NUR 104/NUR104 Exam 2 V1 | Foundations of
Nursing Q&A with Rationale | Fortis College
1. A nurse is caring for a patient who has a serum sodium level of 128 mEq/L. Which clinical
manifestation should the nurse closely monitor for?
A. Confusion and lethargy
B. Extreme thirst and dry mucous membranes
C. Cardiac dysrhythmias and T-wave peaking
D. Muscle tetany and positive Chvostek’s sign
Correct Answer: A
Explanation: A serum sodium level below 135 mEq/L indicates hyponatremia, which
causes water to shift into brain cells, leading to cerebral edema. Confusion, lethargy, and
seizures are priority neurological assessments for these patients. Thirst is more
characteristic of hypernatremia, while the other options relate to potassium and calcium
imbalances respectively.
2. Which of the following patients is at the highest risk for developing respiratory acidosis?
A. A patient with Chronic Obstructive Pulmonary Disease (COPD)
B. A patient experiencing a severe panic attack
C. A patient with excessive vomiting for 24 hours
D. A patient with uncontrolled Type 1 Diabetes Mellitus
,Correct Answer: A
Explanation: Respiratory acidosis occurs when the lungs cannot effectively remove CO2,
as seen in chronic conditions like COPD that lead to hypoventilation. Patients with COPD
retain carbon dioxide, which increases the hydrogen ion concentration in the blood. The
other conditions mentioned lead to metabolic alkalosis, respiratory alkalosis, or metabolic
acidosis.
3. The nurse is preparing to administer an intramuscular (IM) injection to an obese adult.
Which needle length is most appropriate for the ventrogluteal site?
A. 1.5 inches
B. 1 inch
C. 5/8 inch
D. 2 to 3 inches
Correct Answer: A
Explanation: For an IM injection in the ventrogluteal site of an average to obese adult, a
1.5-inch needle is typically required to ensure the medication reaches the muscle tissue.
Shorter needles may result in the medication being deposited into subcutaneous tissue,
which affects absorption. The nurse must assess the patient’s body mass to determine if a
longer needle is specifically necessary.
, 4. A patient’s arterial blood gas (ABG) results are: pH 7.30, PaCO2 52 mmHg, and HCO3 24
mEq/L. How should the nurse interpret these findings?
A. Respiratory acidosis
B. Metabolic acidosis
C. Metabolic alkalosis
D. Respiratory alkalosis
Correct Answer: A
Explanation: The pH of 7.30 indicates acidosis (less than 7.35), and the PaCO2 of 52 is
elevated (above 45), which points to a respiratory cause. Since the bicarbonate (HCO3) is
within the normal range of 22-26, it is uncompensated respiratory acidosis. This state is
common in patients with hypoventilation or impaired gas exchange.
5. Which electrolyte imbalance is the nurse most likely to observe in a patient with a positive
Trousseau’s sign?
A. Hypocalcemia
B. Hyponatremia
C. Hyperkalemia
D. Hypermagnesemia
Correct Answer: A
Nursing Q&A with Rationale | Fortis College
1. A nurse is caring for a patient who has a serum sodium level of 128 mEq/L. Which clinical
manifestation should the nurse closely monitor for?
A. Confusion and lethargy
B. Extreme thirst and dry mucous membranes
C. Cardiac dysrhythmias and T-wave peaking
D. Muscle tetany and positive Chvostek’s sign
Correct Answer: A
Explanation: A serum sodium level below 135 mEq/L indicates hyponatremia, which
causes water to shift into brain cells, leading to cerebral edema. Confusion, lethargy, and
seizures are priority neurological assessments for these patients. Thirst is more
characteristic of hypernatremia, while the other options relate to potassium and calcium
imbalances respectively.
2. Which of the following patients is at the highest risk for developing respiratory acidosis?
A. A patient with Chronic Obstructive Pulmonary Disease (COPD)
B. A patient experiencing a severe panic attack
C. A patient with excessive vomiting for 24 hours
D. A patient with uncontrolled Type 1 Diabetes Mellitus
,Correct Answer: A
Explanation: Respiratory acidosis occurs when the lungs cannot effectively remove CO2,
as seen in chronic conditions like COPD that lead to hypoventilation. Patients with COPD
retain carbon dioxide, which increases the hydrogen ion concentration in the blood. The
other conditions mentioned lead to metabolic alkalosis, respiratory alkalosis, or metabolic
acidosis.
3. The nurse is preparing to administer an intramuscular (IM) injection to an obese adult.
Which needle length is most appropriate for the ventrogluteal site?
A. 1.5 inches
B. 1 inch
C. 5/8 inch
D. 2 to 3 inches
Correct Answer: A
Explanation: For an IM injection in the ventrogluteal site of an average to obese adult, a
1.5-inch needle is typically required to ensure the medication reaches the muscle tissue.
Shorter needles may result in the medication being deposited into subcutaneous tissue,
which affects absorption. The nurse must assess the patient’s body mass to determine if a
longer needle is specifically necessary.
, 4. A patient’s arterial blood gas (ABG) results are: pH 7.30, PaCO2 52 mmHg, and HCO3 24
mEq/L. How should the nurse interpret these findings?
A. Respiratory acidosis
B. Metabolic acidosis
C. Metabolic alkalosis
D. Respiratory alkalosis
Correct Answer: A
Explanation: The pH of 7.30 indicates acidosis (less than 7.35), and the PaCO2 of 52 is
elevated (above 45), which points to a respiratory cause. Since the bicarbonate (HCO3) is
within the normal range of 22-26, it is uncompensated respiratory acidosis. This state is
common in patients with hypoventilation or impaired gas exchange.
5. Which electrolyte imbalance is the nurse most likely to observe in a patient with a positive
Trousseau’s sign?
A. Hypocalcemia
B. Hyponatremia
C. Hyperkalemia
D. Hypermagnesemia
Correct Answer: A
