NUR 355 Exam 1: Acute & Chronic Health Disruptions In
Adults I V2 - Arizona College Updated and Latest Questions
and Correct Answers with Rationale
1. A patient exhibits restlessness and confusion after surgery. What is the priority nursing action?
A. Administer a sedative to calm the patient.
B. Increase the intravenous fluid rate.
C. Notify the surgeon of the behavioral changes.
D. Check the patient’s oxygen saturation level.
Ans: D
Explanation: The correct action is to assess the patient’s oxygen saturation immediately. Restlessness
and confusion are primary early indicators of hypoxemia in the postoperative period. Sedatives should be
avoided as they may mask worsening respiratory distress or depress breathing further. Nurses must
prioritize physiological assessment before implementing interventions or calling the provider. Ensuring
adequate oxygenation is the first step in maintaining patient safety.
2. Which arterial blood gas (ABG) result is consistent with a patient experiencing a panic attack?
A. pH 7.48, PaCO2 30, HCO3 23
B. pH 7.32, PaCO2 50, HCO3 24
C. pH 7.35, PaCO2 40, HCO3 24
D. pH 7.25, PaCO2 40, HCO3 18
Ans: A
Explanation: The correct answer is pH 7.48 and PaCO2 30, which indicates respiratory alkalosis. Panic
attacks lead to hyperventilation, causing the patient to blow off too much carbon dioxide. This decrease in
,PaCO2 raises the blood pH above the normal range of 7.45. Nurses should encourage slow, deep
breathing or the use of a paper bag to retain CO2. Monitoring the patient’s respiratory rate is essential to
guide further intervention.
3. A nurse is caring for a patient with a potassium level of 2.8 mEq/L. Which assessment finding is most
expected?
A. Hyperactive bowel sounds
B. Prominent U waves on the ECG
C. Increased muscle strength
D. Peaked T waves
Ans: B
Explanation: The correct finding for hypokalemia is the presence of U waves on the electrocardiogram.
Low potassium levels affect cardiac electrical conduction and can lead to life-threatening arrhythmias.
Peaked T waves are associated with hyperkalemia, not hypokalemia, which instead causes flat or
inverted T waves. The nurse must monitor the patient for muscle weakness and cardiac instability.
Immediate potassium replacement is typically required as per facility protocol.
4. Which medication should the nurse anticipate administering for the treatment of malignant
hyperthermia?
A. Atropine sulfate
B. Dantrolene sodium
C. Epinephrine
D. Naloxone
Ans: B
, Explanation: The correct medication for treating malignant hyperthermia is dantrolene sodium. This
drug acts as a skeletal muscle relaxant by inhibiting the release of calcium from the sarcoplasmic
reticulum. Malignant hyperthermia is a rare but fatal reaction to certain anesthetic gases and
succinylcholine. Nurses must recognize early signs like muscle rigidity and unexplained tachycardia.
Rapid administration of dantrolene is critical to saving the patient’s life.
5. A patient is 12 hours postoperative following an abdominal surgery. Which finding requires immediate
intervention?
A. Urine output of 20 mL per hour for two consecutive hours
B. Absent bowel sounds in all quadrants
C. Pain level of 4 on a scale of 0 to 10
D. Serosanguinous drainage on the surgical dressing
Ans: A
Explanation: The correct answer is the low urine output, which may indicate acute kidney injury or
hypovolemia. Normal urine output should be at least 30 mL per hour to ensure adequate organ perfusion.
Absent bowel sounds are common immediately after abdominal surgery due to paralytic ileus.
Serosanguinous drainage is an expected finding on a fresh surgical wound dressing. The nurse must
report low output to the provider to prevent further renal complications.
6. What is the primary purpose of the ‘Time Out’ procedure in the operating room?
A. To allow the surgeon to review the surgical steps.
B. To document the start time of the anesthesia.
C. To ensure the correct patient, site, and procedure.
D. To give the patient one last chance to refuse surgery.
Adults I V2 - Arizona College Updated and Latest Questions
and Correct Answers with Rationale
1. A patient exhibits restlessness and confusion after surgery. What is the priority nursing action?
A. Administer a sedative to calm the patient.
B. Increase the intravenous fluid rate.
C. Notify the surgeon of the behavioral changes.
D. Check the patient’s oxygen saturation level.
Ans: D
Explanation: The correct action is to assess the patient’s oxygen saturation immediately. Restlessness
and confusion are primary early indicators of hypoxemia in the postoperative period. Sedatives should be
avoided as they may mask worsening respiratory distress or depress breathing further. Nurses must
prioritize physiological assessment before implementing interventions or calling the provider. Ensuring
adequate oxygenation is the first step in maintaining patient safety.
2. Which arterial blood gas (ABG) result is consistent with a patient experiencing a panic attack?
A. pH 7.48, PaCO2 30, HCO3 23
B. pH 7.32, PaCO2 50, HCO3 24
C. pH 7.35, PaCO2 40, HCO3 24
D. pH 7.25, PaCO2 40, HCO3 18
Ans: A
Explanation: The correct answer is pH 7.48 and PaCO2 30, which indicates respiratory alkalosis. Panic
attacks lead to hyperventilation, causing the patient to blow off too much carbon dioxide. This decrease in
,PaCO2 raises the blood pH above the normal range of 7.45. Nurses should encourage slow, deep
breathing or the use of a paper bag to retain CO2. Monitoring the patient’s respiratory rate is essential to
guide further intervention.
3. A nurse is caring for a patient with a potassium level of 2.8 mEq/L. Which assessment finding is most
expected?
A. Hyperactive bowel sounds
B. Prominent U waves on the ECG
C. Increased muscle strength
D. Peaked T waves
Ans: B
Explanation: The correct finding for hypokalemia is the presence of U waves on the electrocardiogram.
Low potassium levels affect cardiac electrical conduction and can lead to life-threatening arrhythmias.
Peaked T waves are associated with hyperkalemia, not hypokalemia, which instead causes flat or
inverted T waves. The nurse must monitor the patient for muscle weakness and cardiac instability.
Immediate potassium replacement is typically required as per facility protocol.
4. Which medication should the nurse anticipate administering for the treatment of malignant
hyperthermia?
A. Atropine sulfate
B. Dantrolene sodium
C. Epinephrine
D. Naloxone
Ans: B
, Explanation: The correct medication for treating malignant hyperthermia is dantrolene sodium. This
drug acts as a skeletal muscle relaxant by inhibiting the release of calcium from the sarcoplasmic
reticulum. Malignant hyperthermia is a rare but fatal reaction to certain anesthetic gases and
succinylcholine. Nurses must recognize early signs like muscle rigidity and unexplained tachycardia.
Rapid administration of dantrolene is critical to saving the patient’s life.
5. A patient is 12 hours postoperative following an abdominal surgery. Which finding requires immediate
intervention?
A. Urine output of 20 mL per hour for two consecutive hours
B. Absent bowel sounds in all quadrants
C. Pain level of 4 on a scale of 0 to 10
D. Serosanguinous drainage on the surgical dressing
Ans: A
Explanation: The correct answer is the low urine output, which may indicate acute kidney injury or
hypovolemia. Normal urine output should be at least 30 mL per hour to ensure adequate organ perfusion.
Absent bowel sounds are common immediately after abdominal surgery due to paralytic ileus.
Serosanguinous drainage is an expected finding on a fresh surgical wound dressing. The nurse must
report low output to the provider to prevent further renal complications.
6. What is the primary purpose of the ‘Time Out’ procedure in the operating room?
A. To allow the surgeon to review the surgical steps.
B. To document the start time of the anesthesia.
C. To ensure the correct patient, site, and procedure.
D. To give the patient one last chance to refuse surgery.
