NUR209 / NUR 209 Exam 1 V1 | Medical-
Surgical Nursing II Q&A with Rationale |
Fortis College
1. A nurse is caring for a client with a serum potassium level of 2.8 mEq/L. Which of the
following assessment findings should the nurse expect?
A. Hyperactive bowel sounds and diarrhea
B. Muscle weakness and cardiac dysrhythmias
C. Positive Chvostek’s sign
D. Peaked T waves on the ECG
Correct Answer: B
Expert Explanation: Hypokalemia is characterized by a serum potassium level below 3.5
mEq/L. Low potassium levels can cause significant muscle weakness and interfere with
cardiac electrical conduction, leading to dysrhythmias or flattened T waves. The nurse
must prioritize cardiac monitoring to ensure patient safety and detect life-threatening
changes early.
2. A client’s arterial blood gas (ABG) results are: pH 7.30, PaCO2 50 mm Hg, and HCO3 24
mEq/L. How should the nurse interpret these findings?
A. Metabolic Acidosis
B. Respiratory Alkalosis
,C. Metabolic Alkalosis
D. Respiratory Acidosis
Correct Answer: D
Expert Explanation: The pH of 7.30 indicates acidosis as it is below the normal range of
7.35 to 7.45. The PaCO2 of 50 mm Hg is elevated, which points to a respiratory cause for
the acidotic state. Because the HCO3 is within the normal range of 22 to 26 mEq/L, this
represents uncompensated respiratory acidosis.
3. Which of the following interventions is a priority for a client in the immediate
postoperative period who has a history of malignant hyperthermia?
A. Monitoring the core body temperature
B. Administering IV Dantrolene
C. Applying warm blankets
D. Increasing IV fluid infusion rate
Correct Answer: A
Expert Explanation: Malignant hyperthermia is a life-threatening complication of general
anesthesia that can occur up to 24 hours post-surgery. Frequent monitoring of core
temperature allows for early detection of a rapid rise in body heat. If signs of a reaction
occur, Dantrolene is the primary pharmacological treatment, but monitoring is the initial
priority for high-risk patients.
, 4. A nurse is providing preoperative teaching to a client. Who is legally responsible for
obtaining the informed consent for the surgical procedure?
A. The nurse
B. The anesthesiologist
C. The surgeon
D. The charge nurse
Correct Answer: C
Expert Explanation: The surgeon is legally required to explain the procedure, risks,
benefits, and alternatives to the patient before obtaining consent. The nurse’s role is
typically limited to witnessing the patient’s signature on the document. If the patient has
further questions about the procedure, the nurse must notify the surgeon to return and
provide clarification.
5. A client has sustained partial-thickness burns over 30% of their body. Which phase of burn
care is the nurse currently managing if the goal is to prevent infection and promote wound
healing?
A. Emergent phase
B. Resuscitative phase
C. Acute phase
D. Rehabilitative phase
Surgical Nursing II Q&A with Rationale |
Fortis College
1. A nurse is caring for a client with a serum potassium level of 2.8 mEq/L. Which of the
following assessment findings should the nurse expect?
A. Hyperactive bowel sounds and diarrhea
B. Muscle weakness and cardiac dysrhythmias
C. Positive Chvostek’s sign
D. Peaked T waves on the ECG
Correct Answer: B
Expert Explanation: Hypokalemia is characterized by a serum potassium level below 3.5
mEq/L. Low potassium levels can cause significant muscle weakness and interfere with
cardiac electrical conduction, leading to dysrhythmias or flattened T waves. The nurse
must prioritize cardiac monitoring to ensure patient safety and detect life-threatening
changes early.
2. A client’s arterial blood gas (ABG) results are: pH 7.30, PaCO2 50 mm Hg, and HCO3 24
mEq/L. How should the nurse interpret these findings?
A. Metabolic Acidosis
B. Respiratory Alkalosis
,C. Metabolic Alkalosis
D. Respiratory Acidosis
Correct Answer: D
Expert Explanation: The pH of 7.30 indicates acidosis as it is below the normal range of
7.35 to 7.45. The PaCO2 of 50 mm Hg is elevated, which points to a respiratory cause for
the acidotic state. Because the HCO3 is within the normal range of 22 to 26 mEq/L, this
represents uncompensated respiratory acidosis.
3. Which of the following interventions is a priority for a client in the immediate
postoperative period who has a history of malignant hyperthermia?
A. Monitoring the core body temperature
B. Administering IV Dantrolene
C. Applying warm blankets
D. Increasing IV fluid infusion rate
Correct Answer: A
Expert Explanation: Malignant hyperthermia is a life-threatening complication of general
anesthesia that can occur up to 24 hours post-surgery. Frequent monitoring of core
temperature allows for early detection of a rapid rise in body heat. If signs of a reaction
occur, Dantrolene is the primary pharmacological treatment, but monitoring is the initial
priority for high-risk patients.
, 4. A nurse is providing preoperative teaching to a client. Who is legally responsible for
obtaining the informed consent for the surgical procedure?
A. The nurse
B. The anesthesiologist
C. The surgeon
D. The charge nurse
Correct Answer: C
Expert Explanation: The surgeon is legally required to explain the procedure, risks,
benefits, and alternatives to the patient before obtaining consent. The nurse’s role is
typically limited to witnessing the patient’s signature on the document. If the patient has
further questions about the procedure, the nurse must notify the surgeon to return and
provide clarification.
5. A client has sustained partial-thickness burns over 30% of their body. Which phase of burn
care is the nurse currently managing if the goal is to prevent infection and promote wound
healing?
A. Emergent phase
B. Resuscitative phase
C. Acute phase
D. Rehabilitative phase
