NUR 201/NUR201 Exam 4 V1 | Medical-
Surgical Nursing I Q&A with Rationale |
Fortis College
1. A patient presents with a serum potassium level of 6.2 mEq/L. Which EKG change should
the nurse expect to observe?
A. Prominent U waves
B. Tall, peaked T waves
C. ST segment depression
D. Shortened PR interval
Correct Answer: B
Expert Explanation: Hyperkalemia is defined as a serum potassium level above 5.0 mEq/L
and frequently results in cardiac rhythm disturbances. Tall, peaked T waves are a classic
early sign of hyperkalemia on an EKG. This occurs because the excess potassium affects the
repolarization phase of the cardiac action potential.
2. Which arterial blood gas (ABG) result is most indicative of compensated respiratory
acidosis?
A. pH 7.48, PaCO2 30, HCO3 20
B. pH 7.30, PaCO2 50, HCO3 24
C. pH 7.36, PaCO2 55, HCO3 30
,D. pH 7.35, PaCO2 35, HCO3 22
Correct Answer: C
Expert Explanation: In respiratory acidosis, the pH is initially low and PaCO2 is high.
Compensation occurs when the kidneys retain bicarbonate (HCO3) to normalize the pH. A
pH of 7.36 is within the normal range but on the acidic side, while both PaCO2 and HCO3
are elevated, indicating full compensation.
3. A patient with Chronic Kidney Disease (CKD) is prescribed a low-protein diet. What is the
primary rationale for this intervention?
A. To prevent the development of kidney stones
B. To increase the glomerular filtration rate (GFR)
C. To reduce the risk of hypercalcemia
D. To minimize the accumulation of nitrogenous waste products
Correct Answer: D
Expert Explanation: Protein metabolism results in the production of urea and other
nitrogenous wastes that the kidneys must excrete. In CKD, the kidneys cannot efficiently
clear these toxins, leading to uremia. Restricting protein intake helps lower the workload
on the kidneys and reduces uremic symptoms.
4. During a physical assessment, the nurse taps the patient’s facial nerve and observes a brief
contraction of the facial muscles. How should the nurse document this finding?
A. Positive Chvostek’s sign
, B. Positive Romberg’s sign
C. Negative Babinski’s sign
D. Positive Trousseau’s sign
Correct Answer: A
Expert Explanation: A positive Chvostek’s sign is characterized by facial twitching when
the facial nerve is tapped. This physical finding is an indicator of neuromuscular irritability,
most commonly associated with hypocalcemia. The nurse should immediately report this
finding and check the patient’s serum calcium levels.
5. Which clinical manifestation is a hallmark sign of Fluid Volume Deficit (Dehydration)?
A. Bounding pulse
B. Jugular venous distension
C. Crackles in the lungs
D. Orthostatic hypotension
Correct Answer: D
Expert Explanation: Fluid volume deficit leads to a decrease in circulating blood volume,
which lowers blood pressure. Orthostatic hypotension occurs when the body cannot
compensate for the drop in volume when moving from a lying to a standing position. Other
signs include poor skin turgor, dry mucous membranes, and tachycardia.
Surgical Nursing I Q&A with Rationale |
Fortis College
1. A patient presents with a serum potassium level of 6.2 mEq/L. Which EKG change should
the nurse expect to observe?
A. Prominent U waves
B. Tall, peaked T waves
C. ST segment depression
D. Shortened PR interval
Correct Answer: B
Expert Explanation: Hyperkalemia is defined as a serum potassium level above 5.0 mEq/L
and frequently results in cardiac rhythm disturbances. Tall, peaked T waves are a classic
early sign of hyperkalemia on an EKG. This occurs because the excess potassium affects the
repolarization phase of the cardiac action potential.
2. Which arterial blood gas (ABG) result is most indicative of compensated respiratory
acidosis?
A. pH 7.48, PaCO2 30, HCO3 20
B. pH 7.30, PaCO2 50, HCO3 24
C. pH 7.36, PaCO2 55, HCO3 30
,D. pH 7.35, PaCO2 35, HCO3 22
Correct Answer: C
Expert Explanation: In respiratory acidosis, the pH is initially low and PaCO2 is high.
Compensation occurs when the kidneys retain bicarbonate (HCO3) to normalize the pH. A
pH of 7.36 is within the normal range but on the acidic side, while both PaCO2 and HCO3
are elevated, indicating full compensation.
3. A patient with Chronic Kidney Disease (CKD) is prescribed a low-protein diet. What is the
primary rationale for this intervention?
A. To prevent the development of kidney stones
B. To increase the glomerular filtration rate (GFR)
C. To reduce the risk of hypercalcemia
D. To minimize the accumulation of nitrogenous waste products
Correct Answer: D
Expert Explanation: Protein metabolism results in the production of urea and other
nitrogenous wastes that the kidneys must excrete. In CKD, the kidneys cannot efficiently
clear these toxins, leading to uremia. Restricting protein intake helps lower the workload
on the kidneys and reduces uremic symptoms.
4. During a physical assessment, the nurse taps the patient’s facial nerve and observes a brief
contraction of the facial muscles. How should the nurse document this finding?
A. Positive Chvostek’s sign
, B. Positive Romberg’s sign
C. Negative Babinski’s sign
D. Positive Trousseau’s sign
Correct Answer: A
Expert Explanation: A positive Chvostek’s sign is characterized by facial twitching when
the facial nerve is tapped. This physical finding is an indicator of neuromuscular irritability,
most commonly associated with hypocalcemia. The nurse should immediately report this
finding and check the patient’s serum calcium levels.
5. Which clinical manifestation is a hallmark sign of Fluid Volume Deficit (Dehydration)?
A. Bounding pulse
B. Jugular venous distension
C. Crackles in the lungs
D. Orthostatic hypotension
Correct Answer: D
Expert Explanation: Fluid volume deficit leads to a decrease in circulating blood volume,
which lowers blood pressure. Orthostatic hypotension occurs when the body cannot
compensate for the drop in volume when moving from a lying to a standing position. Other
signs include poor skin turgor, dry mucous membranes, and tachycardia.
