NUR 201/NUR201 Exam 1 V3 | Medical-Surgical
Nursing I Q&A with Rationale | Fortis College
1. A nurse is caring for a patient with a serum sodium level of 125 mEq/L. Which nursing
intervention is a priority for this patient?
A. Implement seizure precautions and monitor neurological status.
B. Encourage increased fluid intake to dilute serum solutes.
C. Administer a dose of oral potassium supplements as ordered.
D. Provide a diet low in salt and high in leafy green vegetables.
Correct Answer: A
Explanation: A serum sodium level of 125 mEq/L indicates hyponatremia, which poses a
significant risk for cerebral edema and seizures. The nurse must prioritize safety by
implementing seizure precautions and performing frequent neurological assessments.
Rapid shifts in sodium levels can lead to permanent neurological damage, so monitoring is
vital.
2. When assessing a patient for hypocalcemia, the nurse taps the patient’s facial nerve in
front of the ear. The patient’s facial muscles twitch. How should the nurse document this
finding?
A. Positive Chvostek’s sign
B. Negative Romberg’s sign
,C. Positive Trousseau’s sign
D. Negative Babinski’s reflex
Correct Answer: A
Explanation: Twitching of the facial muscles in response to tapping over the facial nerve is
known as Chvostek’s sign. This is a clinical manifestation of increased neuromuscular
excitability often associated with hypocalcemia. The nurse should follow up by checking
serum calcium levels and assessing for other symptoms like tingling in the extremities.
3. A patient’s arterial blood gas (ABG) results are: pH 7.31, PaCO2 50 mmHg, and HCO3 24
mEq/L. How should the nurse interpret these results?
A. Respiratory Acidosis
B. Respiratory Alkalosis
C. Metabolic Acidosis
D. Metabolic Alkalosis
Correct Answer: A
Explanation: A pH of 7.31 indicates acidosis since it is below the normal range of 7.35 to
7.45. The PaCO2 is elevated at 50 mmHg, which points toward a respiratory cause for the
acid-base imbalance. Because the HCO3 is within the normal range, this represents
uncompensated respiratory acidosis.
, 4. An elderly patient is admitted with a fluid volume deficit. Which clinical finding is the most
reliable indicator of fluid status in this population?
A. Skin turgor on the back of the hand
B. Daily weights using the same scale
C. Client’s report of thirst levels
D. The presence of peripheral edema
Correct Answer: B
Explanation: Daily weights are the most objective and reliable measurement of fluid
volume changes in any patient population. Skin turgor is often unreliable in the elderly due
to the natural loss of skin elasticity associated with aging. Consistently weighing the patient
at the same time each day provides the most accurate data for trends in fluid balance.
5. Which patient is at the highest risk for developing respiratory acidosis?
A. A patient who is hyperventilating due to a panic attack
B. A patient with a history of chronic obstructive pulmonary disease (COPD)
C. A patient with persistent vomiting and gastric suctioning
D. A patient taking excessive amounts of bicarbonate-containing antacids
Correct Answer: B
Explanation: Respiratory acidosis is caused by hypoventilation, which leads to the
retention of carbon dioxide. Patients with COPD often have impaired gas exchange and
Nursing I Q&A with Rationale | Fortis College
1. A nurse is caring for a patient with a serum sodium level of 125 mEq/L. Which nursing
intervention is a priority for this patient?
A. Implement seizure precautions and monitor neurological status.
B. Encourage increased fluid intake to dilute serum solutes.
C. Administer a dose of oral potassium supplements as ordered.
D. Provide a diet low in salt and high in leafy green vegetables.
Correct Answer: A
Explanation: A serum sodium level of 125 mEq/L indicates hyponatremia, which poses a
significant risk for cerebral edema and seizures. The nurse must prioritize safety by
implementing seizure precautions and performing frequent neurological assessments.
Rapid shifts in sodium levels can lead to permanent neurological damage, so monitoring is
vital.
2. When assessing a patient for hypocalcemia, the nurse taps the patient’s facial nerve in
front of the ear. The patient’s facial muscles twitch. How should the nurse document this
finding?
A. Positive Chvostek’s sign
B. Negative Romberg’s sign
,C. Positive Trousseau’s sign
D. Negative Babinski’s reflex
Correct Answer: A
Explanation: Twitching of the facial muscles in response to tapping over the facial nerve is
known as Chvostek’s sign. This is a clinical manifestation of increased neuromuscular
excitability often associated with hypocalcemia. The nurse should follow up by checking
serum calcium levels and assessing for other symptoms like tingling in the extremities.
3. A patient’s arterial blood gas (ABG) results are: pH 7.31, PaCO2 50 mmHg, and HCO3 24
mEq/L. How should the nurse interpret these results?
A. Respiratory Acidosis
B. Respiratory Alkalosis
C. Metabolic Acidosis
D. Metabolic Alkalosis
Correct Answer: A
Explanation: A pH of 7.31 indicates acidosis since it is below the normal range of 7.35 to
7.45. The PaCO2 is elevated at 50 mmHg, which points toward a respiratory cause for the
acid-base imbalance. Because the HCO3 is within the normal range, this represents
uncompensated respiratory acidosis.
, 4. An elderly patient is admitted with a fluid volume deficit. Which clinical finding is the most
reliable indicator of fluid status in this population?
A. Skin turgor on the back of the hand
B. Daily weights using the same scale
C. Client’s report of thirst levels
D. The presence of peripheral edema
Correct Answer: B
Explanation: Daily weights are the most objective and reliable measurement of fluid
volume changes in any patient population. Skin turgor is often unreliable in the elderly due
to the natural loss of skin elasticity associated with aging. Consistently weighing the patient
at the same time each day provides the most accurate data for trends in fluid balance.
5. Which patient is at the highest risk for developing respiratory acidosis?
A. A patient who is hyperventilating due to a panic attack
B. A patient with a history of chronic obstructive pulmonary disease (COPD)
C. A patient with persistent vomiting and gastric suctioning
D. A patient taking excessive amounts of bicarbonate-containing antacids
Correct Answer: B
Explanation: Respiratory acidosis is caused by hypoventilation, which leads to the
retention of carbon dioxide. Patients with COPD often have impaired gas exchange and
