NU 157 Exam 2 V1 | NU 157 Medical-
Surgical Nursing I-A | NCLEX (NGN) Q&A
with Rationale (NU157 Exam 2) | Galen
1. A nurse is assessing a client who has been diagnosed with fluid volume excess. Which of
the following clinical manifestations should the nurse expect to find? (Select all that apply.)
A. Distended neck veins
B. Bounding pulse
C. Dependent edema
D. Flattened neck veins
E. Crackles upon lung auscultation
F. Thready, weak pulse
Correct Answer: A, B, C, E
Explanation: Fluid volume excess occurs when there is too much fluid in the vascular
space, leading to increased venous pressure and distended neck veins. The heart pumps
harder to move the extra fluid, resulting in a bounding pulse. Crackles occur when fluid
shifts into the alveoli, and dependent edema results from fluid shifting into the interstitial
spaces.
,2. A client’s arterial blood gas (ABG) results are as follows: pH 7.30, PaCO2 52 mmHg, and
HCO3 24 mEq/L. The nurse should interpret these results as which of the following?
A. Metabolic Acidosis
B. Metabolic Alkalosis
C. Respiratory Acidosis
D. Respiratory Alkalosis
Correct Answer: C
Explanation: A pH below 7.35 indicates acidosis. The PaCO2 is elevated above 45 mmHg,
which points toward a respiratory cause. Since the bicarbonate level is within the normal
range of 22 to 26 mEq/L, this is uncompensated respiratory acidosis.
3. The nurse is providing preoperative teaching for a client scheduled for surgery. Which of
the following actions is a priority for the nurse to ensure legal compliance regarding informed
consent?
A. Explain the risks and benefits of the procedure to the client.
B. Determine which surgical technique is best for the client.
C. Witness the client’s signature on the consent form.
D. Describe the alternative treatments available to the client.
Correct Answer: C
, Explanation: The nurse’s primary role in informed consent is to witness the client’s
signature and verify that the client is competent to sign. It is the surgeon’s responsibility to
explain the risks, benefits, and alternatives of the surgery. If the client has questions about
the procedure itself, the nurse must notify the surgeon to come back and clarify.
4. A client is 12 hours postoperative following an abdominal hysterectomy. Which of the
following findings should the nurse report to the provider immediately?
A. Pain level of 5 on a scale of 0 to 10
B. Urine output of 20 mL/hr
C. Serosanguineous drainage on the dressing
D. Hypoactive bowel sounds
Correct Answer: B
Explanation: Urine output should be at least 30 mL/hr to indicate adequate renal
perfusion and fluid balance. A drop below this level can indicate dehydration, hypovolemia,
or acute kidney injury. While the other findings are expected or manageable
postoperatively, the low urine output requires immediate intervention.
5. The nurse is assessing a client for signs of hypocalcemia. Which of the following techniques
should the nurse use to check for Trousseau’s sign?
A. Tap the client’s face just below the temple.
B. Assess for hyperactive deep tendon reflexes.
C. Apply pressure to the client’s calf muscle.
Surgical Nursing I-A | NCLEX (NGN) Q&A
with Rationale (NU157 Exam 2) | Galen
1. A nurse is assessing a client who has been diagnosed with fluid volume excess. Which of
the following clinical manifestations should the nurse expect to find? (Select all that apply.)
A. Distended neck veins
B. Bounding pulse
C. Dependent edema
D. Flattened neck veins
E. Crackles upon lung auscultation
F. Thready, weak pulse
Correct Answer: A, B, C, E
Explanation: Fluid volume excess occurs when there is too much fluid in the vascular
space, leading to increased venous pressure and distended neck veins. The heart pumps
harder to move the extra fluid, resulting in a bounding pulse. Crackles occur when fluid
shifts into the alveoli, and dependent edema results from fluid shifting into the interstitial
spaces.
,2. A client’s arterial blood gas (ABG) results are as follows: pH 7.30, PaCO2 52 mmHg, and
HCO3 24 mEq/L. The nurse should interpret these results as which of the following?
A. Metabolic Acidosis
B. Metabolic Alkalosis
C. Respiratory Acidosis
D. Respiratory Alkalosis
Correct Answer: C
Explanation: A pH below 7.35 indicates acidosis. The PaCO2 is elevated above 45 mmHg,
which points toward a respiratory cause. Since the bicarbonate level is within the normal
range of 22 to 26 mEq/L, this is uncompensated respiratory acidosis.
3. The nurse is providing preoperative teaching for a client scheduled for surgery. Which of
the following actions is a priority for the nurse to ensure legal compliance regarding informed
consent?
A. Explain the risks and benefits of the procedure to the client.
B. Determine which surgical technique is best for the client.
C. Witness the client’s signature on the consent form.
D. Describe the alternative treatments available to the client.
Correct Answer: C
, Explanation: The nurse’s primary role in informed consent is to witness the client’s
signature and verify that the client is competent to sign. It is the surgeon’s responsibility to
explain the risks, benefits, and alternatives of the surgery. If the client has questions about
the procedure itself, the nurse must notify the surgeon to come back and clarify.
4. A client is 12 hours postoperative following an abdominal hysterectomy. Which of the
following findings should the nurse report to the provider immediately?
A. Pain level of 5 on a scale of 0 to 10
B. Urine output of 20 mL/hr
C. Serosanguineous drainage on the dressing
D. Hypoactive bowel sounds
Correct Answer: B
Explanation: Urine output should be at least 30 mL/hr to indicate adequate renal
perfusion and fluid balance. A drop below this level can indicate dehydration, hypovolemia,
or acute kidney injury. While the other findings are expected or manageable
postoperatively, the low urine output requires immediate intervention.
5. The nurse is assessing a client for signs of hypocalcemia. Which of the following techniques
should the nurse use to check for Trousseau’s sign?
A. Tap the client’s face just below the temple.
B. Assess for hyperactive deep tendon reflexes.
C. Apply pressure to the client’s calf muscle.
