NUR 170 Final Exam V3 | NUR 170
Concepts of Medical-Surgical Nursing |
Q&A with Rationale (NUR170 Final Exam) |
Galen College of Nursing
1. A nurse is assessing a patient with a serum potassium level of 2.8 mEq/L. Which clinical
manifestation should the nurse prioritize?
A. Elevated ST segments on the ECG
B. Muscle weakness and cardiac dysrhythmias
C. Hyperactive deep tendon reflexes
D. Increased bowel sounds and diarrhea
Answer: B
Rationale: The correct answer is B because a potassium level of 2.8 mEq/L indicates
hypokalemia, which significantly impacts neuromuscular and cardiac function. Low
potassium can lead to muscle weakness, paralysis, and life-threatening ventricular
dysrhythmias. The nurse must monitor the patient’s cardiac rhythm closely and notify the
provider immediately.
2. An arterial blood gas (ABG) report shows pH 7.30, PaCO2 52 mm Hg, and HCO3 24 mEq/L.
How should the nurse interpret these results?
A. Metabolic Acidosis
,B. Metabolic Alkalosis
C. Respiratory Alkalosis
D. Respiratory Acidosis
Answer: D
Rationale: The nurse should identify this as respiratory acidosis because the pH is below
7.35 (acidemia) and the PaCO2 is above 45 mm Hg (respiratory cause). The normal HCO3
level indicates that compensation by the kidneys has not yet occurred. This condition is
typically caused by hypoventilation or obstructive lung diseases.
3. A patient is scheduled for an elective surgery. Who is legally responsible for obtaining the
informed consent?
A. The nurse manager
B. The surgeon
C. The circulating nurse
D. The surgical nurse
Answer: B
Rationale: The surgeon is legally responsible for providing a detailed explanation of the
procedure, its risks, benefits, and alternatives to the patient. While a nurse may witness the
signature, they do not have the legal authority to provide the initial education required for
, consent. The nurse’s role is primarily to verify that the patient understands what the
surgeon has already explained.
4. Which assessment finding in a postoperative patient should the nurse report as a potential
sign of malignant hyperthermia?
A. Bradycardia and hypotension
B. Core temperature of 98.6°F
C. Generalized muscle rigidity
D. Decreased end-tidal carbon dioxide
Answer: C
Rationale: Muscle rigidity, particularly in the jaw, is one of the earliest signs of malignant
hyperthermia during or after anesthesia. This condition is a life-threatening
pharmacogenetic disorder that causes a hypermetabolic state. Other signs include
tachycardia, tachypnea, and a rapid rise in body temperature, requiring immediate
administration of dantrolene.
5. A nurse is caring for a patient receiving IV fluids. The site is cool to the touch, swollen, and
the patient reports pain. What is the nurse’s first action?
A. Stop the infusion and remove the catheter
B. Apply a warm compress to the site
C. Flush the line with normal saline
Concepts of Medical-Surgical Nursing |
Q&A with Rationale (NUR170 Final Exam) |
Galen College of Nursing
1. A nurse is assessing a patient with a serum potassium level of 2.8 mEq/L. Which clinical
manifestation should the nurse prioritize?
A. Elevated ST segments on the ECG
B. Muscle weakness and cardiac dysrhythmias
C. Hyperactive deep tendon reflexes
D. Increased bowel sounds and diarrhea
Answer: B
Rationale: The correct answer is B because a potassium level of 2.8 mEq/L indicates
hypokalemia, which significantly impacts neuromuscular and cardiac function. Low
potassium can lead to muscle weakness, paralysis, and life-threatening ventricular
dysrhythmias. The nurse must monitor the patient’s cardiac rhythm closely and notify the
provider immediately.
2. An arterial blood gas (ABG) report shows pH 7.30, PaCO2 52 mm Hg, and HCO3 24 mEq/L.
How should the nurse interpret these results?
A. Metabolic Acidosis
,B. Metabolic Alkalosis
C. Respiratory Alkalosis
D. Respiratory Acidosis
Answer: D
Rationale: The nurse should identify this as respiratory acidosis because the pH is below
7.35 (acidemia) and the PaCO2 is above 45 mm Hg (respiratory cause). The normal HCO3
level indicates that compensation by the kidneys has not yet occurred. This condition is
typically caused by hypoventilation or obstructive lung diseases.
3. A patient is scheduled for an elective surgery. Who is legally responsible for obtaining the
informed consent?
A. The nurse manager
B. The surgeon
C. The circulating nurse
D. The surgical nurse
Answer: B
Rationale: The surgeon is legally responsible for providing a detailed explanation of the
procedure, its risks, benefits, and alternatives to the patient. While a nurse may witness the
signature, they do not have the legal authority to provide the initial education required for
, consent. The nurse’s role is primarily to verify that the patient understands what the
surgeon has already explained.
4. Which assessment finding in a postoperative patient should the nurse report as a potential
sign of malignant hyperthermia?
A. Bradycardia and hypotension
B. Core temperature of 98.6°F
C. Generalized muscle rigidity
D. Decreased end-tidal carbon dioxide
Answer: C
Rationale: Muscle rigidity, particularly in the jaw, is one of the earliest signs of malignant
hyperthermia during or after anesthesia. This condition is a life-threatening
pharmacogenetic disorder that causes a hypermetabolic state. Other signs include
tachycardia, tachypnea, and a rapid rise in body temperature, requiring immediate
administration of dantrolene.
5. A nurse is caring for a patient receiving IV fluids. The site is cool to the touch, swollen, and
the patient reports pain. What is the nurse’s first action?
A. Stop the infusion and remove the catheter
B. Apply a warm compress to the site
C. Flush the line with normal saline
