NUR 220 | NUR 220 Medical Surgical Nursing Exam
1 Version 1 | Questions with Correct Answers and
Expert Explanation for Each Question | Baltimore
City Community College
1. A nurse is assessing a client with a serum sodium level of 155 mEq/L. Which of the
following clinical manifestations should the nurse expect to observe?
A. Increased skin turgor and moist membranes
B. Hallucinations and lethargy
C. Restlessness, agitation, and extreme thirst
D. Muscle weakness and bradycardia
Correct Answer: C
Expert Explanation: A serum sodium level above 145 mEq/L indicates
hypernatremia, which commonly manifests as dehydration of the brain cells. These
neurological changes often present as restlessness, agitation, or confusion in the
acute care setting. Thirst is the body’s primary defense mechanism to lower sodium
concentration by increasing fluid intake. Nurses must monitor these patients closely
for worsening mental status as sodium levels fluctuate. Frequent oral care and
monitoring of mucous membranes are essential components of nursing
management for this condition.
,2. The nurse is reviewing the laboratory results for a client receiving furosemide and
notes a potassium level of 3.2 mEq/L. Which assessment finding is most important to
report to the provider?
A. Increased bowel sounds
B. Occasional premature ventricular contractions (PVCs)
C. Muscle cramps in the lower extremities
D. A blood pressure of 110/70 mmHg
Correct Answer: B
Expert Explanation: Hypokalemia, defined as a potassium level below 3.5 mEq/L,
significantly impacts cardiac electrical stability. The presence of premature
ventricular contractions indicates myocardial irritability and a risk for lethal
arrhythmias. While muscle cramps are common in hypokalemia, cardiac
manifestations take priority due to life-threatening potential. Furosemide is a loop
diuretic known to cause significant potassium wasting through the kidneys. The
nurse should advocate for potassium supplementation and continuous cardiac
monitoring to ensure patient safety.
3. A nurse is preparing to enter the room of a client diagnosed with Clostridioides
difficile (C. diff). Which infection control measure is mandatory?
A. Wearing an N95 respirator mask
,B. Donning a gown and gloves before entry
C. Performing hand hygiene with alcohol-based foam
D. Maintaining a distance of 6 feet from the patient
Correct Answer: B
Expert Explanation: C. diff requires contact precautions because the spores are
easily transmitted through direct or indirect contact. Hand hygiene must be
performed with soap and water as alcohol-based rubs are ineffective against C. diff
spores. A gown and gloves are the primary pieces of personal protective equipment
used to prevent environmental contamination. The nurse must ensure that
equipment used in the room remains dedicated to that specific patient. Proper
environmental cleaning with bleach-based solutions is also required to eradicate the
spores from the room.
4. Which client should the nurse assess first after receiving the change-of-shift report?
A. A client with a history of heart failure reporting a weight gain of 2 lbs in 24 hours
B. A client with pneumonia who has a new onset of confusion and restlessness
C. A client who had abdominal surgery 12 hours ago and reports pain as 6/10
D. A client with chronic obstructive pulmonary disease (COPD) with an SpO2 of 91%
on room air
, Correct Answer: B
Expert Explanation: New-onset confusion and restlessness in a patient with
pneumonia are early indicators of hypoxia and clinical deterioration. Using the ABC
(Airway, Breathing, Circulation) framework, respiratory compromise takes
precedence over chronic conditions or stable pain. While a 2 lb weight gain is
concerning for heart failure, it is less acute than potential respiratory failure. A
postoperative patient with 6/10 pain is expected and can be managed after
addressing the hypoxic client. Rapid assessment and intervention are required to
prevent further oxygen desaturation and organ damage.
5. While assessing a client’s blood pressure, the nurse notices that the client’s thumb
and fingers twitch when the blood pressure cuff is inflated. How should the nurse
interpret this finding?
A. It is a normal response to cuff pressure
B. The client likely has hypermagnesemia
C. The client is experiencing an allergic reaction to the cuff material
D. This is a positive Trousseau’s sign indicating hypocalcemia
Correct Answer: D
Expert Explanation: Trousseau’s sign is characterized by carpal spasms induced by
inflating a blood pressure cuff above the systolic pressure. This physical finding is a
1 Version 1 | Questions with Correct Answers and
Expert Explanation for Each Question | Baltimore
City Community College
1. A nurse is assessing a client with a serum sodium level of 155 mEq/L. Which of the
following clinical manifestations should the nurse expect to observe?
A. Increased skin turgor and moist membranes
B. Hallucinations and lethargy
C. Restlessness, agitation, and extreme thirst
D. Muscle weakness and bradycardia
Correct Answer: C
Expert Explanation: A serum sodium level above 145 mEq/L indicates
hypernatremia, which commonly manifests as dehydration of the brain cells. These
neurological changes often present as restlessness, agitation, or confusion in the
acute care setting. Thirst is the body’s primary defense mechanism to lower sodium
concentration by increasing fluid intake. Nurses must monitor these patients closely
for worsening mental status as sodium levels fluctuate. Frequent oral care and
monitoring of mucous membranes are essential components of nursing
management for this condition.
,2. The nurse is reviewing the laboratory results for a client receiving furosemide and
notes a potassium level of 3.2 mEq/L. Which assessment finding is most important to
report to the provider?
A. Increased bowel sounds
B. Occasional premature ventricular contractions (PVCs)
C. Muscle cramps in the lower extremities
D. A blood pressure of 110/70 mmHg
Correct Answer: B
Expert Explanation: Hypokalemia, defined as a potassium level below 3.5 mEq/L,
significantly impacts cardiac electrical stability. The presence of premature
ventricular contractions indicates myocardial irritability and a risk for lethal
arrhythmias. While muscle cramps are common in hypokalemia, cardiac
manifestations take priority due to life-threatening potential. Furosemide is a loop
diuretic known to cause significant potassium wasting through the kidneys. The
nurse should advocate for potassium supplementation and continuous cardiac
monitoring to ensure patient safety.
3. A nurse is preparing to enter the room of a client diagnosed with Clostridioides
difficile (C. diff). Which infection control measure is mandatory?
A. Wearing an N95 respirator mask
,B. Donning a gown and gloves before entry
C. Performing hand hygiene with alcohol-based foam
D. Maintaining a distance of 6 feet from the patient
Correct Answer: B
Expert Explanation: C. diff requires contact precautions because the spores are
easily transmitted through direct or indirect contact. Hand hygiene must be
performed with soap and water as alcohol-based rubs are ineffective against C. diff
spores. A gown and gloves are the primary pieces of personal protective equipment
used to prevent environmental contamination. The nurse must ensure that
equipment used in the room remains dedicated to that specific patient. Proper
environmental cleaning with bleach-based solutions is also required to eradicate the
spores from the room.
4. Which client should the nurse assess first after receiving the change-of-shift report?
A. A client with a history of heart failure reporting a weight gain of 2 lbs in 24 hours
B. A client with pneumonia who has a new onset of confusion and restlessness
C. A client who had abdominal surgery 12 hours ago and reports pain as 6/10
D. A client with chronic obstructive pulmonary disease (COPD) with an SpO2 of 91%
on room air
, Correct Answer: B
Expert Explanation: New-onset confusion and restlessness in a patient with
pneumonia are early indicators of hypoxia and clinical deterioration. Using the ABC
(Airway, Breathing, Circulation) framework, respiratory compromise takes
precedence over chronic conditions or stable pain. While a 2 lb weight gain is
concerning for heart failure, it is less acute than potential respiratory failure. A
postoperative patient with 6/10 pain is expected and can be managed after
addressing the hypoxic client. Rapid assessment and intervention are required to
prevent further oxygen desaturation and organ damage.
5. While assessing a client’s blood pressure, the nurse notices that the client’s thumb
and fingers twitch when the blood pressure cuff is inflated. How should the nurse
interpret this finding?
A. It is a normal response to cuff pressure
B. The client likely has hypermagnesemia
C. The client is experiencing an allergic reaction to the cuff material
D. This is a positive Trousseau’s sign indicating hypocalcemia
Correct Answer: D
Expert Explanation: Trousseau’s sign is characterized by carpal spasms induced by
inflating a blood pressure cuff above the systolic pressure. This physical finding is a
