,NU 171 Exam 4 | Maternal Child Nursing (2026/2027)
PDF | Nursing | Galen College
1. The nurse is assessing a patient with a potassium level of 3.2 mEq/L. Which
electrocardiogram (ECG) change is most characteristic of this electrolyte
imbalance?
A) Tall, peaked T waves
B) Prolonged PR interval
C) Widened QRS complex
D) Presence of U waves
Correct Answer: D) Presence of U waves
Rationale: A potassium level of 3.2 mEq/L indicates hypokalemia. Classic ECG
changes associated with hypokalemia include flat or inverted T waves and the
appearance of U waves. Tall peaked T waves are characteristic of hyperkalemia,
while prolonged PR and widened QRS are also associated with hyperkalemia.
2. The nurse is reviewing the preoperative checklist for a client scheduled for
surgery. Which of the following actions is most critical to ensure patient safety
prior to the procedure?
A) Administering a preoperative sedative
B) Applying anti-embolism stockings
C) Verifying that the surgical site is marked by the surgeon
D) Ensuring the patient has a clear liquid breakfast
Correct Answer: C) Verifying that the surgical site is marked by the surgeon
,Rationale: Verifying the surgical site marking is a critical safety step to prevent
wrong-site surgery. This is a key component of the universal protocol for patient
safety. Administering sedatives and applying stockings are important but
secondary to site verification.
3. A patient's arterial blood gas (ABG) results are: pH 7.31, PaCO2 52 mmHg, and
HCO3 26 mEq/L. How should the nurse interpret these findings?
A) Metabolic Acidosis
B) Respiratory Alkalosis
C) Metabolic Alkalosis
D) Respiratory Acidosis
Correct Answer: D) Respiratory Acidosis
Rationale: The pH is below 7.35 (acidosis) and the PaCO2 is elevated above 45
mmHg, indicating a respiratory cause. The HCO3 is within the normal range (22-
26 mEq/L), meaning the kidneys have not yet compensated. This is an
uncompensated respiratory acidosis.
4. A postoperative patient suddenly reports a "popping" sensation in the
abdominal incision. Upon assessment, the nurse notes that the wound has
opened and internal organs are protruding. What is the nurse's priority action?
A) Attempt to push the organs back into the abdominal cavity gently
B) Place the patient in a high-Fowler's position to assist with breathing
C) Cover the protruding organs with sterile dressings moistened with sterile
normal saline
, D) Leave the patient to call the surgeon immediately from the nurses' station
Correct Answer: C) Cover the protruding organs with sterile dressings moistened
with sterile normal saline
Rationale: This scenario describes wound evisceration, which is a surgical
emergency. The nurse should immediately cover the site with sterile, saline-
soaked dressings to keep the organs moist and prevent infection. The patient
should be placed in a low-Fowler's position with knees bent to reduce
abdominal tension.
5. The nurse is assessing a patient with hypocalcemia. Which assessment finding
is a classic sign of this electrolyte imbalance?
A) Hyperactive deep tendon reflexes
B) Flattened T waves on ECG
C) Muscle weakness and fatigue
D) Positive Chvostek's sign
Correct Answer: D) Positive Chvostek's sign
Rationale: Chvostek's sign (facial twitching when the facial nerve is tapped) is a
classic sign of hypocalcemia. Trousseau's sign (carpal spasm with BP cuff
inflation) is also associated with hypocalcemia. Hyperactive reflexes are
common, but Chvostek's is more specific.
6. The nurse is caring for a patient who is 4 hours post-operative following
abdominal surgery and reports suprapubic discomfort. The patient has not
voided since before surgery. Which action should the nurse take first?
PDF | Nursing | Galen College
1. The nurse is assessing a patient with a potassium level of 3.2 mEq/L. Which
electrocardiogram (ECG) change is most characteristic of this electrolyte
imbalance?
A) Tall, peaked T waves
B) Prolonged PR interval
C) Widened QRS complex
D) Presence of U waves
Correct Answer: D) Presence of U waves
Rationale: A potassium level of 3.2 mEq/L indicates hypokalemia. Classic ECG
changes associated with hypokalemia include flat or inverted T waves and the
appearance of U waves. Tall peaked T waves are characteristic of hyperkalemia,
while prolonged PR and widened QRS are also associated with hyperkalemia.
2. The nurse is reviewing the preoperative checklist for a client scheduled for
surgery. Which of the following actions is most critical to ensure patient safety
prior to the procedure?
A) Administering a preoperative sedative
B) Applying anti-embolism stockings
C) Verifying that the surgical site is marked by the surgeon
D) Ensuring the patient has a clear liquid breakfast
Correct Answer: C) Verifying that the surgical site is marked by the surgeon
,Rationale: Verifying the surgical site marking is a critical safety step to prevent
wrong-site surgery. This is a key component of the universal protocol for patient
safety. Administering sedatives and applying stockings are important but
secondary to site verification.
3. A patient's arterial blood gas (ABG) results are: pH 7.31, PaCO2 52 mmHg, and
HCO3 26 mEq/L. How should the nurse interpret these findings?
A) Metabolic Acidosis
B) Respiratory Alkalosis
C) Metabolic Alkalosis
D) Respiratory Acidosis
Correct Answer: D) Respiratory Acidosis
Rationale: The pH is below 7.35 (acidosis) and the PaCO2 is elevated above 45
mmHg, indicating a respiratory cause. The HCO3 is within the normal range (22-
26 mEq/L), meaning the kidneys have not yet compensated. This is an
uncompensated respiratory acidosis.
4. A postoperative patient suddenly reports a "popping" sensation in the
abdominal incision. Upon assessment, the nurse notes that the wound has
opened and internal organs are protruding. What is the nurse's priority action?
A) Attempt to push the organs back into the abdominal cavity gently
B) Place the patient in a high-Fowler's position to assist with breathing
C) Cover the protruding organs with sterile dressings moistened with sterile
normal saline
, D) Leave the patient to call the surgeon immediately from the nurses' station
Correct Answer: C) Cover the protruding organs with sterile dressings moistened
with sterile normal saline
Rationale: This scenario describes wound evisceration, which is a surgical
emergency. The nurse should immediately cover the site with sterile, saline-
soaked dressings to keep the organs moist and prevent infection. The patient
should be placed in a low-Fowler's position with knees bent to reduce
abdominal tension.
5. The nurse is assessing a patient with hypocalcemia. Which assessment finding
is a classic sign of this electrolyte imbalance?
A) Hyperactive deep tendon reflexes
B) Flattened T waves on ECG
C) Muscle weakness and fatigue
D) Positive Chvostek's sign
Correct Answer: D) Positive Chvostek's sign
Rationale: Chvostek's sign (facial twitching when the facial nerve is tapped) is a
classic sign of hypocalcemia. Trousseau's sign (carpal spasm with BP cuff
inflation) is also associated with hypocalcemia. Hyperactive reflexes are
common, but Chvostek's is more specific.
6. The nurse is caring for a patient who is 4 hours post-operative following
abdominal surgery and reports suprapubic discomfort. The patient has not
voided since before surgery. Which action should the nurse take first?
