NU 192 Exam 3 V3 | NU 192 Medical-
Surgical Nursing II-B | NCLEX (NGN) Q&A
with Rationale (NU192 Exam 3) | Galen
1. A nurse is caring for a client who is in the compensatory stage of shock. Which clinical
findings should the nurse expect? Select all that apply.
A. Heart rate greater than 100 bpm
B. Respiratory rate greater than 20 breaths/min
C. Cold, clammy skin
D. Urinary output less than 30 mL/hr
E. Narrowed pulse pressure
Correct Answer: A, B, C, E
Explanation: In the compensatory stage of shock, the body attempts to maintain
homeostasis through the activation of the sympathetic nervous system. This results in
tachycardia to maintain cardiac output and tachypnea to improve oxygenation. Cold,
clammy skin occurs due to blood being shunted from the periphery to vital organs, and a
narrowed pulse pressure is a classic early sign of decreased stroke volume.
2. A client is admitted to the intensive care unit with acute kidney injury (AKI). The nurse
notes a potassium level of 6.8 mEq/L. Which provider order is the highest priority?
A. Administer sodium polystyrene sulfonate orally
,B. Initiate a continuous infusion of regular insulin and dextrose
C. Obtain a 12-lead electrocardiogram (ECG)
D. Restrict dietary intake of potassium-rich foods
Correct Answer: B
Explanation: Hyperkalemia at 6.8 mEq/L is a life-threatening emergency that can lead to
cardiac arrest. Administering insulin with dextrose facilitates the rapid shift of potassium
from the extracellular fluid into the intracellular space. While an ECG and sodium
polystyrene sulfonate are important, the priority is to immediately lower the serum
potassium level to prevent arrhythmias.
3. The nurse is assessing a client with a history of cirrhosis who presents with increased
confusion and asterixis. Which laboratory result should the nurse prioritize?
A. Prothrombin time (PT)
B. Aspartate aminotransferase (AST)
C. Serum albumin level
D. Serum ammonia level
Correct Answer: D
Explanation: Confusion and asterixis (liver flap) are hallmark signs of hepatic
encephalopathy, which is caused by the accumulation of toxins in the blood. Ammonia is
the primary neurotoxin associated with liver failure that affects brain function. Monitoring
,and treating elevated ammonia levels is essential to prevent further neurological decline in
clients with cirrhosis.
4. A client arrives in the emergency department with suspected sepsis. Which assessments
and interventions are essential components of the 1-hour sepsis bundle? Select all that apply.
A. Measure lactate level
B. Obtain blood cultures before administering antibiotics
C. Administer broad-spectrum antibiotics
D. Administer 30 mL/kg crystalloid for hypotension or lactate ≥4 mmol/L
E. Apply vasopressors if hypotensive during or after fluid resuscitation to maintain MAP
≥65 mmHg
F. Monitor hourly urine output via indwelling catheter
Correct Answer: A, B, C, D, E
Explanation: The 1-hour sepsis bundle is designed to initiate rapid treatment to reduce
mortality in septic patients. It requires measuring lactate levels, obtaining blood cultures,
and starting antibiotics within the first hour of recognition. Furthermore, aggressive fluid
resuscitation and the use of vasopressors are necessary to maintain organ perfusion and
blood pressure.
5. A nurse is caring for a client with a full-thickness burn covering 40% of their total body
surface area (TBSA). During the emergent phase, what is the primary nursing goal?
A. Preventing wound infection
, B. Promoting early range of motion
C. Managing severe pain
D. Maintaining fluid and electrolyte balance
Correct Answer: D
Explanation: In the emergent (resuscitative) phase of burn care, the massive shift of fluids
from the intravascular to the interstitial space leads to hypovolemic shock. Maintaining
fluid and electrolyte balance through aggressive resuscitation is the most critical
intervention for survival. While infection control and pain management are important, they
follow the stabilization of the client’s hemodynamic status.
6. A client is diagnosed with Diabetic Ketoacidosis (DKA). The nurse identifies which findings
as consistent with this diagnosis?
A. Blood glucose 110 mg/dL, pH 7.35, positive ketones
B. Blood glucose 650 mg/dL, pH 7.40, negative ketones
C. Blood glucose 250 mg/dL, pH 7.25, positive ketones
D. Blood glucose 400 mg/dL, pH 7.45, negative ketones
Correct Answer: C
Explanation: Diabetic Ketoacidosis is characterized by hyperglycemia (usually >250
mg/dL), metabolic acidosis (pH <7.30), and the presence of ketones in the blood or urine.
Option B describes Hyperglycemic Hyperosmolar State (HHS), which lacks significant
Surgical Nursing II-B | NCLEX (NGN) Q&A
with Rationale (NU192 Exam 3) | Galen
1. A nurse is caring for a client who is in the compensatory stage of shock. Which clinical
findings should the nurse expect? Select all that apply.
A. Heart rate greater than 100 bpm
B. Respiratory rate greater than 20 breaths/min
C. Cold, clammy skin
D. Urinary output less than 30 mL/hr
E. Narrowed pulse pressure
Correct Answer: A, B, C, E
Explanation: In the compensatory stage of shock, the body attempts to maintain
homeostasis through the activation of the sympathetic nervous system. This results in
tachycardia to maintain cardiac output and tachypnea to improve oxygenation. Cold,
clammy skin occurs due to blood being shunted from the periphery to vital organs, and a
narrowed pulse pressure is a classic early sign of decreased stroke volume.
2. A client is admitted to the intensive care unit with acute kidney injury (AKI). The nurse
notes a potassium level of 6.8 mEq/L. Which provider order is the highest priority?
A. Administer sodium polystyrene sulfonate orally
,B. Initiate a continuous infusion of regular insulin and dextrose
C. Obtain a 12-lead electrocardiogram (ECG)
D. Restrict dietary intake of potassium-rich foods
Correct Answer: B
Explanation: Hyperkalemia at 6.8 mEq/L is a life-threatening emergency that can lead to
cardiac arrest. Administering insulin with dextrose facilitates the rapid shift of potassium
from the extracellular fluid into the intracellular space. While an ECG and sodium
polystyrene sulfonate are important, the priority is to immediately lower the serum
potassium level to prevent arrhythmias.
3. The nurse is assessing a client with a history of cirrhosis who presents with increased
confusion and asterixis. Which laboratory result should the nurse prioritize?
A. Prothrombin time (PT)
B. Aspartate aminotransferase (AST)
C. Serum albumin level
D. Serum ammonia level
Correct Answer: D
Explanation: Confusion and asterixis (liver flap) are hallmark signs of hepatic
encephalopathy, which is caused by the accumulation of toxins in the blood. Ammonia is
the primary neurotoxin associated with liver failure that affects brain function. Monitoring
,and treating elevated ammonia levels is essential to prevent further neurological decline in
clients with cirrhosis.
4. A client arrives in the emergency department with suspected sepsis. Which assessments
and interventions are essential components of the 1-hour sepsis bundle? Select all that apply.
A. Measure lactate level
B. Obtain blood cultures before administering antibiotics
C. Administer broad-spectrum antibiotics
D. Administer 30 mL/kg crystalloid for hypotension or lactate ≥4 mmol/L
E. Apply vasopressors if hypotensive during or after fluid resuscitation to maintain MAP
≥65 mmHg
F. Monitor hourly urine output via indwelling catheter
Correct Answer: A, B, C, D, E
Explanation: The 1-hour sepsis bundle is designed to initiate rapid treatment to reduce
mortality in septic patients. It requires measuring lactate levels, obtaining blood cultures,
and starting antibiotics within the first hour of recognition. Furthermore, aggressive fluid
resuscitation and the use of vasopressors are necessary to maintain organ perfusion and
blood pressure.
5. A nurse is caring for a client with a full-thickness burn covering 40% of their total body
surface area (TBSA). During the emergent phase, what is the primary nursing goal?
A. Preventing wound infection
, B. Promoting early range of motion
C. Managing severe pain
D. Maintaining fluid and electrolyte balance
Correct Answer: D
Explanation: In the emergent (resuscitative) phase of burn care, the massive shift of fluids
from the intravascular to the interstitial space leads to hypovolemic shock. Maintaining
fluid and electrolyte balance through aggressive resuscitation is the most critical
intervention for survival. While infection control and pain management are important, they
follow the stabilization of the client’s hemodynamic status.
6. A client is diagnosed with Diabetic Ketoacidosis (DKA). The nurse identifies which findings
as consistent with this diagnosis?
A. Blood glucose 110 mg/dL, pH 7.35, positive ketones
B. Blood glucose 650 mg/dL, pH 7.40, negative ketones
C. Blood glucose 250 mg/dL, pH 7.25, positive ketones
D. Blood glucose 400 mg/dL, pH 7.45, negative ketones
Correct Answer: C
Explanation: Diabetic Ketoacidosis is characterized by hyperglycemia (usually >250
mg/dL), metabolic acidosis (pH <7.30), and the presence of ketones in the blood or urine.
Option B describes Hyperglycemic Hyperosmolar State (HHS), which lacks significant
