NUR155/NUR 155 Exam 4 V2 | Critical
Thinking for the Practical Nurse Q&A with
Rationale | Hondros College of Nursing
1. A patient presents with a potassium level of 6.2 mEq/L. Which nursing intervention is the
highest priority?
A. Administering a prescribed dose of spironolactone.
B. Placing the patient on a continuous cardiac monitor.
C. Encouraging the intake of bananas and orange juice.
D. Teaching the patient about low-sodium diet options.
Correct Answer: B
Rationale: A potassium level of 6.2 mEq/L indicates severe hyperkalemia, which
significantly increases the risk of life-threatening cardiac dysrhythmias. Continuous cardiac
monitoring is essential to identify changes like peaked T waves or widened QRS complexes
immediately. Spironolactone and potassium-rich foods would worsen the condition, while
diet teaching is not an acute priority.
2. A nurse is caring for a patient who is 12 hours post-abdominal surgery. The patient refuses
to use the incentive spirometer because it ‘hurts too much.’ What is the nurse’s best action?
A. Administer prescribed analgesic and return in 30 minutes.
B. Document the patient’s refusal and notify the surgeon.
,C. Explain that the spirometer prevents the need for oxygen.
D. Tell the patient they will develop pneumonia if they do not comply.
Correct Answer: A
Rationale: Effective pain management is a prerequisite for postoperative respiratory
exercises like incentive spirometry. By administering an analgesic, the nurse reduces the
patient’s discomfort, making them more likely to cooperate with the treatment. This
proactive approach addresses the root cause of the non-compliance and promotes better
pulmonary outcomes.
3. Which arterial blood gas (ABG) result should the nurse identify as respiratory acidosis?
A. pH 7.48, PaCO2 32, HCO3 22
B. pH 7.50, PaCO2 40, HCO3 30
C. pH 7.32, PaCO2 38, HCO3 18
D. pH 7.30, PaCO2 52, HCO3 24
Correct Answer: D
Rationale: Respiratory acidosis is characterized by a pH lower than 7.35 and a PaCO2
higher than 45 mmHg. In this scenario, the pH of 7.30 indicates acidosis and the PaCO2 of
52 indicates a respiratory origin. Option C represents metabolic acidosis, while options A
and D represent alkalotic states.
, 4. The nurse is monitoring a patient receiving a blood transfusion. Five minutes into the
infusion, the patient reports back pain and chills. What is the nurse’s first action?
A. Slow the infusion rate and call the healthcare provider.
B. Stop the infusion and disconnect the tubing at the hub.
C. Administer diphenhydramine as per standing orders.
D. Recheck the patient’s identification against the blood bag.
Correct Answer: B
Rationale: Back pain and chills are hallmark signs of a hemolytic transfusion reaction,
which is a life-threatening emergency. The first priority is to stop the infusion immediately
to prevent further exposure to the incompatible blood. The nurse should then maintain the
line with normal saline using new tubing and notify the provider.
5. A patient with hypocalcemia exhibits a positive Chvostek’s sign. How does the nurse elicit
this sign?
A. Inflating a blood pressure cuff on the upper arm for 3 minutes.
B. Tapping the patient’s face just below the temple.
C. Applying pressure to the patient’s radial nerve.
D. Observing for carpal spasms when the patient is resting.
Correct Answer: B
Thinking for the Practical Nurse Q&A with
Rationale | Hondros College of Nursing
1. A patient presents with a potassium level of 6.2 mEq/L. Which nursing intervention is the
highest priority?
A. Administering a prescribed dose of spironolactone.
B. Placing the patient on a continuous cardiac monitor.
C. Encouraging the intake of bananas and orange juice.
D. Teaching the patient about low-sodium diet options.
Correct Answer: B
Rationale: A potassium level of 6.2 mEq/L indicates severe hyperkalemia, which
significantly increases the risk of life-threatening cardiac dysrhythmias. Continuous cardiac
monitoring is essential to identify changes like peaked T waves or widened QRS complexes
immediately. Spironolactone and potassium-rich foods would worsen the condition, while
diet teaching is not an acute priority.
2. A nurse is caring for a patient who is 12 hours post-abdominal surgery. The patient refuses
to use the incentive spirometer because it ‘hurts too much.’ What is the nurse’s best action?
A. Administer prescribed analgesic and return in 30 minutes.
B. Document the patient’s refusal and notify the surgeon.
,C. Explain that the spirometer prevents the need for oxygen.
D. Tell the patient they will develop pneumonia if they do not comply.
Correct Answer: A
Rationale: Effective pain management is a prerequisite for postoperative respiratory
exercises like incentive spirometry. By administering an analgesic, the nurse reduces the
patient’s discomfort, making them more likely to cooperate with the treatment. This
proactive approach addresses the root cause of the non-compliance and promotes better
pulmonary outcomes.
3. Which arterial blood gas (ABG) result should the nurse identify as respiratory acidosis?
A. pH 7.48, PaCO2 32, HCO3 22
B. pH 7.50, PaCO2 40, HCO3 30
C. pH 7.32, PaCO2 38, HCO3 18
D. pH 7.30, PaCO2 52, HCO3 24
Correct Answer: D
Rationale: Respiratory acidosis is characterized by a pH lower than 7.35 and a PaCO2
higher than 45 mmHg. In this scenario, the pH of 7.30 indicates acidosis and the PaCO2 of
52 indicates a respiratory origin. Option C represents metabolic acidosis, while options A
and D represent alkalotic states.
, 4. The nurse is monitoring a patient receiving a blood transfusion. Five minutes into the
infusion, the patient reports back pain and chills. What is the nurse’s first action?
A. Slow the infusion rate and call the healthcare provider.
B. Stop the infusion and disconnect the tubing at the hub.
C. Administer diphenhydramine as per standing orders.
D. Recheck the patient’s identification against the blood bag.
Correct Answer: B
Rationale: Back pain and chills are hallmark signs of a hemolytic transfusion reaction,
which is a life-threatening emergency. The first priority is to stop the infusion immediately
to prevent further exposure to the incompatible blood. The nurse should then maintain the
line with normal saline using new tubing and notify the provider.
5. A patient with hypocalcemia exhibits a positive Chvostek’s sign. How does the nurse elicit
this sign?
A. Inflating a blood pressure cuff on the upper arm for 3 minutes.
B. Tapping the patient’s face just below the temple.
C. Applying pressure to the patient’s radial nerve.
D. Observing for carpal spasms when the patient is resting.
Correct Answer: B
