NURS 120 MEDICAL-SURGICAL
NURSING EXAM 2 STUDY GUIDE
1. A nurse is caring for a patient who is 2 days postoperative following abdominal surgery.
The patient reports a sudden ‘popping’ sensation and the nurse observes viscera protruding
through the incision. What is the priority nursing action?
A. Notify the surgeon immediately without covering the wound
B. Attempt to push the organs back into the abdominal cavity
C. Place the patient in a High-Fowler’s position
D. Apply a sterile dressing moistened with warm normal saline
Answer: D
Conceptual Explanation: Evisceration is a medical emergency. The nurse should
immediately cover the protruding organs with sterile dressings soaked in sterile normal
saline to prevent drying and infection, then notify the surgeon.
2. Which arterial blood gas (ABG) result should the nurse anticipate for a patient with severe,
prolonged vomiting?
A. pH 7.30, PaCO2 50, HCO3 24
B. pH 7.32, PaCO2 35, HCO3 18
,C. pH 7.48, PaCO2 40, HCO3 30
D. pH 7.50, PaCO2 25, HCO3 22
Answer: C
Conceptual Explanation: Vomiting leads to a loss of gastric acid (HCl), causing metabolic
alkalosis. This is characterized by an elevated pH and elevated HCO3.
3. A patient is receiving a potassium-sparing diuretic. Which food choice indicates the patient
needs further teaching regarding their diet?
A. Apples
B. Cranberry juice
C. Bananas
D. White bread
Answer: C
Conceptual Explanation: Potassium-sparing diuretics retain potassium. Consuming high-
potassium foods like bananas increases the risk of hyperkalemia.
4. A nurse assesses a pressure injury that has full-thickness skin loss involving damage to the
subcutaneous tissue, but the bone and muscle are not exposed. How should the nurse stage
this injury?
A. Stage 1
B. Stage 3
, C. Stage 2
D. Stage 4
Answer: B
Conceptual Explanation: Stage 3 pressure injuries involve full-thickness skin loss with
visible subcutaneous fat, but bone, tendon, and muscle are not exposed.
5. During the preoperative ‘Time-Out,’ what is the primary responsibility of the surgical
team?
A. To administer the first dose of prophylactic antibiotics
B. To verify the correct patient, site, and procedure
C. To ensure the patient has been NPO for at least 12 hours
D. To allow the surgeon to explain the risks of the surgery
Answer: B
Conceptual Explanation: The ‘Time-Out’ is a safety procedure performed just before the
incision to verify the correct patient, correct site, and correct procedure.
6. A patient with a history of chronic obstructive pulmonary disease (COPD) is receiving
oxygen. Which flow rate is typically the maximum recommended to avoid suppressing the
hypoxic drive?
A. 10 L/min
B. 5-6 L/min
NURSING EXAM 2 STUDY GUIDE
1. A nurse is caring for a patient who is 2 days postoperative following abdominal surgery.
The patient reports a sudden ‘popping’ sensation and the nurse observes viscera protruding
through the incision. What is the priority nursing action?
A. Notify the surgeon immediately without covering the wound
B. Attempt to push the organs back into the abdominal cavity
C. Place the patient in a High-Fowler’s position
D. Apply a sterile dressing moistened with warm normal saline
Answer: D
Conceptual Explanation: Evisceration is a medical emergency. The nurse should
immediately cover the protruding organs with sterile dressings soaked in sterile normal
saline to prevent drying and infection, then notify the surgeon.
2. Which arterial blood gas (ABG) result should the nurse anticipate for a patient with severe,
prolonged vomiting?
A. pH 7.30, PaCO2 50, HCO3 24
B. pH 7.32, PaCO2 35, HCO3 18
,C. pH 7.48, PaCO2 40, HCO3 30
D. pH 7.50, PaCO2 25, HCO3 22
Answer: C
Conceptual Explanation: Vomiting leads to a loss of gastric acid (HCl), causing metabolic
alkalosis. This is characterized by an elevated pH and elevated HCO3.
3. A patient is receiving a potassium-sparing diuretic. Which food choice indicates the patient
needs further teaching regarding their diet?
A. Apples
B. Cranberry juice
C. Bananas
D. White bread
Answer: C
Conceptual Explanation: Potassium-sparing diuretics retain potassium. Consuming high-
potassium foods like bananas increases the risk of hyperkalemia.
4. A nurse assesses a pressure injury that has full-thickness skin loss involving damage to the
subcutaneous tissue, but the bone and muscle are not exposed. How should the nurse stage
this injury?
A. Stage 1
B. Stage 3
, C. Stage 2
D. Stage 4
Answer: B
Conceptual Explanation: Stage 3 pressure injuries involve full-thickness skin loss with
visible subcutaneous fat, but bone, tendon, and muscle are not exposed.
5. During the preoperative ‘Time-Out,’ what is the primary responsibility of the surgical
team?
A. To administer the first dose of prophylactic antibiotics
B. To verify the correct patient, site, and procedure
C. To ensure the patient has been NPO for at least 12 hours
D. To allow the surgeon to explain the risks of the surgery
Answer: B
Conceptual Explanation: The ‘Time-Out’ is a safety procedure performed just before the
incision to verify the correct patient, correct site, and correct procedure.
6. A patient with a history of chronic obstructive pulmonary disease (COPD) is receiving
oxygen. Which flow rate is typically the maximum recommended to avoid suppressing the
hypoxic drive?
A. 10 L/min
B. 5-6 L/min
