PNR 201/PNR201 Exam 1 V2 | Medical-
Surgical Nursing Q&A with Rationale |
Fortis College
1. A nurse is assessing a client with a suspected fluid volume deficit. Which of the following
findings should the nurse expect?
A. Distended neck veins
B. Decreased skin turgor
C. Bounding radial pulse
D. Increased blood pressure
Correct Answer: B
Expert Explanation: Decreased skin turgor, also known as tenting, is a common sign of
dehydration or fluid volume deficit. In this state, the body lacks sufficient fluid to maintain
skin elasticity. The nurse should also monitor for other signs such as dry mucous
membranes and concentrated urine output.
2. A client has a potassium level of 3.2 mEq/L. Which of the following foods should the nurse
encourage the client to consume?
A. White bread
B. Cottage cheese
C. Applesauce
,D. Bananas
Correct Answer: D
Expert Explanation: Bananas are high in potassium and are recommended for clients
experiencing hypokalemia, which is defined as a serum potassium level below 3.5 mEq/L.
Low potassium levels can lead to cardiac dysrhythmias and muscle weakness. Increasing
dietary intake of potassium-rich foods is a primary intervention for mild deficiencies.
3. The nurse is reviewing the arterial blood gas (ABG) results for a client: pH 7.30, PaCO2 52
mmHg, and HCO3 26 mEq/L. How should the nurse interpret these results?
A. Metabolic Acidosis
B. Metabolic Alkalosis
C. Respiratory Acidosis
D. Respiratory Alkalosis
Correct Answer: C
Expert Explanation: A pH below 7.35 indicates acidosis, and a PaCO2 above 45 mmHg
indicates a respiratory cause. Since the HCO3 is within the normal range of 22-26 mEq/L,
this is uncompensated respiratory acidosis. The nurse should assess the client’s respiratory
rate and depth to identify the underlying cause of CO2 retention.
4. A client is scheduled for surgery, and the nurse is witnessing the signing of the informed
consent form. What is the nurse’s primary responsibility in this process?
A. Explaining the risks and benefits of the procedure
, B. Answering specific questions about the surgical technique
C. Ensuring the client is signing the form voluntarily
D. Deciding if the surgery is necessary for the client
Correct Answer: C
Expert Explanation: The nurse’s role in informed consent is to act as a witness to the
client’s signature and ensure it is provided voluntarily. The surgeon is responsible for
explaining the procedure, risks, and alternatives. If the nurse notes that the client does not
understand the procedure, the nurse must notify the surgeon before the client signs.
5. A postoperative client is using an incentive spirometer. The nurse knows that the primary
purpose of this device is to prevent which complication?
A. Deep vein thrombosis
B. Pulmonary embolism
C. Atelectasis
D. Incisional dehiscence
Correct Answer: C
Expert Explanation: Incentive spirometry encourages deep breathing, which helps keep
the alveoli open and prevents lung collapse or atelectasis. This is a critical intervention
during the postoperative period when clients are at higher risk for respiratory
Surgical Nursing Q&A with Rationale |
Fortis College
1. A nurse is assessing a client with a suspected fluid volume deficit. Which of the following
findings should the nurse expect?
A. Distended neck veins
B. Decreased skin turgor
C. Bounding radial pulse
D. Increased blood pressure
Correct Answer: B
Expert Explanation: Decreased skin turgor, also known as tenting, is a common sign of
dehydration or fluid volume deficit. In this state, the body lacks sufficient fluid to maintain
skin elasticity. The nurse should also monitor for other signs such as dry mucous
membranes and concentrated urine output.
2. A client has a potassium level of 3.2 mEq/L. Which of the following foods should the nurse
encourage the client to consume?
A. White bread
B. Cottage cheese
C. Applesauce
,D. Bananas
Correct Answer: D
Expert Explanation: Bananas are high in potassium and are recommended for clients
experiencing hypokalemia, which is defined as a serum potassium level below 3.5 mEq/L.
Low potassium levels can lead to cardiac dysrhythmias and muscle weakness. Increasing
dietary intake of potassium-rich foods is a primary intervention for mild deficiencies.
3. The nurse is reviewing the arterial blood gas (ABG) results for a client: pH 7.30, PaCO2 52
mmHg, and HCO3 26 mEq/L. How should the nurse interpret these results?
A. Metabolic Acidosis
B. Metabolic Alkalosis
C. Respiratory Acidosis
D. Respiratory Alkalosis
Correct Answer: C
Expert Explanation: A pH below 7.35 indicates acidosis, and a PaCO2 above 45 mmHg
indicates a respiratory cause. Since the HCO3 is within the normal range of 22-26 mEq/L,
this is uncompensated respiratory acidosis. The nurse should assess the client’s respiratory
rate and depth to identify the underlying cause of CO2 retention.
4. A client is scheduled for surgery, and the nurse is witnessing the signing of the informed
consent form. What is the nurse’s primary responsibility in this process?
A. Explaining the risks and benefits of the procedure
, B. Answering specific questions about the surgical technique
C. Ensuring the client is signing the form voluntarily
D. Deciding if the surgery is necessary for the client
Correct Answer: C
Expert Explanation: The nurse’s role in informed consent is to act as a witness to the
client’s signature and ensure it is provided voluntarily. The surgeon is responsible for
explaining the procedure, risks, and alternatives. If the nurse notes that the client does not
understand the procedure, the nurse must notify the surgeon before the client signs.
5. A postoperative client is using an incentive spirometer. The nurse knows that the primary
purpose of this device is to prevent which complication?
A. Deep vein thrombosis
B. Pulmonary embolism
C. Atelectasis
D. Incisional dehiscence
Correct Answer: C
Expert Explanation: Incentive spirometry encourages deep breathing, which helps keep
the alveoli open and prevents lung collapse or atelectasis. This is a critical intervention
during the postoperative period when clients are at higher risk for respiratory
