NUR 3300 Exam 1 V2 | NUR 3300 Nursing
Practice II | Q&A with Rationale (NUR3300
Exam 1) | William Paterson University
1. A patient presents with a serum potassium level of 6.2 mEq/L. Which nursing intervention
is the highest priority?
A. Administering a dose of spironolactone
B. Encouraging the intake of bananas and orange juice
C. Checking the patient’s deep tendon reflexes
D. Placing the patient on a continuous cardiac monitor
Answer: D
Rationale: Hyperkalemia can lead to life-threatening cardiac dysrhythmias and cardiac
arrest. Placing the patient on a cardiac monitor is the priority to detect rhythm changes
immediately. The nurse should then prepare to administer treatments such as calcium
gluconate or insulin with dextrose as ordered.
2. When assessing a patient with fluid volume deficit, which clinical manifestation should the
nurse expect to observe?
A. Jugular venous distention
B. Pounding peripheral pulses
C. Orthostatic hypotension
,D. Increased urine output
Answer: C
Rationale: Fluid volume deficit leads to decreased circulating blood volume, which often
causes a drop in blood pressure when changing positions. The nurse may also observe poor
skin turgor, dry mucous membranes, and tachycardia. Monitoring vital signs and daily
weights is essential for evaluating the effectiveness of rehydration therapy.
3. A patient’s arterial blood gas (ABG) results are: pH 7.30, PaCO2 55 mmHg, and HCO3 24
mEq/L. How should the nurse interpret these findings?
A. Metabolic acidosis
B. Respiratory alkalosis
C. Metabolic alkalosis
D. Respiratory acidosis
Answer: D
Rationale: The pH is low, indicating acidosis, and the PaCO2 is elevated, which is the
primary cause of the acidosis. The bicarbonate level is within the normal range, indicating
that no compensation has occurred yet. This pattern is characteristic of respiratory
acidosis, often caused by hypoventilation.
4. Which assessment finding is most indicative of hypocalcemia in a patient who recently
underwent a thyroidectomy?
A. Hyperactive deep tendon reflexes
, B. Lethargy and confusion
C. Constipation and abdominal cramping
D. Positive Chvostek’s sign
Answer: D
Rationale: Hypocalcemia can occur after a thyroidectomy if the parathyroid glands are
accidentally damaged or removed. A positive Chvostek’s sign, which is a facial twitch
elicited by tapping the facial nerve, indicates neuromuscular irritability. The nurse must
also monitor for Trousseau’s sign and potential laryngospasm.
5. A nurse is preparing a patient for surgery. What is the nurse’s primary responsibility
regarding the informed consent process?
A. Explaining the risks and benefits of the procedure
B. Describing alternative treatment options to the patient
C. Witnessing the patient’s signature on the consent form
D. Determining if the patient is mentally competent for surgery
Answer: C
Rationale: The surgeon is responsible for explaining the procedure, risks, benefits, and
alternatives to the patient. The nurse’s role is to witness the patient signing the form and
ensure the patient understands they have the right to refuse. If the patient has questions
Practice II | Q&A with Rationale (NUR3300
Exam 1) | William Paterson University
1. A patient presents with a serum potassium level of 6.2 mEq/L. Which nursing intervention
is the highest priority?
A. Administering a dose of spironolactone
B. Encouraging the intake of bananas and orange juice
C. Checking the patient’s deep tendon reflexes
D. Placing the patient on a continuous cardiac monitor
Answer: D
Rationale: Hyperkalemia can lead to life-threatening cardiac dysrhythmias and cardiac
arrest. Placing the patient on a cardiac monitor is the priority to detect rhythm changes
immediately. The nurse should then prepare to administer treatments such as calcium
gluconate or insulin with dextrose as ordered.
2. When assessing a patient with fluid volume deficit, which clinical manifestation should the
nurse expect to observe?
A. Jugular venous distention
B. Pounding peripheral pulses
C. Orthostatic hypotension
,D. Increased urine output
Answer: C
Rationale: Fluid volume deficit leads to decreased circulating blood volume, which often
causes a drop in blood pressure when changing positions. The nurse may also observe poor
skin turgor, dry mucous membranes, and tachycardia. Monitoring vital signs and daily
weights is essential for evaluating the effectiveness of rehydration therapy.
3. A patient’s arterial blood gas (ABG) results are: pH 7.30, PaCO2 55 mmHg, and HCO3 24
mEq/L. How should the nurse interpret these findings?
A. Metabolic acidosis
B. Respiratory alkalosis
C. Metabolic alkalosis
D. Respiratory acidosis
Answer: D
Rationale: The pH is low, indicating acidosis, and the PaCO2 is elevated, which is the
primary cause of the acidosis. The bicarbonate level is within the normal range, indicating
that no compensation has occurred yet. This pattern is characteristic of respiratory
acidosis, often caused by hypoventilation.
4. Which assessment finding is most indicative of hypocalcemia in a patient who recently
underwent a thyroidectomy?
A. Hyperactive deep tendon reflexes
, B. Lethargy and confusion
C. Constipation and abdominal cramping
D. Positive Chvostek’s sign
Answer: D
Rationale: Hypocalcemia can occur after a thyroidectomy if the parathyroid glands are
accidentally damaged or removed. A positive Chvostek’s sign, which is a facial twitch
elicited by tapping the facial nerve, indicates neuromuscular irritability. The nurse must
also monitor for Trousseau’s sign and potential laryngospasm.
5. A nurse is preparing a patient for surgery. What is the nurse’s primary responsibility
regarding the informed consent process?
A. Explaining the risks and benefits of the procedure
B. Describing alternative treatment options to the patient
C. Witnessing the patient’s signature on the consent form
D. Determining if the patient is mentally competent for surgery
Answer: C
Rationale: The surgeon is responsible for explaining the procedure, risks, benefits, and
alternatives to the patient. The nurse’s role is to witness the patient signing the form and
ensure the patient understands they have the right to refuse. If the patient has questions
