NUR 201/NUR201 Exam 1 V3 | Medical-
Surgical Nursing I Q&A with Rationale |
Fortis College
1. A nurse is caring for a client with a serum potassium level of 6.2 mEq/L. Which of the
following is the priority nursing intervention?
A. Place the client on a continuous cardiac monitor.
B. Encourage the consumption of citrus fruits.
C. Administer potassium-sparing diuretics.
D. Monitor the client’s hourly urine output.
Correct Answer: A
Expert Explanation: A potassium level of 6.2 mEq/L indicates hyperkalemia, which poses
a significant risk for lethal cardiac dysrhythmias. Placing the client on a cardiac monitor
allows the nurse to detect peaked T-waves or a widened QRS complex immediately. This
action is the priority because it directly addresses the risk of sudden cardiac arrest.
2. A preoperative nurse is reviewing a client’s chart and notes that the informed consent has
not been signed. Which action should the nurse take?
A. Explain the risks and benefits of the surgery to the client.
B. Notify the surgeon that the consent is missing.
C. Have the client sign the form immediately before sedation.
,D. Witness the client’s signature even if the surgeon is not present.
Correct Answer: B
Expert Explanation: It is the surgeon’s responsibility to provide information regarding the
procedure, risks, and benefits to the client. The nurse’s role is to verify that the signature is
authentic and that the client is competent to sign. If the consent is missing, the nurse must
notify the surgeon to ensure the legal process is completed before the procedure begins.
3. A patient is 2 hours postoperative following an abdominal surgery. The nurse notes that
the patient’s heart rate is 115 bpm and blood pressure is 88/52 mmHg. Which complication
should the nurse suspect?
A. Hypovolemic shock
B. Fluid volume overload
C. Postoperative pain
D. Hyperthermia
Correct Answer: A
Expert Explanation: Tachycardia and hypotension in the early postoperative period are
classic signs of hypovolemic shock, often due to hemorrhage. The body compensates for
low blood volume by increasing the heart rate to maintain cardiac output. The nurse must
recognize these signs as a medical emergency and notify the provider immediately.
, 4. The nurse is evaluating the arterial blood gas (ABG) results for a patient with COPD: pH
7.31, PaCO2 55, HCO3 28. How should the nurse interpret these results?
A. Compensated Respiratory Alkalosis
B. Uncompensated Metabolic Acidosis
C. Partially Compensated Respiratory Acidosis
D. Partially Compensated Metabolic Alkalosis
Correct Answer: C
Expert Explanation: The pH is below 7.35, indicating acidosis, and the PaCO2 is elevated,
indicating a respiratory cause. The HCO3 is also elevated as the kidneys attempt to buffer
the acid, showing partial compensation. Because the pH has not yet reached the normal
range, the compensation is deemed partial.
5. Which clinical manifestation should the nurse expect to find in a client experiencing
hyponatremia?
A. Dry mucous membranes
B. Increased thirst
C. Confusion and seizures
D. Hyperactive deep tendon reflexes
Correct Answer: C
Surgical Nursing I Q&A with Rationale |
Fortis College
1. A nurse is caring for a client with a serum potassium level of 6.2 mEq/L. Which of the
following is the priority nursing intervention?
A. Place the client on a continuous cardiac monitor.
B. Encourage the consumption of citrus fruits.
C. Administer potassium-sparing diuretics.
D. Monitor the client’s hourly urine output.
Correct Answer: A
Expert Explanation: A potassium level of 6.2 mEq/L indicates hyperkalemia, which poses
a significant risk for lethal cardiac dysrhythmias. Placing the client on a cardiac monitor
allows the nurse to detect peaked T-waves or a widened QRS complex immediately. This
action is the priority because it directly addresses the risk of sudden cardiac arrest.
2. A preoperative nurse is reviewing a client’s chart and notes that the informed consent has
not been signed. Which action should the nurse take?
A. Explain the risks and benefits of the surgery to the client.
B. Notify the surgeon that the consent is missing.
C. Have the client sign the form immediately before sedation.
,D. Witness the client’s signature even if the surgeon is not present.
Correct Answer: B
Expert Explanation: It is the surgeon’s responsibility to provide information regarding the
procedure, risks, and benefits to the client. The nurse’s role is to verify that the signature is
authentic and that the client is competent to sign. If the consent is missing, the nurse must
notify the surgeon to ensure the legal process is completed before the procedure begins.
3. A patient is 2 hours postoperative following an abdominal surgery. The nurse notes that
the patient’s heart rate is 115 bpm and blood pressure is 88/52 mmHg. Which complication
should the nurse suspect?
A. Hypovolemic shock
B. Fluid volume overload
C. Postoperative pain
D. Hyperthermia
Correct Answer: A
Expert Explanation: Tachycardia and hypotension in the early postoperative period are
classic signs of hypovolemic shock, often due to hemorrhage. The body compensates for
low blood volume by increasing the heart rate to maintain cardiac output. The nurse must
recognize these signs as a medical emergency and notify the provider immediately.
, 4. The nurse is evaluating the arterial blood gas (ABG) results for a patient with COPD: pH
7.31, PaCO2 55, HCO3 28. How should the nurse interpret these results?
A. Compensated Respiratory Alkalosis
B. Uncompensated Metabolic Acidosis
C. Partially Compensated Respiratory Acidosis
D. Partially Compensated Metabolic Alkalosis
Correct Answer: C
Expert Explanation: The pH is below 7.35, indicating acidosis, and the PaCO2 is elevated,
indicating a respiratory cause. The HCO3 is also elevated as the kidneys attempt to buffer
the acid, showing partial compensation. Because the pH has not yet reached the normal
range, the compensation is deemed partial.
5. Which clinical manifestation should the nurse expect to find in a client experiencing
hyponatremia?
A. Dry mucous membranes
B. Increased thirst
C. Confusion and seizures
D. Hyperactive deep tendon reflexes
Correct Answer: C
