NUR 104/NUR104 Exam 4 V2 | 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 of the
following findings should the nurse expect to observe?
A. Hyperactive bowel sounds
B. Peaked T waves on ECG
C. Muscle weakness and leg cramps
D. Hyperreflexia
Correct Answer: C
Expert Explanation: Hypokalemia is defined as a serum potassium level below 3.5 mEq/L
and frequently presents with muscle weakness or cramps. The nurse should also monitor
for cardiac dysrhythmias and flattened T waves on the electrocardiogram. It is critical to
address this deficiency promptly to prevent respiratory failure or cardiac arrest.
2. Which of the following ABG results indicates metabolic acidosis?
A. pH 7.30, PaCO2 40 mmHg, HCO3 18 mEq/L
B. pH 7.48, PaCO2 30 mmHg, HCO3 24 mEq/L
C. pH 7.32, PaCO2 50 mmHg, HCO3 28 mEq/L
D. pH 7.50, PaCO2 45 mmHg, HCO3 34 mEq/L
,Correct Answer: A
Expert Explanation: In metabolic acidosis, the pH is lower than 7.35 and the bicarbonate
(HCO3) level is lower than 22 mEq/L. This condition can be caused by renal failure,
diabetic ketoacidosis, or severe diarrhea. The nurse must identify the underlying cause and
monitor the patient for compensatory Kussmaul respirations.
3. A nurse is assessing a pressure injury that has full-thickness tissue loss with visible
subcutaneous fat, but no bone or muscle is exposed. How should the nurse stage this injury?
A. Stage 3
B. Stage 2
C. Stage 1
D. Stage 4
Correct Answer: A
Expert Explanation: A Stage 3 pressure injury involves full-thickness skin loss involving
damage to or necrosis of subcutaneous tissue that may extend down to, but not through,
underlying fascia. Bone, tendon, and muscle are not exposed at this stage. Slough or eschar
may be present but does not obscure the depth of tissue loss.
4. Which assessment finding is a priority for a client who is 2 hours post-operative following
abdominal surgery?
A. Nausea and one episode of vomiting
B. Slight serosanguineous drainage on the dressing
, C. Urine output of 20 mL/hr over the last 2 hours
D. Pain level of 6 on a scale of 0 to 10
Correct Answer: C
Expert Explanation: A urine output of less than 30 mL/hr indicates poor renal perfusion
and may be a sign of hypovolemia or impending shock. While pain and nausea are common
post-operative issues, they are not immediately life-threatening. The nurse must report this
finding to the provider and assess the client for signs of internal hemorrhage.
5. A client is receiving oxygen via a simple face mask at 6 L/min. The nurse knows that this
device can deliver what percentage of oxygen (FiO2)?
A. 24% to 44%
B. 60% to 90%
C. 35% to 50%
D. 100%
Correct Answer: C
Expert Explanation: A simple face mask is used for short-term oxygen therapy and can
deliver concentrations of 35% to 50% FiO2 when flow rates are set between 6 and 12
L/min. It is important to ensure the flow rate is at least 5 L/min to prevent rebreathing of
carbon dioxide. The nurse should also monitor the skin under the mask and around the
ears for pressure sores.
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 of the
following findings should the nurse expect to observe?
A. Hyperactive bowel sounds
B. Peaked T waves on ECG
C. Muscle weakness and leg cramps
D. Hyperreflexia
Correct Answer: C
Expert Explanation: Hypokalemia is defined as a serum potassium level below 3.5 mEq/L
and frequently presents with muscle weakness or cramps. The nurse should also monitor
for cardiac dysrhythmias and flattened T waves on the electrocardiogram. It is critical to
address this deficiency promptly to prevent respiratory failure or cardiac arrest.
2. Which of the following ABG results indicates metabolic acidosis?
A. pH 7.30, PaCO2 40 mmHg, HCO3 18 mEq/L
B. pH 7.48, PaCO2 30 mmHg, HCO3 24 mEq/L
C. pH 7.32, PaCO2 50 mmHg, HCO3 28 mEq/L
D. pH 7.50, PaCO2 45 mmHg, HCO3 34 mEq/L
,Correct Answer: A
Expert Explanation: In metabolic acidosis, the pH is lower than 7.35 and the bicarbonate
(HCO3) level is lower than 22 mEq/L. This condition can be caused by renal failure,
diabetic ketoacidosis, or severe diarrhea. The nurse must identify the underlying cause and
monitor the patient for compensatory Kussmaul respirations.
3. A nurse is assessing a pressure injury that has full-thickness tissue loss with visible
subcutaneous fat, but no bone or muscle is exposed. How should the nurse stage this injury?
A. Stage 3
B. Stage 2
C. Stage 1
D. Stage 4
Correct Answer: A
Expert Explanation: A Stage 3 pressure injury involves full-thickness skin loss involving
damage to or necrosis of subcutaneous tissue that may extend down to, but not through,
underlying fascia. Bone, tendon, and muscle are not exposed at this stage. Slough or eschar
may be present but does not obscure the depth of tissue loss.
4. Which assessment finding is a priority for a client who is 2 hours post-operative following
abdominal surgery?
A. Nausea and one episode of vomiting
B. Slight serosanguineous drainage on the dressing
, C. Urine output of 20 mL/hr over the last 2 hours
D. Pain level of 6 on a scale of 0 to 10
Correct Answer: C
Expert Explanation: A urine output of less than 30 mL/hr indicates poor renal perfusion
and may be a sign of hypovolemia or impending shock. While pain and nausea are common
post-operative issues, they are not immediately life-threatening. The nurse must report this
finding to the provider and assess the client for signs of internal hemorrhage.
5. A client is receiving oxygen via a simple face mask at 6 L/min. The nurse knows that this
device can deliver what percentage of oxygen (FiO2)?
A. 24% to 44%
B. 60% to 90%
C. 35% to 50%
D. 100%
Correct Answer: C
Expert Explanation: A simple face mask is used for short-term oxygen therapy and can
deliver concentrations of 35% to 50% FiO2 when flow rates are set between 6 and 12
L/min. It is important to ensure the flow rate is at least 5 L/min to prevent rebreathing of
carbon dioxide. The nurse should also monitor the skin under the mask and around the
ears for pressure sores.
