NUR 3300 Exam 2 V2 | NUR 3300 Nursing
Practice II | Q&A with Rationale (NUR3300
Exam 2) | William Paterson University
1. A patient’s laboratory results reveal a serum potassium level of 3.0 mEq/L. Which nursing
action is the highest priority?
A. Assess the patient’s muscle strength
B. Encourage the intake of bananas and orange juice
C. Place the patient on a cardiac monitor
D. Administer oral potassium supplements as ordered
Answer: C
Rationale: A potassium level of 3.0 mEq/L indicates hypokalemia, which can lead to life-
threatening cardiac dysrhythmias. Continuous cardiac monitoring is essential to detect any
changes in heart rhythm immediately. While assessing muscle strength and administering
supplements are important, cardiac stability is the primary physiological concern in this
scenario.
2. When witnessing a patient sign an informed consent form for surgery, what is the nurse’s
primary responsibility?
A. Ensuring the patient understands the surgical risks
B. Verifying that the patient is signing voluntarily and is competent
,C. Explaining the alternative treatments available
D. Answering specific questions about the surgical technique
Answer: B
Rationale: The nurse’s role in the informed consent process is to act as a witness to the
signature, ensuring it is authentic and the patient is giving consent voluntarily. The surgeon
is legally responsible for explaining the procedure, risks, and alternatives. If the nurse
notices the patient does not understand the surgery, the surgeon must be contacted to
clarify before the patient signs.
3. An arterial blood gas (ABG) report shows: pH 7.25, PaCO2 50 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 below 7.35, indicating acidosis. The PaCO2 is elevated above 45
mmHg, which points to a respiratory cause. Since the bicarbonate (HCO3) is within the
normal range, this is uncompensated respiratory acidosis, often caused by hypoventilation.
, 4. A postoperative patient reports sudden, severe abdominal pain and the nurse observes
that the abdominal wound has opened with organs protruding. What is the immediate
nursing action?
A. Push the organs back into the abdominal cavity
B. Apply a tight abdominal binder to secure the site
C. Call the physician and wait for further instructions
D. Cover the wound with sterile dressings moistened with sterile normal saline
Answer: D
Rationale: Wound evisceration is a medical emergency that requires immediate protection
of the exposed organs. Covering the site with sterile saline-soaked gauze prevents the
tissues from drying out and reduces the risk of infection. The nurse should also notify the
surgical team immediately while keeping the patient in a low-Fowler’s position with knees
flexed.
5. Which assessment finding is most characteristic of hypocalcemia?
A. Diminished deep tendon reflexes
B. Positive Trousseau’s sign
C. Increased urine output
D. Constipation and muscle weakness
Answer: B
Practice II | Q&A with Rationale (NUR3300
Exam 2) | William Paterson University
1. A patient’s laboratory results reveal a serum potassium level of 3.0 mEq/L. Which nursing
action is the highest priority?
A. Assess the patient’s muscle strength
B. Encourage the intake of bananas and orange juice
C. Place the patient on a cardiac monitor
D. Administer oral potassium supplements as ordered
Answer: C
Rationale: A potassium level of 3.0 mEq/L indicates hypokalemia, which can lead to life-
threatening cardiac dysrhythmias. Continuous cardiac monitoring is essential to detect any
changes in heart rhythm immediately. While assessing muscle strength and administering
supplements are important, cardiac stability is the primary physiological concern in this
scenario.
2. When witnessing a patient sign an informed consent form for surgery, what is the nurse’s
primary responsibility?
A. Ensuring the patient understands the surgical risks
B. Verifying that the patient is signing voluntarily and is competent
,C. Explaining the alternative treatments available
D. Answering specific questions about the surgical technique
Answer: B
Rationale: The nurse’s role in the informed consent process is to act as a witness to the
signature, ensuring it is authentic and the patient is giving consent voluntarily. The surgeon
is legally responsible for explaining the procedure, risks, and alternatives. If the nurse
notices the patient does not understand the surgery, the surgeon must be contacted to
clarify before the patient signs.
3. An arterial blood gas (ABG) report shows: pH 7.25, PaCO2 50 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 below 7.35, indicating acidosis. The PaCO2 is elevated above 45
mmHg, which points to a respiratory cause. Since the bicarbonate (HCO3) is within the
normal range, this is uncompensated respiratory acidosis, often caused by hypoventilation.
, 4. A postoperative patient reports sudden, severe abdominal pain and the nurse observes
that the abdominal wound has opened with organs protruding. What is the immediate
nursing action?
A. Push the organs back into the abdominal cavity
B. Apply a tight abdominal binder to secure the site
C. Call the physician and wait for further instructions
D. Cover the wound with sterile dressings moistened with sterile normal saline
Answer: D
Rationale: Wound evisceration is a medical emergency that requires immediate protection
of the exposed organs. Covering the site with sterile saline-soaked gauze prevents the
tissues from drying out and reduces the risk of infection. The nurse should also notify the
surgical team immediately while keeping the patient in a low-Fowler’s position with knees
flexed.
5. Which assessment finding is most characteristic of hypocalcemia?
A. Diminished deep tendon reflexes
B. Positive Trousseau’s sign
C. Increased urine output
D. Constipation and muscle weakness
Answer: B
