NUR 201/NUR201 Exam 2 V3 | Medical-
Surgical Nursing I Q&A with Rationale |
Fortis College
1. A nurse is assessing a patient with a serum potassium level of 3.2 mEq/L. Which medication
in the patient’s history should the nurse identify as a significant risk factor for cardiac
dysrhythmias?
A. Warfarin
B. Digoxin
C. Metformin
D. Albuterol
Correct Answer: B
Expert Explanation: Hypokalemia increases the risk of digoxin toxicity because potassium
and digoxin compete for binding sites on the sodium-potassium ATPase pump. Low
potassium levels allow more digoxin to bind, potentially leading to life-threatening
arrhythmias. The nurse must monitor serum electrolytes closely for any patient receiving
digitalis preparations.
2. A patient’s arterial blood gas (ABG) results are: pH 7.30, PaCO2 52 mmHg, and HCO3 24
mEq/L. How should the nurse interpret these findings?
A. Metabolic Acidosis
,B. Respiratory Alkalosis
C. Metabolic Alkalosis
D. Respiratory Acidosis
Correct Answer: D
Expert Explanation: A pH below 7.35 indicates acidosis, and a PaCO2 above 45 mmHg
indicates a respiratory cause for the imbalance. Since the bicarbonate level is within the
normal range, this represents uncompensated respiratory acidosis. This condition typically
occurs in patients with hypoventilation or impaired gas exchange.
3. During the preoperative assessment, a patient reports an allergy to bananas and avocados.
Which action is most important for the nurse to take?
A. Notify the dietitian to adjust the patient’s menu.
B. Document the food allergies in the medical record only.
C. Administer an antihistamine before the procedure.
D. Alert the surgical team to a potential latex allergy.
Correct Answer: D
Expert Explanation: There is a known cross-reactivity between certain foods, such as
bananas, avocados, and chestnuts, and latex. Patients with these food allergies are at a
higher risk for developing a latex allergy or anaphylaxis during surgery. The nurse must
, ensure that the surgical suite is prepared for a latex-free environment to maintain patient
safety.
4. A nurse is caring for a postoperative patient who has not voided for 8 hours. What is the
priority nursing intervention?
A. Encourage increased fluid intake.
B. Perform a bladder scan.
C. Insert an indwelling urinary catheter.
D. Notify the healthcare provider immediately.
Correct Answer: B
Expert Explanation: Postoperative urinary retention is a common complication due to the
effects of anesthesia and analgesics. A bladder scan is a non-invasive assessment tool used
to determine the volume of urine in the bladder. This objective data helps the nurse decide
if further interventions, such as catheterization, are necessary according to the facility
protocol.
5. A patient with COPD is receiving oxygen at 2 L/min via nasal cannula. Which finding
indicates that the oxygen therapy is effective?
A. Respiratory rate of 28 breaths per minute.
B. Increased use of accessory muscles.
C. PaCO2 level of 55 mmHg.
Surgical Nursing I Q&A with Rationale |
Fortis College
1. A nurse is assessing a patient with a serum potassium level of 3.2 mEq/L. Which medication
in the patient’s history should the nurse identify as a significant risk factor for cardiac
dysrhythmias?
A. Warfarin
B. Digoxin
C. Metformin
D. Albuterol
Correct Answer: B
Expert Explanation: Hypokalemia increases the risk of digoxin toxicity because potassium
and digoxin compete for binding sites on the sodium-potassium ATPase pump. Low
potassium levels allow more digoxin to bind, potentially leading to life-threatening
arrhythmias. The nurse must monitor serum electrolytes closely for any patient receiving
digitalis preparations.
2. A patient’s arterial blood gas (ABG) results are: pH 7.30, PaCO2 52 mmHg, and HCO3 24
mEq/L. How should the nurse interpret these findings?
A. Metabolic Acidosis
,B. Respiratory Alkalosis
C. Metabolic Alkalosis
D. Respiratory Acidosis
Correct Answer: D
Expert Explanation: A pH below 7.35 indicates acidosis, and a PaCO2 above 45 mmHg
indicates a respiratory cause for the imbalance. Since the bicarbonate level is within the
normal range, this represents uncompensated respiratory acidosis. This condition typically
occurs in patients with hypoventilation or impaired gas exchange.
3. During the preoperative assessment, a patient reports an allergy to bananas and avocados.
Which action is most important for the nurse to take?
A. Notify the dietitian to adjust the patient’s menu.
B. Document the food allergies in the medical record only.
C. Administer an antihistamine before the procedure.
D. Alert the surgical team to a potential latex allergy.
Correct Answer: D
Expert Explanation: There is a known cross-reactivity between certain foods, such as
bananas, avocados, and chestnuts, and latex. Patients with these food allergies are at a
higher risk for developing a latex allergy or anaphylaxis during surgery. The nurse must
, ensure that the surgical suite is prepared for a latex-free environment to maintain patient
safety.
4. A nurse is caring for a postoperative patient who has not voided for 8 hours. What is the
priority nursing intervention?
A. Encourage increased fluid intake.
B. Perform a bladder scan.
C. Insert an indwelling urinary catheter.
D. Notify the healthcare provider immediately.
Correct Answer: B
Expert Explanation: Postoperative urinary retention is a common complication due to the
effects of anesthesia and analgesics. A bladder scan is a non-invasive assessment tool used
to determine the volume of urine in the bladder. This objective data helps the nurse decide
if further interventions, such as catheterization, are necessary according to the facility
protocol.
5. A patient with COPD is receiving oxygen at 2 L/min via nasal cannula. Which finding
indicates that the oxygen therapy is effective?
A. Respiratory rate of 28 breaths per minute.
B. Increased use of accessory muscles.
C. PaCO2 level of 55 mmHg.
