NUR176/NUR 176 Exam 1 V2 | Concepts
of Adult Health Nursing for the Practical
Nurse I Q&A with Rationale | Hondros
College of Nursing
1. A nurse is caring for a client who is scheduled for surgery. The client expresses concern
about the procedure and states, ‘I am not sure I want to do this anymore.’ Which action
should the nurse take first?
A. Reassure the client that the surgeon is highly skilled and there is nothing to worry about.
B. Inform the client that the surgery is necessary for their health and they should proceed.
C. Document that the client is being difficult and prepare to administer the preoperative
sedative.
D. Notify the surgeon that the client has questions and is expressing hesitation about the
surgery.
Correct Answer: D
Rationale: The nurse’s role in informed consent is to witness the signature and ensure the
client understands the process. If a client expresses doubt or lacks understanding, the
nurse must notify the provider so they can provide further clarification. It is not within the
nurse’s scope to explain the risks and benefits of a surgical procedure or to coerce the
client into proceeding.
,2. A client presents with a potassium level of 2.8 mEq/L. Which of the following findings
should the nurse expect to observe during the assessment?
A. Muscle weakness and leg cramps
B. Hyperactive bowel sounds
C. Peaked T-waves on the EKG
D. Positive Chvostek’s sign
Correct Answer: A
Rationale: Hypokalemia, defined as a potassium level below 3.5 mEq/L, affects muscle
contraction and nerve conduction. Clients often report muscle weakness, fatigue, and leg
cramps as early signs of depletion. Severe hypokalemia can lead to life-threatening cardiac
arrhythmias and paralytic ileus, requiring prompt intervention.
3. Which intravenous fluid is considered isotonic and is commonly used for fluid volume
replacement in a client with dehydration?
A. 0.45% Sodium Chloride
B. 10% Dextrose in Water
C. 3% Sodium Chloride
D. 0.9% Sodium Chloride
Correct Answer: D
, Rationale: Isotonic solutions have the same osmolality as body fluids, meaning they do not
cause cells to shrink or swell. 0.9% Sodium Chloride, also known as Normal Saline, is the
gold standard for expanding extracellular fluid volume. It is frequently used in clinical
settings for resuscitation and to treat hypotension caused by hypovolemia.
4. A client is 2 days postoperative following abdominal surgery. The nurse notes that the
client’s wound has separated and a loop of bowel is protruding. What is the priority nursing
action?
A. Push the bowel back into the abdominal cavity gently.
B. Leave the wound open to air and call the physician immediately.
C. Cover the protruding organ with sterile dressings soaked in sterile normal saline.
D. Place the client in a high-Fowler’s position to improve breathing.
Correct Answer: C
Rationale: Wound evisceration is a medical emergency that requires immediate
intervention to prevent organ desiccation and infection. The nurse should cover the
exposed tissue with sterile, saline-soaked dressings and keep the client calm while
notifying the surgical team. The client should be placed in a low-Fowler’s position with
knees flexed to reduce abdominal pressure.
5. A nurse is reviewing the arterial blood gas (ABG) results for a client: pH 7.30, PaCO2 52
mmHg, and HCO3 24 mEq/L. How should the nurse interpret these findings?
A. Metabolic Acidosis
of Adult Health Nursing for the Practical
Nurse I Q&A with Rationale | Hondros
College of Nursing
1. A nurse is caring for a client who is scheduled for surgery. The client expresses concern
about the procedure and states, ‘I am not sure I want to do this anymore.’ Which action
should the nurse take first?
A. Reassure the client that the surgeon is highly skilled and there is nothing to worry about.
B. Inform the client that the surgery is necessary for their health and they should proceed.
C. Document that the client is being difficult and prepare to administer the preoperative
sedative.
D. Notify the surgeon that the client has questions and is expressing hesitation about the
surgery.
Correct Answer: D
Rationale: The nurse’s role in informed consent is to witness the signature and ensure the
client understands the process. If a client expresses doubt or lacks understanding, the
nurse must notify the provider so they can provide further clarification. It is not within the
nurse’s scope to explain the risks and benefits of a surgical procedure or to coerce the
client into proceeding.
,2. A client presents with a potassium level of 2.8 mEq/L. Which of the following findings
should the nurse expect to observe during the assessment?
A. Muscle weakness and leg cramps
B. Hyperactive bowel sounds
C. Peaked T-waves on the EKG
D. Positive Chvostek’s sign
Correct Answer: A
Rationale: Hypokalemia, defined as a potassium level below 3.5 mEq/L, affects muscle
contraction and nerve conduction. Clients often report muscle weakness, fatigue, and leg
cramps as early signs of depletion. Severe hypokalemia can lead to life-threatening cardiac
arrhythmias and paralytic ileus, requiring prompt intervention.
3. Which intravenous fluid is considered isotonic and is commonly used for fluid volume
replacement in a client with dehydration?
A. 0.45% Sodium Chloride
B. 10% Dextrose in Water
C. 3% Sodium Chloride
D. 0.9% Sodium Chloride
Correct Answer: D
, Rationale: Isotonic solutions have the same osmolality as body fluids, meaning they do not
cause cells to shrink or swell. 0.9% Sodium Chloride, also known as Normal Saline, is the
gold standard for expanding extracellular fluid volume. It is frequently used in clinical
settings for resuscitation and to treat hypotension caused by hypovolemia.
4. A client is 2 days postoperative following abdominal surgery. The nurse notes that the
client’s wound has separated and a loop of bowel is protruding. What is the priority nursing
action?
A. Push the bowel back into the abdominal cavity gently.
B. Leave the wound open to air and call the physician immediately.
C. Cover the protruding organ with sterile dressings soaked in sterile normal saline.
D. Place the client in a high-Fowler’s position to improve breathing.
Correct Answer: C
Rationale: Wound evisceration is a medical emergency that requires immediate
intervention to prevent organ desiccation and infection. The nurse should cover the
exposed tissue with sterile, saline-soaked dressings and keep the client calm while
notifying the surgical team. The client should be placed in a low-Fowler’s position with
knees flexed to reduce abdominal pressure.
5. A nurse is reviewing the arterial blood gas (ABG) results for a client: pH 7.30, PaCO2 52
mmHg, and HCO3 24 mEq/L. How should the nurse interpret these findings?
A. Metabolic Acidosis
