NUR 104/NUR104 Exam 2 V3 | Foundations
of Nursing Q&A with Rationale | Fortis
College
1. A nurse is caring for a client with a serum potassium level of 2.8 mEq/L. Which assessment
finding should the nurse prioritize?
A. Increased bowel sounds
B. Hyperactive deep tendon reflexes
C. Cardiac dysrhythmias
D. Tall, peaked T-waves on ECG
Correct Answer: C
Expert Explanation: Hypokalemia, defined as a potassium level below 3.5 mEq/L,
significantly affects cardiac electrical conduction. The nurse must prioritize cardiac
monitoring because low potassium can lead to life-threatening ventricular arrhythmias.
Other signs include muscle weakness, leg cramps, and decreased deep tendon reflexes.
2. The nurse is reviewing the arterial blood gas (ABG) results for a client with COPD: pH 7.31,
PaCO2 52 mmHg, HCO3 26 mEq/L. How should the nurse interpret these results?
A. Respiratory Acidosis
B. Respiratory Alkalosis
C. Metabolic Acidosis
,D. Metabolic Alkalosis
Correct Answer: A
Expert Explanation: The pH of 7.31 indicates acidosis as it is below the normal range of
7.35 to 7.45. The elevated PaCO2 of 52 mmHg suggests a respiratory cause, which is
common in patients with COPD who retain carbon dioxide. The normal bicarbonate level
indicates that the kidneys have not yet fully compensated for the imbalance.
3. A client has an order for a hypertonic intravenous solution. Which of the following fluids
should the nurse prepare to administer?
A. 0.45% Sodium Chloride
B. 0.9% Sodium Chloride
C. 5% Dextrose in 0.9% Sodium Chloride
D. Lactated Ringer’s
Correct Answer: C
Expert Explanation: Hypertonic solutions have a higher osmolarity than plasma, causing
water to move out of the cells and into the intravascular space. D5NS (5% Dextrose in 0.9%
NaCl) is a common hypertonic fluid used to treat specific electrolyte imbalances. The nurse
must monitor the client closely for signs of fluid volume overload when administering
hypertonic solutions.
, 4. While assessing a client’s surgical incision, the nurse notes a partial separation of the
wound layers with protrusion of visceral organs. What is the nurse’s immediate priority?
A. Apply a dry sterile dressing and call the surgeon.
B. Push the organs back into the abdominal cavity.
C. Cover the area with sterile dressings soaked in sterile normal saline.
D. Place the client in a high-Fowler’s position.
Correct Answer: C
Expert Explanation: This scenario describes wound evisceration, which is a medical
emergency requiring immediate surgical intervention. Covering the exposed organs with
sterile, saline-soaked dressings prevents the tissues from drying out and reduces the risk of
infection. The nurse should also notify the surgical team immediately and keep the client
NPO.
5. A nurse is teaching a postoperative client how to use an incentive spirometer. Which
instruction should the nurse include?
A. Exhale forcefully into the device as hard as possible.
B. Perform the exercise twice a day after meals.
C. Use the device only if you feel short of breath.
D. Inhale slowly and deeply to elevate the cylinder.
Correct Answer: D
of Nursing Q&A with Rationale | Fortis
College
1. A nurse is caring for a client with a serum potassium level of 2.8 mEq/L. Which assessment
finding should the nurse prioritize?
A. Increased bowel sounds
B. Hyperactive deep tendon reflexes
C. Cardiac dysrhythmias
D. Tall, peaked T-waves on ECG
Correct Answer: C
Expert Explanation: Hypokalemia, defined as a potassium level below 3.5 mEq/L,
significantly affects cardiac electrical conduction. The nurse must prioritize cardiac
monitoring because low potassium can lead to life-threatening ventricular arrhythmias.
Other signs include muscle weakness, leg cramps, and decreased deep tendon reflexes.
2. The nurse is reviewing the arterial blood gas (ABG) results for a client with COPD: pH 7.31,
PaCO2 52 mmHg, HCO3 26 mEq/L. How should the nurse interpret these results?
A. Respiratory Acidosis
B. Respiratory Alkalosis
C. Metabolic Acidosis
,D. Metabolic Alkalosis
Correct Answer: A
Expert Explanation: The pH of 7.31 indicates acidosis as it is below the normal range of
7.35 to 7.45. The elevated PaCO2 of 52 mmHg suggests a respiratory cause, which is
common in patients with COPD who retain carbon dioxide. The normal bicarbonate level
indicates that the kidneys have not yet fully compensated for the imbalance.
3. A client has an order for a hypertonic intravenous solution. Which of the following fluids
should the nurse prepare to administer?
A. 0.45% Sodium Chloride
B. 0.9% Sodium Chloride
C. 5% Dextrose in 0.9% Sodium Chloride
D. Lactated Ringer’s
Correct Answer: C
Expert Explanation: Hypertonic solutions have a higher osmolarity than plasma, causing
water to move out of the cells and into the intravascular space. D5NS (5% Dextrose in 0.9%
NaCl) is a common hypertonic fluid used to treat specific electrolyte imbalances. The nurse
must monitor the client closely for signs of fluid volume overload when administering
hypertonic solutions.
, 4. While assessing a client’s surgical incision, the nurse notes a partial separation of the
wound layers with protrusion of visceral organs. What is the nurse’s immediate priority?
A. Apply a dry sterile dressing and call the surgeon.
B. Push the organs back into the abdominal cavity.
C. Cover the area with sterile dressings soaked in sterile normal saline.
D. Place the client in a high-Fowler’s position.
Correct Answer: C
Expert Explanation: This scenario describes wound evisceration, which is a medical
emergency requiring immediate surgical intervention. Covering the exposed organs with
sterile, saline-soaked dressings prevents the tissues from drying out and reduces the risk of
infection. The nurse should also notify the surgical team immediately and keep the client
NPO.
5. A nurse is teaching a postoperative client how to use an incentive spirometer. Which
instruction should the nurse include?
A. Exhale forcefully into the device as hard as possible.
B. Perform the exercise twice a day after meals.
C. Use the device only if you feel short of breath.
D. Inhale slowly and deeply to elevate the cylinder.
Correct Answer: D
