NUR 201/NUR201 Exam 1 V1 | Medical-Surgical
Nursing I Q&A with Rationale | Fortis College
1. A nurse is reviewing the lab results of a patient with a serum potassium level of 2.8 mEq/L.
Which assessment finding is the priority?
A. Irregular heart rhythm
B. Hyperactive bowel sounds
C. Increased muscle tone
D. Elevated blood pressure
Correct Answer: A
Explanation: A potassium level of 2.8 mEq/L indicates severe hypokalemia, which
significantly affects myocardial electrical conduction. The nurse must prioritize cardiac
monitoring because this electrolyte imbalance can lead to life-threatening ventricular
arrhythmias or cardiac arrest. Other signs of hypokalemia include muscle weakness and
diminished deep tendon reflexes, not hyperactive sounds or increased tone.
2. The surgeon is explaining the risks and benefits of a planned cholecystectomy to a patient.
What is the primary role of the nurse during the informed consent process?
A. Explaining the surgical procedure to the patient
B. Witnessing the patient sign the consent form
C. Answering detailed questions about surgical risks
,D. Obtaining the signature for the surgical procedure
Correct Answer: B
Explanation: The nurse acts as a witness to the patient’s signature, ensuring that the
patient is competent and signing voluntarily. It is the surgeon’s legal responsibility to
explain the procedure, risks, and alternatives to the patient. If the nurse identifies that the
patient does not understand the procedure, the nurse must notify the surgeon to come
back and provide further clarification.
3. A postoperative patient’s abdominal wound has eviscerated. Which action should the
nurse take first?
A. Push the protruding organs back into the abdomen
B. Apply a tight abdominal binder to the site
C. Place the patient in a high-Fowler’s position
D. Cover the wound with a sterile, saline-soaked dressing
Correct Answer: D
Explanation: Evisceration is a surgical emergency where internal organs protrude through
an incision. The nurse should immediately cover the exposed tissue with sterile dressings
moistened with sterile normal saline to prevent tissue drying and necrosis. The nurse must
then notify the surgical team and prepare the patient for an emergency return to the
operating room.
,4. An arterial blood gas (ABG) report shows pH 7.30, PaCO2 52 mmHg, and HCO3 24 mEq/L.
How should the nurse interpret these results?
A. Metabolic Acidosis
B. Respiratory Acidosis
C. Metabolic Alkalosis
D. Respiratory Alkalosis
Correct Answer: B
Explanation: The pH of 7.30 is below the normal range of 7.35-7.45, indicating acidosis.
The PaCO2 of 52 mmHg is elevated (normal 35-45), suggesting that the respiratory system
is the cause of the acidity. Since the bicarbonate (HCO3) is within the normal range of 22-
26 mEq/L, this is uncompensated respiratory acidosis, often caused by hypoventilation.
5. Which patient is at the highest risk for developing fluid volume deficit?
A. A patient with heart failure receiving IV fluids
B. A patient with end-stage renal disease
C. A patient with syndrome of inappropriate antidiuretic hormone (SIADH)
D. A patient with a nasogastric tube to low suction
Correct Answer: D
Explanation: Nasogastric suctioning removes gastric secretions which are rich in water
and electrolytes, placing the patient at high risk for dehydration and metabolic alkalosis.
, Heart failure and renal disease typically predispose patients to fluid volume excess due to
impaired excretion. SIADH causes water retention and hyponatremia, leading to fluid
volume excess rather than deficit.
6. During the preoperative assessment, a patient reports an allergy to bananas and avocados.
Which action is most important for the nurse to take?
A. Notify the surgical team of a possible latex allergy
B. Document the food allergy in the medical record only
C. Ask the patient if they are allergic to shellfish
D. Administer an antihistamine as a prophylactic measure
Correct Answer: A
Explanation: There is a known cross-reactivity between certain foods, such as bananas,
avocados, and kiwi, and latex. A patient reporting these food allergies is at a significantly
higher risk for having a latex allergy, which can lead to anaphylaxis during surgery. The
nurse must communicate this to the entire surgical team to ensure a latex-free
environment is maintained.
7. A nurse is monitoring a patient during the immediate postoperative period. The patient
develops muscle rigidity and a rapidly rising temperature. Which medication should the nurse
prepare?
A. Naloxone
B. Atropine sulfate
Nursing I Q&A with Rationale | Fortis College
1. A nurse is reviewing the lab results of a patient with a serum potassium level of 2.8 mEq/L.
Which assessment finding is the priority?
A. Irregular heart rhythm
B. Hyperactive bowel sounds
C. Increased muscle tone
D. Elevated blood pressure
Correct Answer: A
Explanation: A potassium level of 2.8 mEq/L indicates severe hypokalemia, which
significantly affects myocardial electrical conduction. The nurse must prioritize cardiac
monitoring because this electrolyte imbalance can lead to life-threatening ventricular
arrhythmias or cardiac arrest. Other signs of hypokalemia include muscle weakness and
diminished deep tendon reflexes, not hyperactive sounds or increased tone.
2. The surgeon is explaining the risks and benefits of a planned cholecystectomy to a patient.
What is the primary role of the nurse during the informed consent process?
A. Explaining the surgical procedure to the patient
B. Witnessing the patient sign the consent form
C. Answering detailed questions about surgical risks
,D. Obtaining the signature for the surgical procedure
Correct Answer: B
Explanation: The nurse acts as a witness to the patient’s signature, ensuring that the
patient is competent and signing voluntarily. It is the surgeon’s legal responsibility to
explain the procedure, risks, and alternatives to the patient. If the nurse identifies that the
patient does not understand the procedure, the nurse must notify the surgeon to come
back and provide further clarification.
3. A postoperative patient’s abdominal wound has eviscerated. Which action should the
nurse take first?
A. Push the protruding organs back into the abdomen
B. Apply a tight abdominal binder to the site
C. Place the patient in a high-Fowler’s position
D. Cover the wound with a sterile, saline-soaked dressing
Correct Answer: D
Explanation: Evisceration is a surgical emergency where internal organs protrude through
an incision. The nurse should immediately cover the exposed tissue with sterile dressings
moistened with sterile normal saline to prevent tissue drying and necrosis. The nurse must
then notify the surgical team and prepare the patient for an emergency return to the
operating room.
,4. An arterial blood gas (ABG) report shows pH 7.30, PaCO2 52 mmHg, and HCO3 24 mEq/L.
How should the nurse interpret these results?
A. Metabolic Acidosis
B. Respiratory Acidosis
C. Metabolic Alkalosis
D. Respiratory Alkalosis
Correct Answer: B
Explanation: The pH of 7.30 is below the normal range of 7.35-7.45, indicating acidosis.
The PaCO2 of 52 mmHg is elevated (normal 35-45), suggesting that the respiratory system
is the cause of the acidity. Since the bicarbonate (HCO3) is within the normal range of 22-
26 mEq/L, this is uncompensated respiratory acidosis, often caused by hypoventilation.
5. Which patient is at the highest risk for developing fluid volume deficit?
A. A patient with heart failure receiving IV fluids
B. A patient with end-stage renal disease
C. A patient with syndrome of inappropriate antidiuretic hormone (SIADH)
D. A patient with a nasogastric tube to low suction
Correct Answer: D
Explanation: Nasogastric suctioning removes gastric secretions which are rich in water
and electrolytes, placing the patient at high risk for dehydration and metabolic alkalosis.
, Heart failure and renal disease typically predispose patients to fluid volume excess due to
impaired excretion. SIADH causes water retention and hyponatremia, leading to fluid
volume excess rather than deficit.
6. During the preoperative assessment, a patient reports an allergy to bananas and avocados.
Which action is most important for the nurse to take?
A. Notify the surgical team of a possible latex allergy
B. Document the food allergy in the medical record only
C. Ask the patient if they are allergic to shellfish
D. Administer an antihistamine as a prophylactic measure
Correct Answer: A
Explanation: There is a known cross-reactivity between certain foods, such as bananas,
avocados, and kiwi, and latex. A patient reporting these food allergies is at a significantly
higher risk for having a latex allergy, which can lead to anaphylaxis during surgery. The
nurse must communicate this to the entire surgical team to ensure a latex-free
environment is maintained.
7. A nurse is monitoring a patient during the immediate postoperative period. The patient
develops muscle rigidity and a rapidly rising temperature. Which medication should the nurse
prepare?
A. Naloxone
B. Atropine sulfate
