,NU 185 Exam 1 | Medical-Surgical Nursing II
(2026/2027) PDF | Nursing | Galen College
1. Which of the following best describes the primary purpose of the nursing
process?
A) To ensure all patients receive identical care regardless of individual needs
B) To provide a systematic, problem-solving framework for delivering
individualized nursing care
C) To prioritize administrative tasks over patient care
D) To document patient outcomes after discharge
Correct Answer: To provide a systematic, problem-solving framework for
delivering individualized nursing care
Rationale: The nursing process (ADPIE) is a critical thinking method that guides
assessment, diagnosis, planning, implementation, and evaluation. It ensures
care is tailored to each patient's unique needs, not a one-size-fits-all approach,
and forms the foundation of clinical decision-making.
2. What is the primary function of the assessment phase in the nursing process?
A) To establish patient goals and expected outcomes
B) To systematically collect and analyze patient data
C) To implement nursing interventions based on evidence
D) To evaluate the effectiveness of nursing care
,Correct Answer: To systematically collect and analyze patient data
Rationale: The assessment phase is the first step of the nursing process,
involving the systematic collection of subjective and objective data through
history taking, physical examination, and diagnostic testing. This data forms the
foundation for identifying patient problems and planning care.
3. A nurse notes that a patient's potassium level is 6.2 mEq/L. Which ECG
change should the nurse expect to see?
A) U waves
B) Peaked T waves
C) ST segment depression
D) Inverted T waves
Correct Answer: Peaked T waves
Rationale: Hyperkalemia (potassium >5.0 mEq/L) typically causes tall, peaked T
waves, widened QRS complexes, and potentially cardiac arrest. U waves are
associated with hypokalemia, while ST depression and inverted T waves are not
classic findings for hyperkalemia.
4. A patient has an arterial blood gas result of pH 7.28, PaCO2 50 mmHg, and
HCO3 24 mEq/L. How should the nurse interpret this?
A) Metabolic Acidosis
B) Respiratory Alkalosis
, C) Metabolic Alkalosis
D) Respiratory Acidosis
Correct Answer: Respiratory Acidosis
Rationale: A pH below 7.35 indicates acidosis. A PaCO2 above 45 mmHg with a
normal HCO3 indicates the cause is respiratory. The lungs are retaining carbon
dioxide, leading to an acidic state.
5. Which assessment finding is a hallmark sign of hypocalcemia?
A) Hyperactive bowel sounds
B) Negative Romberg test
C) Positive Trousseau's sign
D) Bounding peripheral pulses
Correct Answer: Positive Trousseau's sign
Rationale: Trousseau's sign (carpal spasm induced by inflating a blood pressure
cuff) and Chvostek's sign are classic indicators of neuromuscular irritability
caused by hypocalcemia. Hyperactive bowel sounds are not typically associated
with hypocalcemia.
6. A patient with a potassium level of 6.2 mEq/L is prescribed a medication to
lower the potassium level immediately. Which medication should the nurse
anticipate administering?
(2026/2027) PDF | Nursing | Galen College
1. Which of the following best describes the primary purpose of the nursing
process?
A) To ensure all patients receive identical care regardless of individual needs
B) To provide a systematic, problem-solving framework for delivering
individualized nursing care
C) To prioritize administrative tasks over patient care
D) To document patient outcomes after discharge
Correct Answer: To provide a systematic, problem-solving framework for
delivering individualized nursing care
Rationale: The nursing process (ADPIE) is a critical thinking method that guides
assessment, diagnosis, planning, implementation, and evaluation. It ensures
care is tailored to each patient's unique needs, not a one-size-fits-all approach,
and forms the foundation of clinical decision-making.
2. What is the primary function of the assessment phase in the nursing process?
A) To establish patient goals and expected outcomes
B) To systematically collect and analyze patient data
C) To implement nursing interventions based on evidence
D) To evaluate the effectiveness of nursing care
,Correct Answer: To systematically collect and analyze patient data
Rationale: The assessment phase is the first step of the nursing process,
involving the systematic collection of subjective and objective data through
history taking, physical examination, and diagnostic testing. This data forms the
foundation for identifying patient problems and planning care.
3. A nurse notes that a patient's potassium level is 6.2 mEq/L. Which ECG
change should the nurse expect to see?
A) U waves
B) Peaked T waves
C) ST segment depression
D) Inverted T waves
Correct Answer: Peaked T waves
Rationale: Hyperkalemia (potassium >5.0 mEq/L) typically causes tall, peaked T
waves, widened QRS complexes, and potentially cardiac arrest. U waves are
associated with hypokalemia, while ST depression and inverted T waves are not
classic findings for hyperkalemia.
4. A patient has an arterial blood gas result of pH 7.28, PaCO2 50 mmHg, and
HCO3 24 mEq/L. How should the nurse interpret this?
A) Metabolic Acidosis
B) Respiratory Alkalosis
, C) Metabolic Alkalosis
D) Respiratory Acidosis
Correct Answer: Respiratory Acidosis
Rationale: A pH below 7.35 indicates acidosis. A PaCO2 above 45 mmHg with a
normal HCO3 indicates the cause is respiratory. The lungs are retaining carbon
dioxide, leading to an acidic state.
5. Which assessment finding is a hallmark sign of hypocalcemia?
A) Hyperactive bowel sounds
B) Negative Romberg test
C) Positive Trousseau's sign
D) Bounding peripheral pulses
Correct Answer: Positive Trousseau's sign
Rationale: Trousseau's sign (carpal spasm induced by inflating a blood pressure
cuff) and Chvostek's sign are classic indicators of neuromuscular irritability
caused by hypocalcemia. Hyperactive bowel sounds are not typically associated
with hypocalcemia.
6. A patient with a potassium level of 6.2 mEq/L is prescribed a medication to
lower the potassium level immediately. Which medication should the nurse
anticipate administering?
