NUR176/NUR 176 Exam 1 V1 | Concepts of
Adult Health Nursing for the Practical
Nurse I Q&A with Rationale | Hondros
College of Nursing
1. A nurse is preparing a patient for surgery. Which of the following tasks is the primary
responsibility of the nurse regarding informed consent?
A. Explaining the risks and benefits of the procedure to the patient.
B. Deciding whether the patient requires surgery.
C. Witnessing the patient sign the consent form.
D. Discussing alternative treatment options with the patient.
Correct Answer: C
Rationale: The nurse’s role in informed consent is limited to witnessing the patient’s
signature and ensuring that the patient appears competent to provide consent. It is the
surgeon’s legal responsibility to explain the procedure, risks, and benefits to the patient. If
the nurse notes that the patient does not understand the procedure, the nurse must notify
the surgeon before the signature is witnessed.
2. A post-operative patient reports a ‘popping’ sensation at the abdominal incision site after
coughing. Upon inspection, the nurse notes that the wound has opened and internal organs
are visible. Which is the priority action?
A. Apply a dry sterile dressing immediately.
,B. Cover the wound with sterile dressings soaked in normal saline.
C. Place the patient in a High-Fowler’s position.
D. Push the organs back into the abdominal cavity.
Correct Answer: B
Rationale: Evisceration is a surgical emergency where abdominal organs protrude through
a dehisced incision. The nurse should immediately cover the exposed organs with sterile
dressings moistened with sterile normal saline to prevent tissue drying and necrosis. The
nurse should also notify the surgeon immediately and maintain the patient in a low-
Fowler’s position with knees flexed to minimize abdominal tension.
3. Which clinical manifestation should a nurse expect to find in a patient with a potassium
level of 2.8 mEq/L?
A. Muscle weakness and cardiac dysrhythmias.
B. Peaked T waves on an EKG.
C. Increased deep tendon reflexes.
D. Positive Trousseau’s sign.
Correct Answer: A
Rationale: A potassium level of 2.8 mEq/L indicates hypokalemia, which commonly
presents with muscle weakness, leg cramps, and cardiac dysrhythmias. Potassium is
essential for the electrical conduction of the heart and muscle contraction. Peaked T waves
, are associated with hyperkalemia, not hypokalemia, while positive Trousseau’s sign relates
to hypocalcemia.
4. A patient’s ABG results are: pH 7.25, PaCO2 50, and HCO3 24. How should the nurse
interpret these findings?
A. Metabolic Acidosis
B. Respiratory Acidosis
C. Respiratory Alkalosis
D. Metabolic Alkalosis
Correct Answer: B
Rationale: The pH of 7.25 is below the normal range of 7.35-7.45, indicating acidosis. The
PaCO2 of 50 is elevated above the normal range of 35-45, while the HCO3 is within normal
limits. Because the elevated PaCO2 matches the acidic pH, this represents respiratory
acidosis, typically caused by hypoventilation.
5. A nurse is assessing a patient for fluid volume excess. Which finding is most consistent with
this diagnosis?
A. Sunken eyeballs and dry mucous membranes.
B. Decreased blood pressure and rapid pulse.
C. Poor skin turgor and dark amber urine.
D. Distended neck veins and crackles in the lungs.
Adult Health Nursing for the Practical
Nurse I Q&A with Rationale | Hondros
College of Nursing
1. A nurse is preparing a patient for surgery. Which of the following tasks is the primary
responsibility of the nurse regarding informed consent?
A. Explaining the risks and benefits of the procedure to the patient.
B. Deciding whether the patient requires surgery.
C. Witnessing the patient sign the consent form.
D. Discussing alternative treatment options with the patient.
Correct Answer: C
Rationale: The nurse’s role in informed consent is limited to witnessing the patient’s
signature and ensuring that the patient appears competent to provide consent. It is the
surgeon’s legal responsibility to explain the procedure, risks, and benefits to the patient. If
the nurse notes that the patient does not understand the procedure, the nurse must notify
the surgeon before the signature is witnessed.
2. A post-operative patient reports a ‘popping’ sensation at the abdominal incision site after
coughing. Upon inspection, the nurse notes that the wound has opened and internal organs
are visible. Which is the priority action?
A. Apply a dry sterile dressing immediately.
,B. Cover the wound with sterile dressings soaked in normal saline.
C. Place the patient in a High-Fowler’s position.
D. Push the organs back into the abdominal cavity.
Correct Answer: B
Rationale: Evisceration is a surgical emergency where abdominal organs protrude through
a dehisced incision. The nurse should immediately cover the exposed organs with sterile
dressings moistened with sterile normal saline to prevent tissue drying and necrosis. The
nurse should also notify the surgeon immediately and maintain the patient in a low-
Fowler’s position with knees flexed to minimize abdominal tension.
3. Which clinical manifestation should a nurse expect to find in a patient with a potassium
level of 2.8 mEq/L?
A. Muscle weakness and cardiac dysrhythmias.
B. Peaked T waves on an EKG.
C. Increased deep tendon reflexes.
D. Positive Trousseau’s sign.
Correct Answer: A
Rationale: A potassium level of 2.8 mEq/L indicates hypokalemia, which commonly
presents with muscle weakness, leg cramps, and cardiac dysrhythmias. Potassium is
essential for the electrical conduction of the heart and muscle contraction. Peaked T waves
, are associated with hyperkalemia, not hypokalemia, while positive Trousseau’s sign relates
to hypocalcemia.
4. A patient’s ABG results are: pH 7.25, PaCO2 50, and HCO3 24. How should the nurse
interpret these findings?
A. Metabolic Acidosis
B. Respiratory Acidosis
C. Respiratory Alkalosis
D. Metabolic Alkalosis
Correct Answer: B
Rationale: The pH of 7.25 is below the normal range of 7.35-7.45, indicating acidosis. The
PaCO2 of 50 is elevated above the normal range of 35-45, while the HCO3 is within normal
limits. Because the elevated PaCO2 matches the acidic pH, this represents respiratory
acidosis, typically caused by hypoventilation.
5. A nurse is assessing a patient for fluid volume excess. Which finding is most consistent with
this diagnosis?
A. Sunken eyeballs and dry mucous membranes.
B. Decreased blood pressure and rapid pulse.
C. Poor skin turgor and dark amber urine.
D. Distended neck veins and crackles in the lungs.
