NUR 201/NUR201 Exam 3 V3 | Medical-Surgical
Nursing I Q&A with Rationale | Fortis College
1. A nurse is caring for a client with a serum potassium level of 5.8 mEq/L. Which of the
following findings is the priority for the nurse to monitor?
A. Increased bowel sounds and diarrhea
B. Hyperactive deep tendon reflexes
C. Cardiac dysrhythmias on the EKG
D. Decreased urine output
Correct Answer: C
Explanation: Hyperkalemia is defined as a serum potassium level greater than 5.0 mEq/L.
It poses a significant risk for life-threatening cardiac dysrhythmias including ventricular
fibrillation or cardiac arrest. The nurse must prioritize monitoring the cardiac rhythm and
report changes immediately to ensure patient safety.
2. Which of the following ABG results indicates a client is experiencing uncompensated
respiratory acidosis?
A. pH 7.48, PaCO2 30 mm Hg, HCO3 22 mEq/L
B. pH 7.30, PaCO2 50 mm Hg, HCO3 24 mEq/L
C. pH 7.32, PaCO2 38 mm Hg, HCO3 18 mEq/L
D. pH 7.35, PaCO2 48 mm Hg, HCO3 28 mEq/L
,Correct Answer: B
Explanation: Respiratory acidosis is characterized by a low pH (less than 7.35) and an
elevated PaCO2 (greater than 45 mm Hg). In the uncompensated state, the bicarbonate
level (HCO3) remains within the normal range of 22 to 26 mEq/L. This specific finding
suggests that the kidneys have not yet begun to conserve bicarbonate to offset the acidotic
state.
3. A nurse is performing a preoperative assessment on a client. Which of the following
medications should the nurse instruct the client to withhold for at least 7 days before
surgery?
A. Warfarin
B. Acetaminophen
C. Metoprolol
D. Levothyroxine
Correct Answer: A
Explanation: Warfarin is an anticoagulant that increases the risk of excessive bleeding
during and after surgical procedures. It is generally recommended to discontinue warfarin
approximately 5 to 7 days before an elective surgery. The nurse must verify this instruction
with the surgeon and monitor the client’s international normalized ratio (INR) levels.
, 4. A nurse is monitoring a client who is post-operative following abdominal surgery. Which of
the following is the earliest sign of hypovolemic shock?
A. Decrease in blood pressure
B. Decreased urine output
C. Cold, clammy skin
D. Increase in heart rate
Correct Answer: D
Explanation: Tachycardia is often the earliest compensatory sign of hypovolemic shock as
the body attempts to maintain cardiac output. A drop in blood pressure is typically a late
sign of shock, indicating that compensatory mechanisms are failing. Monitoring vital signs
frequently allows the nurse to detect these subtle changes before the condition becomes
critical.
5. A client presents with a serum sodium level of 128 mEq/L. The nurse should anticipate
which of the following clinical manifestations?
A. Thirst and dry mucous membranes
B. Elevated temperature
C. Confusion and headache
D. Restlessness and agitation
Correct Answer: C
Nursing I Q&A with Rationale | Fortis College
1. A nurse is caring for a client with a serum potassium level of 5.8 mEq/L. Which of the
following findings is the priority for the nurse to monitor?
A. Increased bowel sounds and diarrhea
B. Hyperactive deep tendon reflexes
C. Cardiac dysrhythmias on the EKG
D. Decreased urine output
Correct Answer: C
Explanation: Hyperkalemia is defined as a serum potassium level greater than 5.0 mEq/L.
It poses a significant risk for life-threatening cardiac dysrhythmias including ventricular
fibrillation or cardiac arrest. The nurse must prioritize monitoring the cardiac rhythm and
report changes immediately to ensure patient safety.
2. Which of the following ABG results indicates a client is experiencing uncompensated
respiratory acidosis?
A. pH 7.48, PaCO2 30 mm Hg, HCO3 22 mEq/L
B. pH 7.30, PaCO2 50 mm Hg, HCO3 24 mEq/L
C. pH 7.32, PaCO2 38 mm Hg, HCO3 18 mEq/L
D. pH 7.35, PaCO2 48 mm Hg, HCO3 28 mEq/L
,Correct Answer: B
Explanation: Respiratory acidosis is characterized by a low pH (less than 7.35) and an
elevated PaCO2 (greater than 45 mm Hg). In the uncompensated state, the bicarbonate
level (HCO3) remains within the normal range of 22 to 26 mEq/L. This specific finding
suggests that the kidneys have not yet begun to conserve bicarbonate to offset the acidotic
state.
3. A nurse is performing a preoperative assessment on a client. Which of the following
medications should the nurse instruct the client to withhold for at least 7 days before
surgery?
A. Warfarin
B. Acetaminophen
C. Metoprolol
D. Levothyroxine
Correct Answer: A
Explanation: Warfarin is an anticoagulant that increases the risk of excessive bleeding
during and after surgical procedures. It is generally recommended to discontinue warfarin
approximately 5 to 7 days before an elective surgery. The nurse must verify this instruction
with the surgeon and monitor the client’s international normalized ratio (INR) levels.
, 4. A nurse is monitoring a client who is post-operative following abdominal surgery. Which of
the following is the earliest sign of hypovolemic shock?
A. Decrease in blood pressure
B. Decreased urine output
C. Cold, clammy skin
D. Increase in heart rate
Correct Answer: D
Explanation: Tachycardia is often the earliest compensatory sign of hypovolemic shock as
the body attempts to maintain cardiac output. A drop in blood pressure is typically a late
sign of shock, indicating that compensatory mechanisms are failing. Monitoring vital signs
frequently allows the nurse to detect these subtle changes before the condition becomes
critical.
5. A client presents with a serum sodium level of 128 mEq/L. The nurse should anticipate
which of the following clinical manifestations?
A. Thirst and dry mucous membranes
B. Elevated temperature
C. Confusion and headache
D. Restlessness and agitation
Correct Answer: C
