NUR 201/NUR201 Exam 1 V2 | Medical-Surgical
Nursing I Q&A with Rationale | Fortis College
1. A nurse is reviewing the laboratory results of a client with a potassium level of 2.8 mEq/L.
Which of the following assessment findings should the nurse expect?
A. Muscle weakness and leg cramps
B. Peaked T waves on the EKG
C. Positive Trousseau’s sign
D. Hyperactive bowel sounds
Correct Answer: A
Explanation: Hypokalemia, defined as a potassium level below 3.5 mEq/L, affects the
contractility of skeletal and smooth muscles. This electrolyte imbalance often manifests as
muscle weakness, fatigue, and leg cramps. The nurse must monitor the client closely for
cardiac arrhythmias as well, though peaked T waves are associated with hyperkalemia, not
hypokalemia.
2. Which electrolyte imbalance is primarily associated with the presence of Chvostek’s sign
and Trousseau’s sign?
A. Hypocalcemia
B. Hypernatremia
C. Hyperkalemia
,D. Hypomagnesemia
Correct Answer: A
Explanation: Hypocalcemia increases neuromuscular excitability, which can be
demonstrated through Chvostek’s and Trousseau’s signs. Chvostek’s sign is an abnormal
spasm of the facial muscles elicited by tapping the facial nerve, while Trousseau’s sign
involves carpal spasm induced by inflating a blood pressure cuff. Both are classic indicators
that the client requires immediate calcium replacement and monitoring to prevent seizures
or tetany.
3. A client presents to the emergency department with a pH of 7.30, PaCO2 of 52 mmHg, and
HCO3 of 24 mEq/L. How should the nurse interpret these arterial blood gas (ABG) results?
A. Metabolic Acidosis
B. Respiratory Alkalosis
C. Respiratory Acidosis
D. Metabolic Alkalosis
Correct Answer: C
Explanation: The pH of 7.30 indicates acidosis, as it is below the normal range of 7.35 to
7.45. The PaCO2 of 52 mmHg is elevated, which suggests that the cause of the acidosis is
respiratory in nature. Since the bicarbonate (HCO3) level remains within the normal range
of 22 to 26 mEq/L, this is classified as uncompensated respiratory acidosis.
, 4. The nurse is preparing a client for an elective surgery. Which action is the primary
responsibility of the nurse regarding informed consent?
A. Explain the risks and benefits of the procedure
B. Obtain the signature and witness the client signing the form
C. Describe alternative treatments to the client
D. Decide if the client is mentally competent
Correct Answer: B
Explanation: The nurse acts as a witness to the client’s signature on the informed consent
form, ensuring the client is signing voluntarily. It is the surgeon’s responsibility to explain
the risks, benefits, and alternatives of the procedure to the client. If the nurse identifies that
the client does not understand the procedure, the nurse must notify the surgeon to come
back and provide further clarification.
5. During the intraoperative phase, which medication is specifically indicated for the
treatment of Malignant Hyperthermia?
A. Succinylcholine
B. Atropine
C. Epinephrine
D. Dantrolene sodium
Correct Answer: D
Nursing I Q&A with Rationale | Fortis College
1. A nurse is reviewing the laboratory results of a client with a potassium level of 2.8 mEq/L.
Which of the following assessment findings should the nurse expect?
A. Muscle weakness and leg cramps
B. Peaked T waves on the EKG
C. Positive Trousseau’s sign
D. Hyperactive bowel sounds
Correct Answer: A
Explanation: Hypokalemia, defined as a potassium level below 3.5 mEq/L, affects the
contractility of skeletal and smooth muscles. This electrolyte imbalance often manifests as
muscle weakness, fatigue, and leg cramps. The nurse must monitor the client closely for
cardiac arrhythmias as well, though peaked T waves are associated with hyperkalemia, not
hypokalemia.
2. Which electrolyte imbalance is primarily associated with the presence of Chvostek’s sign
and Trousseau’s sign?
A. Hypocalcemia
B. Hypernatremia
C. Hyperkalemia
,D. Hypomagnesemia
Correct Answer: A
Explanation: Hypocalcemia increases neuromuscular excitability, which can be
demonstrated through Chvostek’s and Trousseau’s signs. Chvostek’s sign is an abnormal
spasm of the facial muscles elicited by tapping the facial nerve, while Trousseau’s sign
involves carpal spasm induced by inflating a blood pressure cuff. Both are classic indicators
that the client requires immediate calcium replacement and monitoring to prevent seizures
or tetany.
3. A client presents to the emergency department with a pH of 7.30, PaCO2 of 52 mmHg, and
HCO3 of 24 mEq/L. How should the nurse interpret these arterial blood gas (ABG) results?
A. Metabolic Acidosis
B. Respiratory Alkalosis
C. Respiratory Acidosis
D. Metabolic Alkalosis
Correct Answer: C
Explanation: The pH of 7.30 indicates acidosis, as it is below the normal range of 7.35 to
7.45. The PaCO2 of 52 mmHg is elevated, which suggests that the cause of the acidosis is
respiratory in nature. Since the bicarbonate (HCO3) level remains within the normal range
of 22 to 26 mEq/L, this is classified as uncompensated respiratory acidosis.
, 4. The nurse is preparing a client for an elective surgery. Which action is the primary
responsibility of the nurse regarding informed consent?
A. Explain the risks and benefits of the procedure
B. Obtain the signature and witness the client signing the form
C. Describe alternative treatments to the client
D. Decide if the client is mentally competent
Correct Answer: B
Explanation: The nurse acts as a witness to the client’s signature on the informed consent
form, ensuring the client is signing voluntarily. It is the surgeon’s responsibility to explain
the risks, benefits, and alternatives of the procedure to the client. If the nurse identifies that
the client does not understand the procedure, the nurse must notify the surgeon to come
back and provide further clarification.
5. During the intraoperative phase, which medication is specifically indicated for the
treatment of Malignant Hyperthermia?
A. Succinylcholine
B. Atropine
C. Epinephrine
D. Dantrolene sodium
Correct Answer: D
