NUR 201/NUR201 Exam 1 V2 | Medical-
Surgical Nursing I Q&A with Rationale |
Fortis College
1. A nurse is preparing a client for an elective surgery. Which of the following tasks is the
primary responsibility of the surgeon regarding informed consent?
A. Witnessing the client’s signature on the consent form
B. Explaining the risks, benefits, and alternatives of the surgical procedure
C. Ensuring the client has signed the form before preoperative medications are given
D. Verifying that the client understands the information provided
Correct Answer: B
Expert Explanation: The surgeon is legally responsible for providing a detailed
explanation of the surgery including risks and benefits. The nurse’s role is to witness the
signature and clarify minor points or call the surgeon if the patient is confused. Informed
consent must be obtained before any sedative medications are administered to ensure the
client is competent.
2. A client presents with a serum potassium level of 2.8 mEq/L. Which assessment finding
should the nurse prioritize?
A. Cardiac dysrhythmias on the ECG monitor
B. Decreased bowel sounds
,C. Muscle weakness in the lower extremities
D. Increased sensitivity to digitalis
Correct Answer: A
Expert Explanation: Hypokalemia significantly affects cardiac conduction and can lead to
life-threatening arrhythmias like ventricular tachycardia. While muscle weakness and
decreased bowel sounds are signs of low potassium, cardiac stability is the highest priority.
The nurse must monitor the ECG closely and prepare for potassium replacement therapy.
3. Which arterial blood gas (ABG) result is indicative of uncompensated respiratory acidosis?
A. pH 7.48, PaCO2 32, HCO3 24
B. pH 7.32, PaCO2 40, HCO3 18
C. pH 7.30, PaCO2 55, HCO3 24
D. pH 7.35, PaCO2 45, HCO3 26
Correct Answer: C
Expert Explanation: In respiratory acidosis, the pH is below 7.35 and the PaCO2 is
elevated above 45 mmHg. An uncompensated state is indicated by a normal bicarbonate
(HCO3) level between 22 and 26 mEq/L. This condition often results from hypoventilation
or obstructive lung diseases.
, 4. A nurse is caring for a postoperative client. What is the most effective nursing intervention
to prevent atelectasis?
A. Administering humidified oxygen via nasal cannula
B. Encouraging the use of an incentive spirometer every hour while awake
C. Maintaining the client in a supine position
D. Restricting fluid intake to decrease pulmonary congestion
Correct Answer: B
Expert Explanation: Incentive spirometry promotes deep breathing and alveolar
expansion which prevents the collapse of lung tissue. It is a standard postoperative
intervention to reduce the risk of pneumonia and atelectasis. The nurse should also
encourage early ambulation and frequent position changes to further support respiratory
function.
5. During a surgical procedure, the anesthesiologist notes a sudden rise in the client’s end-
tidal CO2 and muscle rigidity. What is the nurse’s priority action?
A. Apply cooling blankets to the client
B. Administer Dantrolene sodium as ordered
C. Increase the concentration of inhalation anesthetic
D. Check the client’s blood pressure
Correct Answer: B
Surgical Nursing I Q&A with Rationale |
Fortis College
1. A nurse is preparing a client for an elective surgery. Which of the following tasks is the
primary responsibility of the surgeon regarding informed consent?
A. Witnessing the client’s signature on the consent form
B. Explaining the risks, benefits, and alternatives of the surgical procedure
C. Ensuring the client has signed the form before preoperative medications are given
D. Verifying that the client understands the information provided
Correct Answer: B
Expert Explanation: The surgeon is legally responsible for providing a detailed
explanation of the surgery including risks and benefits. The nurse’s role is to witness the
signature and clarify minor points or call the surgeon if the patient is confused. Informed
consent must be obtained before any sedative medications are administered to ensure the
client is competent.
2. A client presents with a serum potassium level of 2.8 mEq/L. Which assessment finding
should the nurse prioritize?
A. Cardiac dysrhythmias on the ECG monitor
B. Decreased bowel sounds
,C. Muscle weakness in the lower extremities
D. Increased sensitivity to digitalis
Correct Answer: A
Expert Explanation: Hypokalemia significantly affects cardiac conduction and can lead to
life-threatening arrhythmias like ventricular tachycardia. While muscle weakness and
decreased bowel sounds are signs of low potassium, cardiac stability is the highest priority.
The nurse must monitor the ECG closely and prepare for potassium replacement therapy.
3. Which arterial blood gas (ABG) result is indicative of uncompensated respiratory acidosis?
A. pH 7.48, PaCO2 32, HCO3 24
B. pH 7.32, PaCO2 40, HCO3 18
C. pH 7.30, PaCO2 55, HCO3 24
D. pH 7.35, PaCO2 45, HCO3 26
Correct Answer: C
Expert Explanation: In respiratory acidosis, the pH is below 7.35 and the PaCO2 is
elevated above 45 mmHg. An uncompensated state is indicated by a normal bicarbonate
(HCO3) level between 22 and 26 mEq/L. This condition often results from hypoventilation
or obstructive lung diseases.
, 4. A nurse is caring for a postoperative client. What is the most effective nursing intervention
to prevent atelectasis?
A. Administering humidified oxygen via nasal cannula
B. Encouraging the use of an incentive spirometer every hour while awake
C. Maintaining the client in a supine position
D. Restricting fluid intake to decrease pulmonary congestion
Correct Answer: B
Expert Explanation: Incentive spirometry promotes deep breathing and alveolar
expansion which prevents the collapse of lung tissue. It is a standard postoperative
intervention to reduce the risk of pneumonia and atelectasis. The nurse should also
encourage early ambulation and frequent position changes to further support respiratory
function.
5. During a surgical procedure, the anesthesiologist notes a sudden rise in the client’s end-
tidal CO2 and muscle rigidity. What is the nurse’s priority action?
A. Apply cooling blankets to the client
B. Administer Dantrolene sodium as ordered
C. Increase the concentration of inhalation anesthetic
D. Check the client’s blood pressure
Correct Answer: B
