NUR 355 Exam 1: Acute & Chronic Health Disruptions In
Adults I V1 - Arizona College Updated and Latest Questions
and Correct Answers with Rationale
1. What is the primary role of the nurse when a patient is signing an informed consent form for surgery?
A. Explaining the risks and benefits of the surgical procedure
B. Providing detailed information about alternative treatments
C. Deciding if the patient should proceed with the surgery
D. Witnessing the patient’s signature on the document
Ans: D
Explanation: The nurse’s primary responsibility is to witness the patient signing the consent form
voluntarily. It is the surgeon’s responsibility to explain the risks, benefits, and alternatives of the
procedure. The nurse ensures the patient is competent and understands they are signing a legal
document. If the patient has further questions about the procedure, the nurse should notify the surgeon.
Proper documentation of the witnessing process is essential for legal protection of the facility.
2. Which electrolyte imbalance is most commonly associated with the presence of Chvostek’s sign?
A. Hypocalcemia
B. Hyponatremia
C. Hyperkalemia
D. Hypermagnesemia
Ans: A
Explanation: Hypocalcemia is characterized by a serum calcium level below the normal range.
Chvostek’s sign is an abnormal reaction to the stimulation of the facial nerve. To test this, the nurse taps
,the cheek just in front of the ear. A positive sign involves twitching of the facial muscles on the same side.
This assessment indicates neuromuscular irritability caused by low calcium levels.
3. A patient is 24 hours postoperative and has not yet voided. What is the nurse’s first action?
A. Insert a straight catheter immediately
B. Increase the rate of intravenous fluids
C. Perform a bladder scan to assess volume
D. Notify the surgeon of possible renal failure
Ans: C
Explanation: Postoperative urinary retention is a common occurrence due to anesthesia and pain
medications. The nurse should first assess the amount of urine in the bladder using a non-invasive
bladder scanner. This data helps determine if the issue is retention or a lack of urine production. If the
bladder is full, the nurse can then implement measures to assist with voiding. Communicating the scan
results to the provider guides further medical interventions.
4. What is the most effective nursing intervention to prevent atelectasis in a postoperative patient?
A. Administering prophylactic antibiotics
B. Encouraging the use of an incentive spirometer
C. Maintaining a strict bed rest protocol
D. Restricting fluid intake to prevent edema
Ans: B
Explanation: Atelectasis involves the collapse of alveoli, which can lead to pneumonia after surgery.
Incentive spirometry encourages deep breathing and lung expansion to prevent this complication. The
, nurse should teach the patient to use the device ten times every hour while awake. Monitoring breath
sounds and oxygen saturation provides evidence of the intervention’s effectiveness. Early mobilization
and frequent position changes also support optimal pulmonary function.
5. Which acid-base imbalance is a patient with chronic obstructive pulmonary disease (COPD) at highest risk
for?
A. Metabolic Acidosis
B. Respiratory Acidosis
C. Metabolic Alkalosis
D. Respiratory Alkalosis
Ans: B
Explanation: COPD causes chronic airflow limitation and the retention of carbon dioxide in the lungs.
High levels of carbon dioxide lead to an increase in hydrogen ions and a lower pH. This condition is
known as respiratory acidosis because the primary cause is pulmonary dysfunction. The nurse monitors
arterial blood gas results to evaluate the severity of the imbalance. Treatment focuses on improving
ventilation and oxygenation to stabilize the patient’s acid-base status.
6. When assessing a wound, the nurse notes thick, yellow-green drainage. How should this be documented?
A. Purulent drainage
B. Sanguineous drainage
C. Serosanguineous drainage
D. Serous drainage
Ans: A
Adults I V1 - Arizona College Updated and Latest Questions
and Correct Answers with Rationale
1. What is the primary role of the nurse when a patient is signing an informed consent form for surgery?
A. Explaining the risks and benefits of the surgical procedure
B. Providing detailed information about alternative treatments
C. Deciding if the patient should proceed with the surgery
D. Witnessing the patient’s signature on the document
Ans: D
Explanation: The nurse’s primary responsibility is to witness the patient signing the consent form
voluntarily. It is the surgeon’s responsibility to explain the risks, benefits, and alternatives of the
procedure. The nurse ensures the patient is competent and understands they are signing a legal
document. If the patient has further questions about the procedure, the nurse should notify the surgeon.
Proper documentation of the witnessing process is essential for legal protection of the facility.
2. Which electrolyte imbalance is most commonly associated with the presence of Chvostek’s sign?
A. Hypocalcemia
B. Hyponatremia
C. Hyperkalemia
D. Hypermagnesemia
Ans: A
Explanation: Hypocalcemia is characterized by a serum calcium level below the normal range.
Chvostek’s sign is an abnormal reaction to the stimulation of the facial nerve. To test this, the nurse taps
,the cheek just in front of the ear. A positive sign involves twitching of the facial muscles on the same side.
This assessment indicates neuromuscular irritability caused by low calcium levels.
3. A patient is 24 hours postoperative and has not yet voided. What is the nurse’s first action?
A. Insert a straight catheter immediately
B. Increase the rate of intravenous fluids
C. Perform a bladder scan to assess volume
D. Notify the surgeon of possible renal failure
Ans: C
Explanation: Postoperative urinary retention is a common occurrence due to anesthesia and pain
medications. The nurse should first assess the amount of urine in the bladder using a non-invasive
bladder scanner. This data helps determine if the issue is retention or a lack of urine production. If the
bladder is full, the nurse can then implement measures to assist with voiding. Communicating the scan
results to the provider guides further medical interventions.
4. What is the most effective nursing intervention to prevent atelectasis in a postoperative patient?
A. Administering prophylactic antibiotics
B. Encouraging the use of an incentive spirometer
C. Maintaining a strict bed rest protocol
D. Restricting fluid intake to prevent edema
Ans: B
Explanation: Atelectasis involves the collapse of alveoli, which can lead to pneumonia after surgery.
Incentive spirometry encourages deep breathing and lung expansion to prevent this complication. The
, nurse should teach the patient to use the device ten times every hour while awake. Monitoring breath
sounds and oxygen saturation provides evidence of the intervention’s effectiveness. Early mobilization
and frequent position changes also support optimal pulmonary function.
5. Which acid-base imbalance is a patient with chronic obstructive pulmonary disease (COPD) at highest risk
for?
A. Metabolic Acidosis
B. Respiratory Acidosis
C. Metabolic Alkalosis
D. Respiratory Alkalosis
Ans: B
Explanation: COPD causes chronic airflow limitation and the retention of carbon dioxide in the lungs.
High levels of carbon dioxide lead to an increase in hydrogen ions and a lower pH. This condition is
known as respiratory acidosis because the primary cause is pulmonary dysfunction. The nurse monitors
arterial blood gas results to evaluate the severity of the imbalance. Treatment focuses on improving
ventilation and oxygenation to stabilize the patient’s acid-base status.
6. When assessing a wound, the nurse notes thick, yellow-green drainage. How should this be documented?
A. Purulent drainage
B. Sanguineous drainage
C. Serosanguineous drainage
D. Serous drainage
Ans: A
