NR226/NR 226 Exam 3 V1 | Fundamentals of
Patient Care Q&A with Rationale | Chamberlain
University
1. A nurse is witnessing a client sign an informed consent form for an upcoming abdominal
surgery. What is the nurse’s primary responsibility in this process?
A. Ensuring the client understands the risks and benefits of the surgery
B. Explaining the surgical procedure and alternative treatments
C. Confirming that the client is signing the form voluntarily
D. Determining if the client is medically fit for the procedure
Correct Answer: C
Explanation: The nurse’s role in informed consent is to act as a witness to the signature
process. This includes verifying that the client is competent, the signature is authentic, and
the client appears to be acting of their own free will. The responsibility of explaining the
procedure and its risks belongs solely to the provider performing the surgery.
2. Which arterial blood gas (ABG) result should the nurse anticipate for a client who has been
experiencing severe vomiting for the past 24 hours?
A. pH 7.30, PaCO2 50, HCO3 24
B. pH 7.48, PaCO2 40, HCO3 30
C. pH 7.32, PaCO2 35, HCO3 18
,D. pH 7.50, PaCO2 28, HCO3 22
Correct Answer: B
Explanation: Vomiting leads to the loss of gastric acid, which typically results in metabolic
alkalosis. Metabolic alkalosis is characterized by an elevated pH (greater than 7.45) and an
elevated bicarbonate level (greater than 26 mEq/L). Option B reflects these physiological
changes while the other options represent acidosis or respiratory-driven imbalances.
3. A postoperative client reports sudden shortness of breath and chest pain. Which
complication should the nurse suspect first?
A. Atelectasis
B. Pneumonia
C. Pulmonary Embolism
D. Hypovolemic Shock
Correct Answer: C
Explanation: Sudden onset of dyspnea and chest pain in a surgical patient is a classic
presentation of a pulmonary embolism. This is a life-threatening complication often
resulting from deep vein thrombosis mobilized to the lungs. The nurse must immediately
stabilize the patient, apply oxygen, and notify the rapid response team or provider.
4. During the preoperative assessment, a client reveals a severe allergy to avocados and
bananas. Which action by the nurse is most appropriate?
A. Ask the client if they also have an allergy to shellfish
, B. Document the allergy and notify the surgical team of a potential latex allergy
C. Ignore the information as it pertains to food rather than medication
D. Administer an antihistamine as a prophylactic measure
Correct Answer: B
Explanation: Cross-reactivity exists between certain foods and latex due to similar protein
structures. Clients allergic to avocados, bananas, strawberries, or kiwi are at a significantly
higher risk for latex hypersensitivity. Identifying this risk allows the surgical team to
implement a latex-free environment to prevent anaphylaxis.
5. A nurse is caring for a client with a potassium level of 2.8 mEq/L. Which clinical
manifestation is most likely to be observed?
A. Hyperactive bowel sounds
B. Peaked T waves on ECG
C. Positive Chvostek’s sign
D. Muscle weakness and leg cramps
Correct Answer: D
Explanation: A potassium level of 2.8 mEq/L indicates hypokalemia, which affects
neuromuscular and cardiac function. Common symptoms include muscle weakness,
decreased deep tendon reflexes, and leg cramps. Severe hypokalemia can lead to life-
threatening arrhythmias and paralytic ileus.
Patient Care Q&A with Rationale | Chamberlain
University
1. A nurse is witnessing a client sign an informed consent form for an upcoming abdominal
surgery. What is the nurse’s primary responsibility in this process?
A. Ensuring the client understands the risks and benefits of the surgery
B. Explaining the surgical procedure and alternative treatments
C. Confirming that the client is signing the form voluntarily
D. Determining if the client is medically fit for the procedure
Correct Answer: C
Explanation: The nurse’s role in informed consent is to act as a witness to the signature
process. This includes verifying that the client is competent, the signature is authentic, and
the client appears to be acting of their own free will. The responsibility of explaining the
procedure and its risks belongs solely to the provider performing the surgery.
2. Which arterial blood gas (ABG) result should the nurse anticipate for a client who has been
experiencing severe vomiting for the past 24 hours?
A. pH 7.30, PaCO2 50, HCO3 24
B. pH 7.48, PaCO2 40, HCO3 30
C. pH 7.32, PaCO2 35, HCO3 18
,D. pH 7.50, PaCO2 28, HCO3 22
Correct Answer: B
Explanation: Vomiting leads to the loss of gastric acid, which typically results in metabolic
alkalosis. Metabolic alkalosis is characterized by an elevated pH (greater than 7.45) and an
elevated bicarbonate level (greater than 26 mEq/L). Option B reflects these physiological
changes while the other options represent acidosis or respiratory-driven imbalances.
3. A postoperative client reports sudden shortness of breath and chest pain. Which
complication should the nurse suspect first?
A. Atelectasis
B. Pneumonia
C. Pulmonary Embolism
D. Hypovolemic Shock
Correct Answer: C
Explanation: Sudden onset of dyspnea and chest pain in a surgical patient is a classic
presentation of a pulmonary embolism. This is a life-threatening complication often
resulting from deep vein thrombosis mobilized to the lungs. The nurse must immediately
stabilize the patient, apply oxygen, and notify the rapid response team or provider.
4. During the preoperative assessment, a client reveals a severe allergy to avocados and
bananas. Which action by the nurse is most appropriate?
A. Ask the client if they also have an allergy to shellfish
, B. Document the allergy and notify the surgical team of a potential latex allergy
C. Ignore the information as it pertains to food rather than medication
D. Administer an antihistamine as a prophylactic measure
Correct Answer: B
Explanation: Cross-reactivity exists between certain foods and latex due to similar protein
structures. Clients allergic to avocados, bananas, strawberries, or kiwi are at a significantly
higher risk for latex hypersensitivity. Identifying this risk allows the surgical team to
implement a latex-free environment to prevent anaphylaxis.
5. A nurse is caring for a client with a potassium level of 2.8 mEq/L. Which clinical
manifestation is most likely to be observed?
A. Hyperactive bowel sounds
B. Peaked T waves on ECG
C. Positive Chvostek’s sign
D. Muscle weakness and leg cramps
Correct Answer: D
Explanation: A potassium level of 2.8 mEq/L indicates hypokalemia, which affects
neuromuscular and cardiac function. Common symptoms include muscle weakness,
decreased deep tendon reflexes, and leg cramps. Severe hypokalemia can lead to life-
threatening arrhythmias and paralytic ileus.
