NUR 104/NUR104 Exam 4 V1 | Foundations
of Nursing Q&A with Rationale | Fortis
College
1. A patient is admitted with a serum sodium level of 128 mEq/L. Which nursing intervention
is most appropriate for a patient with this condition?
A. Implement seizure precautions and monitor neurological status
B. Administer a loop diuretic as ordered
C. Encourage increased fluid intake to 3L per day
D. Provide a diet rich in bananas and oranges
Correct Answer: A
Expert Explanation: A serum sodium level of 128 mEq/L indicates hyponatremia, which
can cause cerebral edema and increase the risk of seizures. The nurse must prioritize safety
by implementing seizure precautions and performing frequent neurological assessments.
Restricting fluids is often required rather than increasing them to prevent further dilution
of sodium.
2. When interpreting arterial blood gas (ABG) results, the nurse notes a pH of 7.30, a PaCO2
of 52 mmHg, and an HCO3 of 25 mEq/L. Which condition do these results indicate?
A. Metabolic Acidosis
B. Respiratory Acidosis
,C. Respiratory Alkalosis
D. Metabolic Alkalosis
Correct Answer: B
Expert Explanation: The pH level of 7.30 is below the normal range of 7.35-7.45,
indicating acidosis. The PaCO2 is elevated above the normal range of 35-45 mmHg, which
suggests the respiratory system is the cause. Since the HCO3 is within the normal range, the
imbalance is categorized as uncompensated respiratory acidosis.
3. A nurse is caring for a postoperative patient who reports sudden chest pain and shortness
of breath. Which complication should the nurse suspect first?
A. Pulmonary Embolism
B. Pneumonia
C. Atelectasis
D. Hypovolemic Shock
Correct Answer: A
Expert Explanation: Sudden onset of chest pain and dyspnea in a postoperative patient
are classic signs of a pulmonary embolism. This is a medical emergency caused by a blood
clot traveling to the lungs. The nurse should immediately assess oxygen saturation and
notify the surgical team.
, 4. The nurse is preparing a patient for surgery and notices the surgical consent form is not
signed. What is the nurse’s primary responsibility regarding the consent?
A. Explain the risks and benefits of the surgery to the patient
B. Witness the patient’s signature and ensure they understand the procedure
C. Ask the family to sign the consent form on the patient’s behalf
D. Notify the surgeon that the consent form has not been signed
Correct Answer: D
Expert Explanation: The surgeon is legally responsible for explaining the procedure and
obtaining informed consent. The nurse’s role is to witness the signature and verify that the
patient has been informed. If the form is not signed, the nurse must contact the surgeon to
complete the process before the patient is medicated.
5. A patient is receiving an intravenous infusion of 0.45% normal saline. How is this solution
classified?
A. Isotonic
B. Hypertonic
C. Colloid
D. Hypotonic
Correct Answer: D
of Nursing Q&A with Rationale | Fortis
College
1. A patient is admitted with a serum sodium level of 128 mEq/L. Which nursing intervention
is most appropriate for a patient with this condition?
A. Implement seizure precautions and monitor neurological status
B. Administer a loop diuretic as ordered
C. Encourage increased fluid intake to 3L per day
D. Provide a diet rich in bananas and oranges
Correct Answer: A
Expert Explanation: A serum sodium level of 128 mEq/L indicates hyponatremia, which
can cause cerebral edema and increase the risk of seizures. The nurse must prioritize safety
by implementing seizure precautions and performing frequent neurological assessments.
Restricting fluids is often required rather than increasing them to prevent further dilution
of sodium.
2. When interpreting arterial blood gas (ABG) results, the nurse notes a pH of 7.30, a PaCO2
of 52 mmHg, and an HCO3 of 25 mEq/L. Which condition do these results indicate?
A. Metabolic Acidosis
B. Respiratory Acidosis
,C. Respiratory Alkalosis
D. Metabolic Alkalosis
Correct Answer: B
Expert Explanation: The pH level of 7.30 is below the normal range of 7.35-7.45,
indicating acidosis. The PaCO2 is elevated above the normal range of 35-45 mmHg, which
suggests the respiratory system is the cause. Since the HCO3 is within the normal range, the
imbalance is categorized as uncompensated respiratory acidosis.
3. A nurse is caring for a postoperative patient who reports sudden chest pain and shortness
of breath. Which complication should the nurse suspect first?
A. Pulmonary Embolism
B. Pneumonia
C. Atelectasis
D. Hypovolemic Shock
Correct Answer: A
Expert Explanation: Sudden onset of chest pain and dyspnea in a postoperative patient
are classic signs of a pulmonary embolism. This is a medical emergency caused by a blood
clot traveling to the lungs. The nurse should immediately assess oxygen saturation and
notify the surgical team.
, 4. The nurse is preparing a patient for surgery and notices the surgical consent form is not
signed. What is the nurse’s primary responsibility regarding the consent?
A. Explain the risks and benefits of the surgery to the patient
B. Witness the patient’s signature and ensure they understand the procedure
C. Ask the family to sign the consent form on the patient’s behalf
D. Notify the surgeon that the consent form has not been signed
Correct Answer: D
Expert Explanation: The surgeon is legally responsible for explaining the procedure and
obtaining informed consent. The nurse’s role is to witness the signature and verify that the
patient has been informed. If the form is not signed, the nurse must contact the surgeon to
complete the process before the patient is medicated.
5. A patient is receiving an intravenous infusion of 0.45% normal saline. How is this solution
classified?
A. Isotonic
B. Hypertonic
C. Colloid
D. Hypotonic
Correct Answer: D
