NUR 3300 Exam 1 V3 | NUR 3300 Nursing
Practice II | Q&A with Rationale (NUR3300
Exam 1) | William Paterson University
1. A patient presents with a serum sodium level of 155 mEq/L. Which clinical manifestation
should the nurse anticipate during the assessment?
A. Hyperactive bowel sounds and diarrhea
B. Restlessness, agitation, and extreme thirst
C. Muscle weakness and shallow respirations
D. Bounding pulses and peripheral edema
Answer: B
Rationale: Hypernatremia is defined as a serum sodium level exceeding 145 mEq/L, which
causes water to move out of the cells. This leads to cellular dehydration, which primarily
affects the central nervous system, resulting in restlessness and agitation. The nurse must
recognize that thirst is the body’s primary defense mechanism to restore fluid balance in
this state.
2. The nurse is caring for a patient with a history of heart failure who is receiving Digoxin and
Furosemide. Which electrolyte imbalance increases the risk of digoxin toxicity?
A. Hypokalemia
B. Hypercalcemia
,C. Hypernatremia
D. Hypomagnesemia
Answer: A
Rationale: Hypokalemia, or low serum potassium, sensitizes the myocardium to the effects
of digoxin. Potassium and digoxin compete for the same binding sites on the sodium-
potassium ATPase pump in the cardiac muscle. Therefore, a decrease in potassium allows
more digoxin to bind, which can lead to life-threatening arrhythmias.
3. A patient with chronic obstructive pulmonary disease (COPD) has the following ABG
results: pH 7.32, PaCO2 55 mm Hg, and HCO3 28 mEq/L. The nurse interprets these findings
as:
A. Metabolic Alkalosis, partially compensated
B. Metabolic Acidosis, uncompensated
C. Respiratory Alkalosis, fully compensated
D. Respiratory Acidosis, partially compensated
Answer: D
Rationale: The pH is below 7.35, indicating acidosis, and the PaCO2 is elevated above 45
mm Hg, indicating a respiratory cause. The HCO3 is elevated above 26 mEq/L, which shows
the kidneys are attempting to compensate by retaining bicarbonate. Because the pH has not
yet returned to the normal range, the compensation is considered partial.
, 4. Which nursing action is the priority when a patient reports feeling a ‘pop’ in their surgical
incision followed by a sudden discharge of serosanguinous fluid?
A. Instruct the patient to remain still and take deep breaths
B. Immediately re-approximate the wound edges with sterile tape
C. Obtain a set of vital signs and call the rapid response team
D. Apply a sterile dressing soaked in normal saline over the wound
Answer: D
Rationale: The patient’s description suggests wound evisceration, which is a medical
emergency where internal organs protrude through the incision. The nurse must protect
the exposed tissue from drying out and becoming infected by using sterile, saline-soaked
dressings. After securing the site, the surgeon must be notified immediately for surgical
intervention.
5. A patient is scheduled for an elective cholecystectomy. The nurse notes the patient is
confused about the risks of the surgery. What is the nurse’s primary responsibility?
A. Explain the potential risks and benefits of the surgery to the patient
B. Ask the patient to sign the consent form and then call the surgeon
C. Notify the surgeon that the patient needs further clarification
D. Document that the patient is refusing the surgical procedure
Answer: C
Practice II | Q&A with Rationale (NUR3300
Exam 1) | William Paterson University
1. A patient presents with a serum sodium level of 155 mEq/L. Which clinical manifestation
should the nurse anticipate during the assessment?
A. Hyperactive bowel sounds and diarrhea
B. Restlessness, agitation, and extreme thirst
C. Muscle weakness and shallow respirations
D. Bounding pulses and peripheral edema
Answer: B
Rationale: Hypernatremia is defined as a serum sodium level exceeding 145 mEq/L, which
causes water to move out of the cells. This leads to cellular dehydration, which primarily
affects the central nervous system, resulting in restlessness and agitation. The nurse must
recognize that thirst is the body’s primary defense mechanism to restore fluid balance in
this state.
2. The nurse is caring for a patient with a history of heart failure who is receiving Digoxin and
Furosemide. Which electrolyte imbalance increases the risk of digoxin toxicity?
A. Hypokalemia
B. Hypercalcemia
,C. Hypernatremia
D. Hypomagnesemia
Answer: A
Rationale: Hypokalemia, or low serum potassium, sensitizes the myocardium to the effects
of digoxin. Potassium and digoxin compete for the same binding sites on the sodium-
potassium ATPase pump in the cardiac muscle. Therefore, a decrease in potassium allows
more digoxin to bind, which can lead to life-threatening arrhythmias.
3. A patient with chronic obstructive pulmonary disease (COPD) has the following ABG
results: pH 7.32, PaCO2 55 mm Hg, and HCO3 28 mEq/L. The nurse interprets these findings
as:
A. Metabolic Alkalosis, partially compensated
B. Metabolic Acidosis, uncompensated
C. Respiratory Alkalosis, fully compensated
D. Respiratory Acidosis, partially compensated
Answer: D
Rationale: The pH is below 7.35, indicating acidosis, and the PaCO2 is elevated above 45
mm Hg, indicating a respiratory cause. The HCO3 is elevated above 26 mEq/L, which shows
the kidneys are attempting to compensate by retaining bicarbonate. Because the pH has not
yet returned to the normal range, the compensation is considered partial.
, 4. Which nursing action is the priority when a patient reports feeling a ‘pop’ in their surgical
incision followed by a sudden discharge of serosanguinous fluid?
A. Instruct the patient to remain still and take deep breaths
B. Immediately re-approximate the wound edges with sterile tape
C. Obtain a set of vital signs and call the rapid response team
D. Apply a sterile dressing soaked in normal saline over the wound
Answer: D
Rationale: The patient’s description suggests wound evisceration, which is a medical
emergency where internal organs protrude through the incision. The nurse must protect
the exposed tissue from drying out and becoming infected by using sterile, saline-soaked
dressings. After securing the site, the surgeon must be notified immediately for surgical
intervention.
5. A patient is scheduled for an elective cholecystectomy. The nurse notes the patient is
confused about the risks of the surgery. What is the nurse’s primary responsibility?
A. Explain the potential risks and benefits of the surgery to the patient
B. Ask the patient to sign the consent form and then call the surgeon
C. Notify the surgeon that the patient needs further clarification
D. Document that the patient is refusing the surgical procedure
Answer: C
