NUR185/NUR 185 Exam 1 V1 | Concepts of
Adult Health Nursing for the Practical
Nurse II Q&A with Rationale | Hondros
College of Nursing
1. A nurse is assessing a patient with a serum potassium level of 2.5 mEq/L. Which clinical
manifestation should the nurse prioritize for immediate intervention?
A. Increased bowel sounds and abdominal cramping
B. Tented skin turgor and dry mucous membranes
C. Hyperreflexia and muscle twitching
D. Cardiac dysrhythmias and prominent U waves
Correct Answer: D
Rationale: Hypokalemia affects the electrical conduction of the heart, leading to life-
threatening arrhythmias. The presence of U waves on an ECG is a classic indicator of severe
potassium depletion. The nurse must prioritize cardiac monitoring to prevent sudden
cardiac arrest.
2. Which arterial blood gas (ABG) result is most indicative of a patient experiencing
uncompensated respiratory acidosis?
A. pH 7.48, PaCO2 30 mmHg, HCO3 22 mEq/L
B. pH 7.30, PaCO2 50 mmHg, HCO3 24 mEq/L
,C. pH 7.32, PaCO2 38 mmHg, HCO3 18 mEq/L
D. pH 7.50, PaCO2 40 mmHg, HCO3 30 mEq/L
Correct Answer: B
Rationale: Respiratory acidosis is characterized by a low pH and an elevated PaCO2 level.
In an uncompensated state, the bicarbonate (HCO3) remains within the normal range of 22
to 26 mEq/L. This condition often results from hypoventilation or obstructive lung
diseases.
3. A patient is undergoing external beam radiation therapy for lung cancer. What instruction
should the nurse include regarding skin care at the treatment site?
A. Apply a heating pad to the area to increase circulation
B. Vigorously scrub the markings off with a washcloth
C. Avoid applying lotions, powders, or perfumes to the irradiated area
D. Expose the treatment area to direct sunlight for vitamin D synthesis
Correct Answer: C
Rationale: Irradiated skin is extremely fragile and susceptible to breakdown and infection.
Patients should avoid any topical substances that contain chemicals or alcohols unless
specifically prescribed by the radiologist. Gentle cleansing with lukewarm water and
avoiding friction are essential to maintain skin integrity.
, 4. In the preoperative setting, the nurse is responsible for ensuring the surgical consent is
signed. What is the nurse’s primary role regarding informed consent?
A. Explaining the risks and benefits of the procedure
B. Choosing the surgical technique for the patient
C. Witnessing the patient’s signature on the form
D. Obtaining the consent if the surgeon is unavailable
Correct Answer: C
Rationale: The nurse’s legal role is to witness the signature and verify that the patient
appears competent to sign. It is the surgeon’s responsibility to explain the procedure, risks,
and benefits to the patient. If the patient has questions about the surgery itself, the nurse
must notify the surgeon to return and provide further clarification.
5. A patient has a serum sodium level of 152 mEq/L. Which nursing intervention is most
appropriate for this patient?
A. Administering 3% hypertonic saline intravenously
B. Restricting fluid intake to 1000 mL per day
C. Administering oral salt tablets
D. Encouraging the intake of oral fluids
Correct Answer: D
Adult Health Nursing for the Practical
Nurse II Q&A with Rationale | Hondros
College of Nursing
1. A nurse is assessing a patient with a serum potassium level of 2.5 mEq/L. Which clinical
manifestation should the nurse prioritize for immediate intervention?
A. Increased bowel sounds and abdominal cramping
B. Tented skin turgor and dry mucous membranes
C. Hyperreflexia and muscle twitching
D. Cardiac dysrhythmias and prominent U waves
Correct Answer: D
Rationale: Hypokalemia affects the electrical conduction of the heart, leading to life-
threatening arrhythmias. The presence of U waves on an ECG is a classic indicator of severe
potassium depletion. The nurse must prioritize cardiac monitoring to prevent sudden
cardiac arrest.
2. Which arterial blood gas (ABG) result is most indicative of a patient experiencing
uncompensated respiratory acidosis?
A. pH 7.48, PaCO2 30 mmHg, HCO3 22 mEq/L
B. pH 7.30, PaCO2 50 mmHg, HCO3 24 mEq/L
,C. pH 7.32, PaCO2 38 mmHg, HCO3 18 mEq/L
D. pH 7.50, PaCO2 40 mmHg, HCO3 30 mEq/L
Correct Answer: B
Rationale: Respiratory acidosis is characterized by a low pH and an elevated PaCO2 level.
In an uncompensated state, the bicarbonate (HCO3) remains within the normal range of 22
to 26 mEq/L. This condition often results from hypoventilation or obstructive lung
diseases.
3. A patient is undergoing external beam radiation therapy for lung cancer. What instruction
should the nurse include regarding skin care at the treatment site?
A. Apply a heating pad to the area to increase circulation
B. Vigorously scrub the markings off with a washcloth
C. Avoid applying lotions, powders, or perfumes to the irradiated area
D. Expose the treatment area to direct sunlight for vitamin D synthesis
Correct Answer: C
Rationale: Irradiated skin is extremely fragile and susceptible to breakdown and infection.
Patients should avoid any topical substances that contain chemicals or alcohols unless
specifically prescribed by the radiologist. Gentle cleansing with lukewarm water and
avoiding friction are essential to maintain skin integrity.
, 4. In the preoperative setting, the nurse is responsible for ensuring the surgical consent is
signed. What is the nurse’s primary role regarding informed consent?
A. Explaining the risks and benefits of the procedure
B. Choosing the surgical technique for the patient
C. Witnessing the patient’s signature on the form
D. Obtaining the consent if the surgeon is unavailable
Correct Answer: C
Rationale: The nurse’s legal role is to witness the signature and verify that the patient
appears competent to sign. It is the surgeon’s responsibility to explain the procedure, risks,
and benefits to the patient. If the patient has questions about the surgery itself, the nurse
must notify the surgeon to return and provide further clarification.
5. A patient has a serum sodium level of 152 mEq/L. Which nursing intervention is most
appropriate for this patient?
A. Administering 3% hypertonic saline intravenously
B. Restricting fluid intake to 1000 mL per day
C. Administering oral salt tablets
D. Encouraging the intake of oral fluids
Correct Answer: D
