NUR 201/NUR201 Exam 1 V1 | Medical-
Surgical Nursing I Q&A with Rationale |
Fortis College
1. A nurse is assessing a client with fluid volume excess. Which of the following clinical
manifestations should the nurse expect to observe?
A. Flat neck veins while supine
B. Increased hematocrit levels
C. Full, bounding peripheral pulses
D. Decreased blood pressure
Correct Answer: C
Expert Explanation: Fluid volume excess leads to an increase in circulating blood volume,
which typically manifests as bounding pulses and jugular vein distension. Other common
signs include peripheral edema, crackles in the lungs, and weight gain. The hematocrit is
usually decreased due to hemodilution rather than increased.
2. A client is diagnosed with hypokalemia. Which of the following cardiac changes should the
nurse monitor for on the EKG?
A. Tall, peaked T waves
B. Presence of U waves
C. Shortened QT interval
,D. Widened QRS complex
Correct Answer: B
Expert Explanation: Hypokalemia often causes the appearance of a U wave and a flattened
or inverted T wave on an EKG. These changes indicate delayed ventricular repolarization
due to low potassium levels. Tall, peaked T waves are conversely associated with
hyperkalemia, not hypokalemia.
3. The nurse is caring for a client with a suspected diagnosis of respiratory acidosis. Which of
the following arterial blood gas (ABG) results supports this diagnosis?
A. pH 7.30, PaCO2 50 mm Hg
B. pH 7.50, PaCO2 30 mm Hg
C. pH 7.32, HCO3 18 mEq/L
D. pH 7.48, HCO3 28 mEq/L
Correct Answer: A
Expert Explanation: Respiratory acidosis is characterized by a low pH (below 7.35) and
an elevated PaCO2 (above 45 mm Hg). This condition occurs when the lungs are unable to
effectively remove carbon dioxide, leading to an accumulation of acid. Choice C represents
metabolic acidosis, as indicated by the low bicarbonate level.
4. A preoperative nurse is preparing a client for surgery. What is the nurse’s primary
responsibility regarding informed consent?
A. Witnessing the client’s signature on the consent form
, B. Obtaining the signature of the client for the surgery
C. Explaining the risks and benefits of the procedure
D. Choosing the specific surgical technique to be used
Correct Answer: A
Expert Explanation: The nurse’s role in informed consent is to witness the client’s
signature and verify that the client appears competent to give consent. It is the surgeon’s
legal responsibility to explain the procedure, risks, benefits, and alternatives. The nurse
should notify the surgeon if the client expresses a lack of understanding regarding the
procedure.
5. During a surgery, the anesthesiologist notices the client has developed a sudden rise in
end-tidal CO2 and a high temperature. Which medication should the nurse anticipate
administering?
A. Atropine sulfate
B. Dantrolene sodium
C. Epinephrine
D. Naloxone
Correct Answer: B
Expert Explanation: Malignant hyperthermia is a life-threatening complication of general
anesthesia characterized by rapid hypermetabolism, muscle rigidity, and hyperthermia.
Surgical Nursing I Q&A with Rationale |
Fortis College
1. A nurse is assessing a client with fluid volume excess. Which of the following clinical
manifestations should the nurse expect to observe?
A. Flat neck veins while supine
B. Increased hematocrit levels
C. Full, bounding peripheral pulses
D. Decreased blood pressure
Correct Answer: C
Expert Explanation: Fluid volume excess leads to an increase in circulating blood volume,
which typically manifests as bounding pulses and jugular vein distension. Other common
signs include peripheral edema, crackles in the lungs, and weight gain. The hematocrit is
usually decreased due to hemodilution rather than increased.
2. A client is diagnosed with hypokalemia. Which of the following cardiac changes should the
nurse monitor for on the EKG?
A. Tall, peaked T waves
B. Presence of U waves
C. Shortened QT interval
,D. Widened QRS complex
Correct Answer: B
Expert Explanation: Hypokalemia often causes the appearance of a U wave and a flattened
or inverted T wave on an EKG. These changes indicate delayed ventricular repolarization
due to low potassium levels. Tall, peaked T waves are conversely associated with
hyperkalemia, not hypokalemia.
3. The nurse is caring for a client with a suspected diagnosis of respiratory acidosis. Which of
the following arterial blood gas (ABG) results supports this diagnosis?
A. pH 7.30, PaCO2 50 mm Hg
B. pH 7.50, PaCO2 30 mm Hg
C. pH 7.32, HCO3 18 mEq/L
D. pH 7.48, HCO3 28 mEq/L
Correct Answer: A
Expert Explanation: Respiratory acidosis is characterized by a low pH (below 7.35) and
an elevated PaCO2 (above 45 mm Hg). This condition occurs when the lungs are unable to
effectively remove carbon dioxide, leading to an accumulation of acid. Choice C represents
metabolic acidosis, as indicated by the low bicarbonate level.
4. A preoperative nurse is preparing a client for surgery. What is the nurse’s primary
responsibility regarding informed consent?
A. Witnessing the client’s signature on the consent form
, B. Obtaining the signature of the client for the surgery
C. Explaining the risks and benefits of the procedure
D. Choosing the specific surgical technique to be used
Correct Answer: A
Expert Explanation: The nurse’s role in informed consent is to witness the client’s
signature and verify that the client appears competent to give consent. It is the surgeon’s
legal responsibility to explain the procedure, risks, benefits, and alternatives. The nurse
should notify the surgeon if the client expresses a lack of understanding regarding the
procedure.
5. During a surgery, the anesthesiologist notices the client has developed a sudden rise in
end-tidal CO2 and a high temperature. Which medication should the nurse anticipate
administering?
A. Atropine sulfate
B. Dantrolene sodium
C. Epinephrine
D. Naloxone
Correct Answer: B
Expert Explanation: Malignant hyperthermia is a life-threatening complication of general
anesthesia characterized by rapid hypermetabolism, muscle rigidity, and hyperthermia.
