NU 186 Exam 1 V1 | NU 186 Medical-
Surgical Nursing II-A | NCLEX (NGN) Q&A
with Rationale (NU186 Exam 1) | Galen
1. A nurse is caring for a patient admitted with metabolic acidosis. Which clinical
manifestations should the nurse expect to observe? (Select all that apply.)
A. Kussmaul respirations
B. Hyperkalemia
C. Headache and confusion
D. Hypertension
E. Warm, flushed skin
Correct Answer: A, B, C, E
Explanation: Metabolic acidosis results in a decreased pH and decreased bicarbonate
levels, often leading to compensatory Kussmaul respirations to expel CO2. Hyperkalemia
occurs as hydrogen ions move into the cells and potassium moves out to maintain electrical
neutrality. Neurological signs such as headache and confusion are common due to the effect
of acidemia on the central nervous system.
,2. The nurse identifies a regular rhythm with a rate of 50 beats/minute, a normal P wave
before every QRS, and a PR interval of 0.16 seconds on the telemetry monitor. If the patient
is symptomatic, which medication should the nurse prepare to administer?
A. Atropine
B. Amiodarone
C. Digoxin
D. Epinephrine
Correct Answer: A
Explanation: The rhythm described is sinus bradycardia because it is regular with a rate
under 60 bpm and normal conduction intervals. Atropine is the first-line drug for
symptomatic bradycardia as it blocks vagal effects on the SA node. The nurse must assess
for symptoms such as hypotension, dizziness, or chest pain before intervention.
3. Which clinical conditions or factors place a patient at high risk for developing respiratory
acidosis? (Select all that apply.)
A. Chronic Obstructive Pulmonary Disease (COPD)
B. Opioid overdose
C. Anxiety-induced hyperventilation
D. Obstructive sleep apnea
E. Severe pneumonia
,F. Chest wall trauma
Correct Answer: A, B, D, E, F
Explanation: Respiratory acidosis is caused by hypoventilation and the subsequent
retention of carbon dioxide. Conditions such as COPD, pneumonia, and chest wall trauma
physically impair gas exchange or ventilation. Opioids suppress the central nervous system
respiratory center, while hyperventilation actually causes respiratory alkalosis by blowing
off too much CO2.
4. A patient on a mechanical ventilator triggers a high-pressure alarm. Which action should
the nurse take first?
A. Assess the patient’s need for suctioning
B. Check for a leak in the ventilator circuit
C. Silence the alarm and wait to see if it recurs
D. Increase the oxygen concentration to 100%
Correct Answer: A
Explanation: High-pressure alarms are triggered by increased resistance in the airway,
which can be caused by secretions, biting the tube, or coughing. Suctioning the patient is a
primary intervention to clear secretions and reduce airway resistance. If suctioning does
not resolve the alarm, the nurse should check for tube kinks or tension pneumothorax.
, 5. A nurse is caring for a patient suspected of having a pulmonary embolism (PE). What is the
priority nursing intervention when the patient suddenly develops dyspnea and chest pain?
A. Obtain an arterial blood gas (ABG) sample
B. Administer morphine for pain control
C. Prepare the patient for a spiral CT scan
D. Elevate the head of the bed and apply oxygen
Correct Answer: D
Explanation: Immediate nursing actions for a suspected PE focus on optimizing
oxygenation and ventilation. Elevating the head of the bed (Fowler’s position) facilitates
lung expansion and reduces the work of breathing. Providing supplemental oxygen helps
combat the hypoxemia resulting from the ventilation-perfusion mismatch.
6. A patient with Chronic Kidney Disease (CKD) has a serum potassium level of 6.8 mEq/L.
Which cardiac monitor finding is the nurse most likely to observe?
A. Prominent U waves
B. ST-segment depression
C. Tall, peaked T waves
D. Shortened PR interval
Correct Answer: C
Surgical Nursing II-A | NCLEX (NGN) Q&A
with Rationale (NU186 Exam 1) | Galen
1. A nurse is caring for a patient admitted with metabolic acidosis. Which clinical
manifestations should the nurse expect to observe? (Select all that apply.)
A. Kussmaul respirations
B. Hyperkalemia
C. Headache and confusion
D. Hypertension
E. Warm, flushed skin
Correct Answer: A, B, C, E
Explanation: Metabolic acidosis results in a decreased pH and decreased bicarbonate
levels, often leading to compensatory Kussmaul respirations to expel CO2. Hyperkalemia
occurs as hydrogen ions move into the cells and potassium moves out to maintain electrical
neutrality. Neurological signs such as headache and confusion are common due to the effect
of acidemia on the central nervous system.
,2. The nurse identifies a regular rhythm with a rate of 50 beats/minute, a normal P wave
before every QRS, and a PR interval of 0.16 seconds on the telemetry monitor. If the patient
is symptomatic, which medication should the nurse prepare to administer?
A. Atropine
B. Amiodarone
C. Digoxin
D. Epinephrine
Correct Answer: A
Explanation: The rhythm described is sinus bradycardia because it is regular with a rate
under 60 bpm and normal conduction intervals. Atropine is the first-line drug for
symptomatic bradycardia as it blocks vagal effects on the SA node. The nurse must assess
for symptoms such as hypotension, dizziness, or chest pain before intervention.
3. Which clinical conditions or factors place a patient at high risk for developing respiratory
acidosis? (Select all that apply.)
A. Chronic Obstructive Pulmonary Disease (COPD)
B. Opioid overdose
C. Anxiety-induced hyperventilation
D. Obstructive sleep apnea
E. Severe pneumonia
,F. Chest wall trauma
Correct Answer: A, B, D, E, F
Explanation: Respiratory acidosis is caused by hypoventilation and the subsequent
retention of carbon dioxide. Conditions such as COPD, pneumonia, and chest wall trauma
physically impair gas exchange or ventilation. Opioids suppress the central nervous system
respiratory center, while hyperventilation actually causes respiratory alkalosis by blowing
off too much CO2.
4. A patient on a mechanical ventilator triggers a high-pressure alarm. Which action should
the nurse take first?
A. Assess the patient’s need for suctioning
B. Check for a leak in the ventilator circuit
C. Silence the alarm and wait to see if it recurs
D. Increase the oxygen concentration to 100%
Correct Answer: A
Explanation: High-pressure alarms are triggered by increased resistance in the airway,
which can be caused by secretions, biting the tube, or coughing. Suctioning the patient is a
primary intervention to clear secretions and reduce airway resistance. If suctioning does
not resolve the alarm, the nurse should check for tube kinks or tension pneumothorax.
, 5. A nurse is caring for a patient suspected of having a pulmonary embolism (PE). What is the
priority nursing intervention when the patient suddenly develops dyspnea and chest pain?
A. Obtain an arterial blood gas (ABG) sample
B. Administer morphine for pain control
C. Prepare the patient for a spiral CT scan
D. Elevate the head of the bed and apply oxygen
Correct Answer: D
Explanation: Immediate nursing actions for a suspected PE focus on optimizing
oxygenation and ventilation. Elevating the head of the bed (Fowler’s position) facilitates
lung expansion and reduces the work of breathing. Providing supplemental oxygen helps
combat the hypoxemia resulting from the ventilation-perfusion mismatch.
6. A patient with Chronic Kidney Disease (CKD) has a serum potassium level of 6.8 mEq/L.
Which cardiac monitor finding is the nurse most likely to observe?
A. Prominent U waves
B. ST-segment depression
C. Tall, peaked T waves
D. Shortened PR interval
Correct Answer: C
