PNR 201/PNR201 Exam 1 V3 | Medical-
Surgical Nursing Q&A with Rationale |
Fortis College
1. A nurse is caring for a client with a serum potassium level of 2.9 mEq/L. Which assessment
finding should the nurse prioritize?
A. Abdominal cramping
B. Muscle weakness and cardiac dysrhythmias
C. Hyperactive deep tendon reflexes
D. Tall, peaked T-waves on ECG
Correct Answer: B
Expert Explanation: Hypokalemia is a serum potassium level below 3.5 mEq/L and can
lead to life-threatening cardiac dysrhythmias. Muscle weakness is a common clinical
manifestation because potassium is essential for nerve impulse transmission and muscle
contraction. The nurse must monitor the client’s cardiac rhythm closely to prevent cardiac
arrest.
2. Which clinical manifestation is most indicative of fluid volume deficit in an older adult
client?
A. Distended neck veins
B. Decreased skin turgor over the sternum
,C. Increased blood pressure
D. Pitting edema in the lower extremities
Correct Answer: B
Expert Explanation: Decreased skin turgor is a hallmark sign of dehydration or fluid
volume deficit. In older adults, it is best assessed over the sternum or forehead because
skin on the arms loses elasticity with age. Other signs include dry mucous membranes,
tachycardia, and concentrated urine.
3. A client’s arterial blood gas (ABG) results are: pH 7.31, PaCO2 50 mmHg, and HCO3 24
mEq/L. How should the nurse interpret these findings?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic alkalosis
D. Metabolic acidosis
Correct Answer: A
Expert Explanation: The pH is below 7.35, which indicates acidosis. The PaCO2 is elevated
above 45 mmHg, which points toward a respiratory cause. Since the bicarbonate (HCO3)
level is within the normal range of 22-26 mEq/L, this is uncompensated respiratory
acidosis.
, 4. Which medication is the primary treatment for a client experiencing malignant
hyperthermia during surgery?
A. Atropine sulfate
B. Succinylcholine
C. Epinephrine
D. Dantrolene sodium
Correct Answer: D
Expert Explanation: Malignant hyperthermia is a rare but life-threatening complication of
general anesthesia. Dantrolene sodium is a skeletal muscle relaxant that specifically treats
this condition by inhibiting calcium release. Immediate administration is critical to lower
body temperature and stabilize the metabolic state.
5. The nurse is providing preoperative teaching to a client. What is the primary purpose of
teaching the client to use an incentive spirometer?
A. To prevent the development of atelectasis
B. To reduce the need for postoperative analgesia
C. To increase the strength of the diaphragm
D. To promote venous return to the heart
Correct Answer: A
Surgical Nursing Q&A with Rationale |
Fortis College
1. A nurse is caring for a client with a serum potassium level of 2.9 mEq/L. Which assessment
finding should the nurse prioritize?
A. Abdominal cramping
B. Muscle weakness and cardiac dysrhythmias
C. Hyperactive deep tendon reflexes
D. Tall, peaked T-waves on ECG
Correct Answer: B
Expert Explanation: Hypokalemia is a serum potassium level below 3.5 mEq/L and can
lead to life-threatening cardiac dysrhythmias. Muscle weakness is a common clinical
manifestation because potassium is essential for nerve impulse transmission and muscle
contraction. The nurse must monitor the client’s cardiac rhythm closely to prevent cardiac
arrest.
2. Which clinical manifestation is most indicative of fluid volume deficit in an older adult
client?
A. Distended neck veins
B. Decreased skin turgor over the sternum
,C. Increased blood pressure
D. Pitting edema in the lower extremities
Correct Answer: B
Expert Explanation: Decreased skin turgor is a hallmark sign of dehydration or fluid
volume deficit. In older adults, it is best assessed over the sternum or forehead because
skin on the arms loses elasticity with age. Other signs include dry mucous membranes,
tachycardia, and concentrated urine.
3. A client’s arterial blood gas (ABG) results are: pH 7.31, PaCO2 50 mmHg, and HCO3 24
mEq/L. How should the nurse interpret these findings?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic alkalosis
D. Metabolic acidosis
Correct Answer: A
Expert Explanation: The pH is below 7.35, which indicates acidosis. The PaCO2 is elevated
above 45 mmHg, which points toward a respiratory cause. Since the bicarbonate (HCO3)
level is within the normal range of 22-26 mEq/L, this is uncompensated respiratory
acidosis.
, 4. Which medication is the primary treatment for a client experiencing malignant
hyperthermia during surgery?
A. Atropine sulfate
B. Succinylcholine
C. Epinephrine
D. Dantrolene sodium
Correct Answer: D
Expert Explanation: Malignant hyperthermia is a rare but life-threatening complication of
general anesthesia. Dantrolene sodium is a skeletal muscle relaxant that specifically treats
this condition by inhibiting calcium release. Immediate administration is critical to lower
body temperature and stabilize the metabolic state.
5. The nurse is providing preoperative teaching to a client. What is the primary purpose of
teaching the client to use an incentive spirometer?
A. To prevent the development of atelectasis
B. To reduce the need for postoperative analgesia
C. To increase the strength of the diaphragm
D. To promote venous return to the heart
Correct Answer: A
