as urgent as potential renal failure or shock. Pain and serosanguineous
drainage are expected findings that require monitoring but do not take precedence over
low urine output.
2. A nurse is caring for a client with a serum potassium level of 2.8 mEq/L. Which of the
following cardiac rhythm changes should the nurse monitor for? (Select all that apply.)
A. Prominent U waves
,B. Inverted T waves
C. ST segment depression
D. Peaked T waves
E. Widened QRS complex
F. Prolonged PR interval
Correct Answer: A,B,C
Explanation: Hypokalemia, defined as a potassium level below 3.5 mEq/L, causes specific
electrocardiogram changes including prominent U waves, T wave inversion, and ST
segment depression. Peaked T waves and a widened QRS complex are classic signs of
hyperkalemia rather than hypokalemia. Nurses must monitor these changes closely as
severe hypokalemia can lead to lethal arrhythmias.
3. A patient is scheduled for an elective surgery. During the preoperative assessment, the
patient states, ‘I am not really sure what the surgeon is going to do during the procedure.’
Which action should the nurse take?
A. Notify the surgeon that the patient needs further clarification
B. Explain the surgical procedure to the patient in detail
C. Proceed with the preoperative checklist as the consent is already signed
D. Ask the patient’s spouse to explain the procedure to the patient
Correct Answer: A
,Explanation: The nurse’s role in informed consent is to witness the signature and ensure
the patient is competent; however, the surgeon is responsible for providing the explanation
of the procedure. If the patient expresses a lack of understanding, the nurse must advocate
for the patient by notifying the surgeon to provide more information. The nurse should not
explain the procedure themselves, as this is outside the nursing scope of practice regarding
surgical consent.
4. Which of the following interventions is the priority for a nurse when a patient exhibits
signs of Malignant Hyperthermia during general anesthesia?
A. Apply cooling blankets to the patient’s skin
B. Administer intravenous dantrolene sodium
C. Administer 100% oxygen via a non-rebreather mask
D. Increase the concentration of the anesthetic gas
Correct Answer: B
Explanation: Dantrolene sodium is the specific skeletal muscle relaxant used to treat
Malignant Hyperthermia by inhibiting calcium release from the sarcoplasmic reticulum.
While oxygenation and cooling are important supportive measures, they do not treat the
underlying pathophysiology of the crisis. Increasing anesthetic gas would worsen the
condition as these gases are often the triggering agents.
, 5. A nurse is assessing a patient with a suspected fluid volume deficit. Which of the following
clinical manifestations should the nurse expect? (Select all that apply.)
A. Orthostatic hypotension
B. Increased skin turgor
C. Flat neck veins when supine
D. Tachycardia
E. Decreased urine specific gravity
Correct Answer: A,C,D
Explanation: Fluid volume deficit typically presents with orthostatic hypotension, flat neck
veins, and a rapid heart rate (tachycardia) as the body compensates for low circulating
volume. Decreased skin turgor (tenting) rather than increased turgor is a classic sign of
dehydration. Urine specific gravity would typically be increased in this scenario as the
kidneys attempt to conserve water.
6. A client’s arterial blood gas (ABG) results are: pH 7.31, PaCO2 50 mmHg, and HCO3 24
mEq/L. The nurse interprets these results as which of the following?
A. Metabolic acidosis
B. Respiratory alkalosis
C. Metabolic alkalosis
D. Respiratory acidosis
Surgical Nursing I-A | NCLEX (NGN) Q&A
with Rationale (NU157 Exam 2) | Galen
1. A nurse is assessing a patient who is 6 hours postoperative following abdominal surgery.
Which of the following findings should the nurse prioritize as the most immediate concern?
A. Pain level of 6 on a scale of 0 to 10
B. Urine output of 20 mL over the last hour
C. Absent bowel sounds in all four quadrants
D. Serosanguineous drainage on the surgical dressing
Correct Answer: B
Explanation: A urine output of less than 30 mL/hr is a significant finding that may indicate
decreased renal perfusion or hypovolemia, necessitating immediate intervention. While
absent bowel sounds are common shortly after abdominal surgery due to paralytic ileus,
they are not as urgent as potential renal failure or shock. Pain and serosanguineous
drainage are expected findings that require monitoring but do not take precedence over
low urine output.
2. A nurse is caring for a client with a serum potassium level of 2.8 mEq/L. Which of the
following cardiac rhythm changes should the nurse monitor for? (Select all that apply.)
A. Prominent U waves
,B. Inverted T waves
C. ST segment depression
D. Peaked T waves
E. Widened QRS complex
F. Prolonged PR interval
Correct Answer: A,B,C
Explanation: Hypokalemia, defined as a potassium level below 3.5 mEq/L, causes specific
electrocardiogram changes including prominent U waves, T wave inversion, and ST
segment depression. Peaked T waves and a widened QRS complex are classic signs of
hyperkalemia rather than hypokalemia. Nurses must monitor these changes closely as
severe hypokalemia can lead to lethal arrhythmias.
3. A patient is scheduled for an elective surgery. During the preoperative assessment, the
patient states, ‘I am not really sure what the surgeon is going to do during the procedure.’
Which action should the nurse take?
A. Notify the surgeon that the patient needs further clarification
B. Explain the surgical procedure to the patient in detail
C. Proceed with the preoperative checklist as the consent is already signed
D. Ask the patient’s spouse to explain the procedure to the patient
Correct Answer: A
,Explanation: The nurse’s role in informed consent is to witness the signature and ensure
the patient is competent; however, the surgeon is responsible for providing the explanation
of the procedure. If the patient expresses a lack of understanding, the nurse must advocate
for the patient by notifying the surgeon to provide more information. The nurse should not
explain the procedure themselves, as this is outside the nursing scope of practice regarding
surgical consent.
4. Which of the following interventions is the priority for a nurse when a patient exhibits
signs of Malignant Hyperthermia during general anesthesia?
A. Apply cooling blankets to the patient’s skin
B. Administer intravenous dantrolene sodium
C. Administer 100% oxygen via a non-rebreather mask
D. Increase the concentration of the anesthetic gas
Correct Answer: B
Explanation: Dantrolene sodium is the specific skeletal muscle relaxant used to treat
Malignant Hyperthermia by inhibiting calcium release from the sarcoplasmic reticulum.
While oxygenation and cooling are important supportive measures, they do not treat the
underlying pathophysiology of the crisis. Increasing anesthetic gas would worsen the
condition as these gases are often the triggering agents.
, 5. A nurse is assessing a patient with a suspected fluid volume deficit. Which of the following
clinical manifestations should the nurse expect? (Select all that apply.)
A. Orthostatic hypotension
B. Increased skin turgor
C. Flat neck veins when supine
D. Tachycardia
E. Decreased urine specific gravity
Correct Answer: A,C,D
Explanation: Fluid volume deficit typically presents with orthostatic hypotension, flat neck
veins, and a rapid heart rate (tachycardia) as the body compensates for low circulating
volume. Decreased skin turgor (tenting) rather than increased turgor is a classic sign of
dehydration. Urine specific gravity would typically be increased in this scenario as the
kidneys attempt to conserve water.
6. A client’s arterial blood gas (ABG) results are: pH 7.31, PaCO2 50 mmHg, and HCO3 24
mEq/L. The nurse interprets these results as which of the following?
A. Metabolic acidosis
B. Respiratory alkalosis
C. Metabolic alkalosis
D. Respiratory acidosis
