NUR 205 | NUR 205 Med Surg Exam 1 Version 1 |
Questions with Correct Answers and Expert
Explanation for Each Question | Saint Paul’s School
of Nursing
1. A patient presents with a serum potassium level of 2.8 mEq/L. Which clinical
manifestation should the nurse prioritize for assessment?
A. Hyperactive bowel sounds
B. Increased muscle tone
C. Cardiac dysrhythmias
D. High blood pressure
Correct Answer: C
Expert Explanation: Hypokalemia is defined as a serum potassium level below 3.5
mEq/L. This electrolyte imbalance significantly affects cardiac conduction and can
lead to life-threatening arrhythmias. The nurse must prioritize cardiac monitoring
to detect early signs of instability. Other symptoms may include muscle weakness
and diminished deep tendon reflexes. Prompt intervention with potassium
replacement is essential to restore electrolyte balance and prevent cardiac arrest.
2. Which intervention is most important for a nurse to implement when caring for a
patient with a diagnosis of fluid volume deficit?
A. Limit sodium intake
,B. Encourage bed rest
C. Monitor daily weights
D. Administer diuretics
Correct Answer: C
Expert Explanation: Daily weight measurement is the most sensitive and accurate
indicator of fluid volume status changes. One kilogram of weight change is roughly
equivalent to one liter of fluid gain or loss. The nurse should ensure the patient is
weighed at the same time each day using the same scale. This objective data helps
the healthcare team adjust fluid replacement therapies effectively. Monitoring
intake and output is also necessary but less precise than weight monitoring.
3. A nurse is preparing to enter the room of a patient with suspected Tuberculosis
(TB). Which type of personal protective equipment (PPE) is required?
A. N95 respirator
B. Surgical mask
C. Goggles and gown
D. Gloves only
Correct Answer: A
,Expert Explanation: Tuberculosis is transmitted via airborne droplets that can
remain suspended in the air for long periods. Standard surgical masks do not
provide adequate filtration for these microscopic particles. An N95 respirator is
required as it fits tightly and filters out at least 95 percent of airborne particles. The
patient must also be placed in a negative pressure room to prevent the spread of the
pathogen. Consistent use of appropriate PPE is vital for healthcare worker safety in
acute care settings.
4. Which assessment finding would most likely indicate that a patient is experiencing
fluid volume excess?
A. Distended neck veins
B. Poor skin turgor
C. Dry mucous membranes
D. Decreased urine output
Correct Answer: A
Expert Explanation: Fluid volume excess causes an increase in vascular volume,
which often manifests as jugular venous distention. The nurse should assess the
patient in a semi-Fowler’s position to accurately observe for this sign. Other
common findings include peripheral edema, crackles in the lungs, and rapid weight
gain. This condition can lead to pulmonary edema if not managed with fluid
, restriction or diuretics. Frequent respiratory assessments are necessary to ensure
the patient’s oxygenation remains stable.
5. A patient is admitted with a serum sodium level of 155 mEq/L. Which nursing
intervention is most appropriate?
A. Administer 3% saline
B. Restrict all fluid intake
C. Encourage increased oral water intake
D. Provide high-sodium snacks
Correct Answer: C
Expert Explanation: A serum sodium level above 145 mEq/L indicates
hypernatremia, which reflects a relative water deficit. Increasing oral fluid intake or
administering hypotonic IV fluids helps dilute the excess sodium in the blood.
Hypertonic solutions like 3% saline are contraindicated as they would worsen the
sodium excess. The nurse should also monitor the patient for neurological changes
such as agitation or seizures. Gradual correction of sodium levels is necessary to
prevent cerebral edema.
6. When assessing a patient for orthostatic hypotension, the nurse should notify the
provider if the systolic blood pressure drops by at least how much?
A. 5 mmHg
Questions with Correct Answers and Expert
Explanation for Each Question | Saint Paul’s School
of Nursing
1. A patient presents with a serum potassium level of 2.8 mEq/L. Which clinical
manifestation should the nurse prioritize for assessment?
A. Hyperactive bowel sounds
B. Increased muscle tone
C. Cardiac dysrhythmias
D. High blood pressure
Correct Answer: C
Expert Explanation: Hypokalemia is defined as a serum potassium level below 3.5
mEq/L. This electrolyte imbalance significantly affects cardiac conduction and can
lead to life-threatening arrhythmias. The nurse must prioritize cardiac monitoring
to detect early signs of instability. Other symptoms may include muscle weakness
and diminished deep tendon reflexes. Prompt intervention with potassium
replacement is essential to restore electrolyte balance and prevent cardiac arrest.
2. Which intervention is most important for a nurse to implement when caring for a
patient with a diagnosis of fluid volume deficit?
A. Limit sodium intake
,B. Encourage bed rest
C. Monitor daily weights
D. Administer diuretics
Correct Answer: C
Expert Explanation: Daily weight measurement is the most sensitive and accurate
indicator of fluid volume status changes. One kilogram of weight change is roughly
equivalent to one liter of fluid gain or loss. The nurse should ensure the patient is
weighed at the same time each day using the same scale. This objective data helps
the healthcare team adjust fluid replacement therapies effectively. Monitoring
intake and output is also necessary but less precise than weight monitoring.
3. A nurse is preparing to enter the room of a patient with suspected Tuberculosis
(TB). Which type of personal protective equipment (PPE) is required?
A. N95 respirator
B. Surgical mask
C. Goggles and gown
D. Gloves only
Correct Answer: A
,Expert Explanation: Tuberculosis is transmitted via airborne droplets that can
remain suspended in the air for long periods. Standard surgical masks do not
provide adequate filtration for these microscopic particles. An N95 respirator is
required as it fits tightly and filters out at least 95 percent of airborne particles. The
patient must also be placed in a negative pressure room to prevent the spread of the
pathogen. Consistent use of appropriate PPE is vital for healthcare worker safety in
acute care settings.
4. Which assessment finding would most likely indicate that a patient is experiencing
fluid volume excess?
A. Distended neck veins
B. Poor skin turgor
C. Dry mucous membranes
D. Decreased urine output
Correct Answer: A
Expert Explanation: Fluid volume excess causes an increase in vascular volume,
which often manifests as jugular venous distention. The nurse should assess the
patient in a semi-Fowler’s position to accurately observe for this sign. Other
common findings include peripheral edema, crackles in the lungs, and rapid weight
gain. This condition can lead to pulmonary edema if not managed with fluid
, restriction or diuretics. Frequent respiratory assessments are necessary to ensure
the patient’s oxygenation remains stable.
5. A patient is admitted with a serum sodium level of 155 mEq/L. Which nursing
intervention is most appropriate?
A. Administer 3% saline
B. Restrict all fluid intake
C. Encourage increased oral water intake
D. Provide high-sodium snacks
Correct Answer: C
Expert Explanation: A serum sodium level above 145 mEq/L indicates
hypernatremia, which reflects a relative water deficit. Increasing oral fluid intake or
administering hypotonic IV fluids helps dilute the excess sodium in the blood.
Hypertonic solutions like 3% saline are contraindicated as they would worsen the
sodium excess. The nurse should also monitor the patient for neurological changes
such as agitation or seizures. Gradual correction of sodium levels is necessary to
prevent cerebral edema.
6. When assessing a patient for orthostatic hypotension, the nurse should notify the
provider if the systolic blood pressure drops by at least how much?
A. 5 mmHg
