BSN 266 Exam 2: Concepts of Nursing II
Updated and Verified Questions and Answers -
Nightingale College
1. A nurse is caring for a client with a potassium level of 6.2 mEq/L. Which of the
following is the priority intervention?
A. Administering oral potassium supplements
B. Assessing the client for leg cramps
C. Obtaining a 12-lead ECG
D. Encouraging intake of bananas
Answer: C
Explanation: Hyperkalemia (potassium > 5.0) can lead to life-threatening cardiac
arrhythmias. Obtaining an ECG is the priority to monitor for changes like peaked T-waves
or a widened QRS complex.
2. Which arterial blood gas (ABG) result indicates compensated respiratory
acidosis?
A. pH 7.30, PaCO2 50, HCO3 24
B. pH 7.36, PaCO2 55, HCO3 30
C. pH 7.48, PaCO2 30, HCO3 22
D. pH 7.42, PaCO2 40, HCO3 24
Answer: B
Explanation: In compensated respiratory acidosis, the pH is within normal range (7.35-
7.45) but on the acidic side, PaCO2 is high, and the kidneys have retained HCO3 to
compensate.
,3. A client is scheduled for surgery. The nurse notices the informed consent has
not been signed. What is the nurse’s primary responsibility?
A. Notify the surgeon that the consent is not signed
B. Explain the risks and benefits of the procedure to the client
C. Have the client sign the form immediately
D. Sign the consent form as a proxy for the client
Answer: A
Explanation: It is the surgeon’s responsibility to explain the procedure and obtain consent.
The nurse’s role is to witness the signature and ensure the process has occurred; if not, the
surgeon must be notified.
4. When assessing a client with fluid volume deficit, which of the following
findings should the nurse expect?
A. Decreased skin turgor
B. Bounding pulse
C. Distended neck veins
D. Increased blood pressure
Answer: A
Explanation: Signs of dehydration or fluid volume deficit include poor skin turgor
(tenting), dry mucous membranes, tachycardia, and orthostatic hypotension.
5. A client presents with a pH of 7.50 and a PaCO2 of 30 mmHg. Which condition
is the client experiencing?
A. Metabolic Acidosis
B. Respiratory Acidosis
C. Metabolic Alkalosis
D. Respiratory Alkalosis
Answer: D
, Explanation: A pH above 7.45 indicates alkalosis. A PaCO2 below 35 indicates a
respiratory cause for the alkalosis.
6. A nurse is teaching a client about a low-sodium diet. Which food choice
indicates understanding of the teaching?
A. Canned vegetable soup
B. Pickled cucumbers
C. Smoked ham
D. Fresh broccoli
Answer: D
Explanation: Fresh fruits and vegetables are naturally low in sodium. Canned, smoked, and
pickled foods are high in sodium preservatives.
7. Which of the following is a symptom of hypocalcemia?
A. Constipation
B. Hyporeflexia
C. Positive Chvostek’s sign
D. Lethargy
Answer: C
Explanation: Hypocalcemia increases neuromuscular excitability, leading to a positive
Chvostek’s sign (facial twitching) and Trousseau’s sign.
8. A client has a chest tube connected to a water-seal drainage system. The
nurse notes constant bubbling in the water-seal chamber. This indicates:
A. The system is functioning normally
B. The client has a pneumothorax
C. There is an air leak in the system
D. The suction level is too high
Answer: C
Updated and Verified Questions and Answers -
Nightingale College
1. A nurse is caring for a client with a potassium level of 6.2 mEq/L. Which of the
following is the priority intervention?
A. Administering oral potassium supplements
B. Assessing the client for leg cramps
C. Obtaining a 12-lead ECG
D. Encouraging intake of bananas
Answer: C
Explanation: Hyperkalemia (potassium > 5.0) can lead to life-threatening cardiac
arrhythmias. Obtaining an ECG is the priority to monitor for changes like peaked T-waves
or a widened QRS complex.
2. Which arterial blood gas (ABG) result indicates compensated respiratory
acidosis?
A. pH 7.30, PaCO2 50, HCO3 24
B. pH 7.36, PaCO2 55, HCO3 30
C. pH 7.48, PaCO2 30, HCO3 22
D. pH 7.42, PaCO2 40, HCO3 24
Answer: B
Explanation: In compensated respiratory acidosis, the pH is within normal range (7.35-
7.45) but on the acidic side, PaCO2 is high, and the kidneys have retained HCO3 to
compensate.
,3. A client is scheduled for surgery. The nurse notices the informed consent has
not been signed. What is the nurse’s primary responsibility?
A. Notify the surgeon that the consent is not signed
B. Explain the risks and benefits of the procedure to the client
C. Have the client sign the form immediately
D. Sign the consent form as a proxy for the client
Answer: A
Explanation: It is the surgeon’s responsibility to explain the procedure and obtain consent.
The nurse’s role is to witness the signature and ensure the process has occurred; if not, the
surgeon must be notified.
4. When assessing a client with fluid volume deficit, which of the following
findings should the nurse expect?
A. Decreased skin turgor
B. Bounding pulse
C. Distended neck veins
D. Increased blood pressure
Answer: A
Explanation: Signs of dehydration or fluid volume deficit include poor skin turgor
(tenting), dry mucous membranes, tachycardia, and orthostatic hypotension.
5. A client presents with a pH of 7.50 and a PaCO2 of 30 mmHg. Which condition
is the client experiencing?
A. Metabolic Acidosis
B. Respiratory Acidosis
C. Metabolic Alkalosis
D. Respiratory Alkalosis
Answer: D
, Explanation: A pH above 7.45 indicates alkalosis. A PaCO2 below 35 indicates a
respiratory cause for the alkalosis.
6. A nurse is teaching a client about a low-sodium diet. Which food choice
indicates understanding of the teaching?
A. Canned vegetable soup
B. Pickled cucumbers
C. Smoked ham
D. Fresh broccoli
Answer: D
Explanation: Fresh fruits and vegetables are naturally low in sodium. Canned, smoked, and
pickled foods are high in sodium preservatives.
7. Which of the following is a symptom of hypocalcemia?
A. Constipation
B. Hyporeflexia
C. Positive Chvostek’s sign
D. Lethargy
Answer: C
Explanation: Hypocalcemia increases neuromuscular excitability, leading to a positive
Chvostek’s sign (facial twitching) and Trousseau’s sign.
8. A client has a chest tube connected to a water-seal drainage system. The
nurse notes constant bubbling in the water-seal chamber. This indicates:
A. The system is functioning normally
B. The client has a pneumothorax
C. There is an air leak in the system
D. The suction level is too high
Answer: C
