NUR 201/NUR201 Exam 3 V1 | Medical-
Surgical Nursing I Q&A with Rationale |
Fortis College
1. A nurse is caring for a client who is experiencing respiratory acidosis. Which of the
following arterial blood gas (ABG) results should the nurse expect?
A. pH 7.48, PaCO2 32 mmHg
B. pH 7.30, PaCO2 52 mmHg
C. pH 7.32, HCO3 18 mEq/L
D. pH 7.50, HCO3 30 mEq/L
Correct Answer: B
Expert Explanation: Respiratory acidosis is characterized by a low pH (below 7.35) and
an elevated PaCO2 (above 45 mmHg). This condition often occurs when there is
hypoventilation leading to the retention of carbon dioxide. The nurse should monitor the
patient’s respiratory rate and depth to identify the underlying cause of the imbalance.
2. A nurse is assessing a client for Trousseau’s sign. Which of the following electrolyte
imbalances is the nurse screening for?
A. Hyperkalemia
B. Hypocalcemia
C. Hyponatremia
,D. Hypermagnesemia
Correct Answer: B
Expert Explanation: Trousseau’s sign involves a carpal spasm induced by inflating a blood
pressure cuff above the systolic pressure for a few minutes. This is a classic clinical
indicator of hypocalcemia or hypomagnesemia due to increased neuromuscular
excitability. The nurse must also look for Chvostek’s sign, which is a facial twitching elicited
by tapping the facial nerve.
3. Which of the following interventions is a priority for a client in the immediate
postoperative period who is under general anesthesia?
A. Monitoring urine output every 4 hours
B. Assessing for surgical site infection
C. Maintaining a patent airway
D. Administering oral pain medication
Correct Answer: C
Expert Explanation: In the PACU, the first priority of the nurse is to ensure that the client’s
airway remains open and that ventilation is adequate. General anesthesia can depress the
respiratory drive and relax the muscles of the upper airway. The nurse must frequently
assess oxygen saturation levels and respiratory effort to prevent hypoxia.
, 4. A client is scheduled for surgery. Who is legally responsible for obtaining the client’s
informed consent?
A. The surgeon
B. The nurse
C. The anesthesiologist
D. The unit manager
Correct Answer: A
Expert Explanation: The surgeon is legally responsible for explaining the procedure, risks,
benefits, and alternatives to the patient. While the nurse may witness the signature, they do
not provide the detailed medical explanation required for consent. If the patient does not
understand the procedure, the nurse must notify the surgeon to return and provide further
clarification.
5. Which clinical manifestation should a nurse monitor for in a patient with a potassium level
of 6.2 mEq/L?
A. Flat T waves
B. Prominent U waves
C. Hyporeflexia
D. Peaked T waves
Correct Answer: D
Surgical Nursing I Q&A with Rationale |
Fortis College
1. A nurse is caring for a client who is experiencing respiratory acidosis. Which of the
following arterial blood gas (ABG) results should the nurse expect?
A. pH 7.48, PaCO2 32 mmHg
B. pH 7.30, PaCO2 52 mmHg
C. pH 7.32, HCO3 18 mEq/L
D. pH 7.50, HCO3 30 mEq/L
Correct Answer: B
Expert Explanation: Respiratory acidosis is characterized by a low pH (below 7.35) and
an elevated PaCO2 (above 45 mmHg). This condition often occurs when there is
hypoventilation leading to the retention of carbon dioxide. The nurse should monitor the
patient’s respiratory rate and depth to identify the underlying cause of the imbalance.
2. A nurse is assessing a client for Trousseau’s sign. Which of the following electrolyte
imbalances is the nurse screening for?
A. Hyperkalemia
B. Hypocalcemia
C. Hyponatremia
,D. Hypermagnesemia
Correct Answer: B
Expert Explanation: Trousseau’s sign involves a carpal spasm induced by inflating a blood
pressure cuff above the systolic pressure for a few minutes. This is a classic clinical
indicator of hypocalcemia or hypomagnesemia due to increased neuromuscular
excitability. The nurse must also look for Chvostek’s sign, which is a facial twitching elicited
by tapping the facial nerve.
3. Which of the following interventions is a priority for a client in the immediate
postoperative period who is under general anesthesia?
A. Monitoring urine output every 4 hours
B. Assessing for surgical site infection
C. Maintaining a patent airway
D. Administering oral pain medication
Correct Answer: C
Expert Explanation: In the PACU, the first priority of the nurse is to ensure that the client’s
airway remains open and that ventilation is adequate. General anesthesia can depress the
respiratory drive and relax the muscles of the upper airway. The nurse must frequently
assess oxygen saturation levels and respiratory effort to prevent hypoxia.
, 4. A client is scheduled for surgery. Who is legally responsible for obtaining the client’s
informed consent?
A. The surgeon
B. The nurse
C. The anesthesiologist
D. The unit manager
Correct Answer: A
Expert Explanation: The surgeon is legally responsible for explaining the procedure, risks,
benefits, and alternatives to the patient. While the nurse may witness the signature, they do
not provide the detailed medical explanation required for consent. If the patient does not
understand the procedure, the nurse must notify the surgeon to return and provide further
clarification.
5. Which clinical manifestation should a nurse monitor for in a patient with a potassium level
of 6.2 mEq/L?
A. Flat T waves
B. Prominent U waves
C. Hyporeflexia
D. Peaked T waves
Correct Answer: D
