NUR 201/NUR201 Exam 3 V2 | Medical-
Surgical Nursing I Q&A with Rationale |
Fortis College
1. A nurse is caring for a patient with a potassium level of 6.2 mEq/L. Which of the following
interventions is the priority for this patient?
A. Administer regular insulin and 50% dextrose intravenously.
B. Encourage the patient to consume more bananas and orange juice.
C. Request a prescription for a potassium-sparing diuretic.
D. Place the patient on a low-sodium diet immediately.
Correct Answer: A
Expert Explanation: Hyperkalemia, defined as a potassium level above 5.0 mEq/L, poses a
significant risk for cardiac dysrhythmias and arrest. Administering insulin along with
dextrose is a standard emergency treatment to shift potassium from the extracellular fluid
into the intracellular space. This intervention provides a rapid, though temporary,
reduction in serum potassium levels to protect the heart.
2. An ABG result shows pH 7.28, PaCO2 55 mmHg, and HCO3 24 mEq/L. How should the nurse
interpret these findings?
A. Metabolic Acidosis
B. Metabolic Alkalosis
,C. Respiratory Acidosis
D. Respiratory Alkalosis
Correct Answer: C
Expert Explanation: The pH of 7.28 indicates acidosis because it is below the normal
range of 7.35 to 7.45. The PaCO2 of 55 mmHg is elevated, which points to a respiratory
cause for the acidotic state. Since the bicarbonate level remains within the normal range,
this is considered uncompensated respiratory acidosis, often seen in conditions like COPD
or respiratory depression.
3. Which clinical manifestation should a nurse expect to find in a patient experiencing
hypocalcemia?
A. Constipation and muscle weakness.
B. Polyuria and polydipsia.
C. Positive Chvostek’s and Trousseau’s signs.
D. Shortened QT interval on an EKG.
Correct Answer: C
Expert Explanation: Hypocalcemia increases neuromuscular excitability, leading to tetany
and spasms. A positive Chvostek’s sign (facial twitching) and Trousseau’s sign (carpal
spasm) are classic indicators of low serum calcium levels. The nurse must monitor these
patients closely for potential laryngospasm or seizures which are life-threatening
complications.
,4. A patient is prescribed Rifampin for the treatment of Tuberculosis. What education should
the nurse provide regarding this medication?
A. This drug is known to cause severe hearing loss.
B. You must take this medication with a high-fat meal.
C. Discontinue the medication once you feel better.
D. The medication may cause your urine and sweat to turn orange.
Correct Answer: D
Expert Explanation: Rifampin is a primary antitubercular agent that frequently causes a
harmless orange-red discoloration of body fluids such as urine, sweat, and tears. Patients
should be warned of this side effect to prevent unnecessary alarm during the long course of
therapy. It is also critical to emphasize adherence to the full regimen to prevent the
development of drug-resistant TB strains.
5. A nurse is assessing a patient with right-sided heart failure. Which of the following findings
is most characteristic of this condition?
A. Jugular venous distention (JVD).
B. Dyspnea on exertion.
C. Crackles in the lung bases.
D. Pink, frothy sputum.
Correct Answer: A
, Expert Explanation: Right-sided heart failure causes blood to back up into the systemic
venous circulation rather than the lungs. This leads to systemic symptoms such as jugular
venous distention, peripheral edema, and hepatomegaly. Symptoms like crackles and
frothy sputum are indicative of left-sided heart failure where blood backs up into the
pulmonary system.
6. When suctioning a patient with a tracheostomy, which action by the nurse is appropriate?
A. Apply suction while inserting the catheter.
B. Hyper-oxygenate the patient before the procedure.
C. Suction for at least 20 to 30 seconds per pass.
D. Use clean technique for the suctioning process.
Correct Answer: B
Expert Explanation: Hyper-oxygenation is essential prior to suctioning to prevent hypoxia
during the procedure. Suctioning should only be applied intermittently while withdrawing
the catheter, never while inserting it. Additionally, each suction pass should last no longer
than 10 to 15 seconds to minimize the risk of cardiac arrhythmias and significant oxygen
desaturation.
7. A patient with COPD is receiving oxygen via nasal cannula. Which oxygen flow rate is
typically recommended to avoid suppressing the hypoxic drive?
A. High-flow via non-rebreather mask
B. 6 to 8 L/min
Surgical Nursing I Q&A with Rationale |
Fortis College
1. A nurse is caring for a patient with a potassium level of 6.2 mEq/L. Which of the following
interventions is the priority for this patient?
A. Administer regular insulin and 50% dextrose intravenously.
B. Encourage the patient to consume more bananas and orange juice.
C. Request a prescription for a potassium-sparing diuretic.
D. Place the patient on a low-sodium diet immediately.
Correct Answer: A
Expert Explanation: Hyperkalemia, defined as a potassium level above 5.0 mEq/L, poses a
significant risk for cardiac dysrhythmias and arrest. Administering insulin along with
dextrose is a standard emergency treatment to shift potassium from the extracellular fluid
into the intracellular space. This intervention provides a rapid, though temporary,
reduction in serum potassium levels to protect the heart.
2. An ABG result shows pH 7.28, PaCO2 55 mmHg, and HCO3 24 mEq/L. How should the nurse
interpret these findings?
A. Metabolic Acidosis
B. Metabolic Alkalosis
,C. Respiratory Acidosis
D. Respiratory Alkalosis
Correct Answer: C
Expert Explanation: The pH of 7.28 indicates acidosis because it is below the normal
range of 7.35 to 7.45. The PaCO2 of 55 mmHg is elevated, which points to a respiratory
cause for the acidotic state. Since the bicarbonate level remains within the normal range,
this is considered uncompensated respiratory acidosis, often seen in conditions like COPD
or respiratory depression.
3. Which clinical manifestation should a nurse expect to find in a patient experiencing
hypocalcemia?
A. Constipation and muscle weakness.
B. Polyuria and polydipsia.
C. Positive Chvostek’s and Trousseau’s signs.
D. Shortened QT interval on an EKG.
Correct Answer: C
Expert Explanation: Hypocalcemia increases neuromuscular excitability, leading to tetany
and spasms. A positive Chvostek’s sign (facial twitching) and Trousseau’s sign (carpal
spasm) are classic indicators of low serum calcium levels. The nurse must monitor these
patients closely for potential laryngospasm or seizures which are life-threatening
complications.
,4. A patient is prescribed Rifampin for the treatment of Tuberculosis. What education should
the nurse provide regarding this medication?
A. This drug is known to cause severe hearing loss.
B. You must take this medication with a high-fat meal.
C. Discontinue the medication once you feel better.
D. The medication may cause your urine and sweat to turn orange.
Correct Answer: D
Expert Explanation: Rifampin is a primary antitubercular agent that frequently causes a
harmless orange-red discoloration of body fluids such as urine, sweat, and tears. Patients
should be warned of this side effect to prevent unnecessary alarm during the long course of
therapy. It is also critical to emphasize adherence to the full regimen to prevent the
development of drug-resistant TB strains.
5. A nurse is assessing a patient with right-sided heart failure. Which of the following findings
is most characteristic of this condition?
A. Jugular venous distention (JVD).
B. Dyspnea on exertion.
C. Crackles in the lung bases.
D. Pink, frothy sputum.
Correct Answer: A
, Expert Explanation: Right-sided heart failure causes blood to back up into the systemic
venous circulation rather than the lungs. This leads to systemic symptoms such as jugular
venous distention, peripheral edema, and hepatomegaly. Symptoms like crackles and
frothy sputum are indicative of left-sided heart failure where blood backs up into the
pulmonary system.
6. When suctioning a patient with a tracheostomy, which action by the nurse is appropriate?
A. Apply suction while inserting the catheter.
B. Hyper-oxygenate the patient before the procedure.
C. Suction for at least 20 to 30 seconds per pass.
D. Use clean technique for the suctioning process.
Correct Answer: B
Expert Explanation: Hyper-oxygenation is essential prior to suctioning to prevent hypoxia
during the procedure. Suctioning should only be applied intermittently while withdrawing
the catheter, never while inserting it. Additionally, each suction pass should last no longer
than 10 to 15 seconds to minimize the risk of cardiac arrhythmias and significant oxygen
desaturation.
7. A patient with COPD is receiving oxygen via nasal cannula. Which oxygen flow rate is
typically recommended to avoid suppressing the hypoxic drive?
A. High-flow via non-rebreather mask
B. 6 to 8 L/min
