NUR 201/NUR201 Exam 2 V1 | Medical-Surgical
Nursing I Q&A with Rationale | Fortis College
1. A patient is admitted with a serum sodium level of 128 mEq/L. Which nursing intervention
is the highest priority for this patient?
A. Initiate seizure precautions and monitor neurological status
B. Encourage increased fluid intake to 3 liters per day
C. Administer high-dose loop diuretics as ordered
D. Provide a salt-restricted diet to prevent fluid retention
Correct Answer: A
Explanation: Hyponatremia, defined as a serum sodium level below 135 mEq/L, can cause
cerebral edema and increased intracranial pressure. The nurse’s priority is to protect the
patient from potential seizures and monitor for changes in mental status that indicate
worsening status. Increasing fluid intake would further dilute the sodium levels, which is
contraindicated in this situation.
2. The nurse is caring for a patient who has developed a positive Chvostek’s sign. Which
electrolyte imbalance should the nurse document?
A. Hyperkalemia
B. Hypocalcemia
C. Hypernatremia
,D. Hypomagnesemia
Correct Answer: B
Explanation: Chvostek’s sign is a clinical indicator of hypocalcemia, characterized by facial
twitching when the facial nerve is tapped. This occurs because low calcium levels increase
neuromuscular irritability and excitability. The nurse should also assess for Trousseau’s
sign and prepare to administer calcium gluconate as prescribed.
3. 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. Metabolic Acidosis
B. Respiratory Alkalosis
C. Respiratory Acidosis
D. Metabolic Alkalosis
Correct Answer: C
Explanation: The pH of 7.30 indicates acidosis (below 7.35), and the elevated PaCO2 of 52
mmHg indicates a respiratory cause (above 45 mmHg). Because the bicarbonate (HCO3) is
within the normal range of 22-26 mEq/L, this is an uncompensated respiratory acidosis.
This condition often results from hypoventilation or obstructive lung diseases.
4. Which of the following is the nurse’s primary responsibility when a patient is signing an
informed consent for surgery?
A. Explaining the risks and benefits of the surgical procedure
, B. Describing the alternative treatments available to the patient
C. Obtaining the consent if the surgeon is too busy
D. Witnessing the patient’s signature and ensuring they are competent
Correct Answer: D
Explanation: The nurse acts as a witness to the patient’s signature on the informed
consent form, verifying that the signature is authentic and the patient is of sound mind. It is
the surgeon’s legal responsibility to explain the procedure, risks, and alternatives. If the
patient has questions about the surgery itself, the nurse must contact the surgeon to clarify
them.
5. A postoperative patient develops a temperature of 104°F, muscle rigidity, and tachycardia
shortly after the administration of general anesthesia. What is the immediate priority action?
A. Increase the flow rate of the IV fluids
B. Apply cooling blankets to the patient’s skin
C. Administer IV Dantrolene as prescribed
D. Perform a set of cultures for suspected sepsis
Correct Answer: C
Explanation: These symptoms are classic indicators of Malignant Hyperthermia, a life-
threatening pharmacogenetic disorder triggered by certain anesthetic agents. Dantrolene
Nursing I Q&A with Rationale | Fortis College
1. A patient is admitted with a serum sodium level of 128 mEq/L. Which nursing intervention
is the highest priority for this patient?
A. Initiate seizure precautions and monitor neurological status
B. Encourage increased fluid intake to 3 liters per day
C. Administer high-dose loop diuretics as ordered
D. Provide a salt-restricted diet to prevent fluid retention
Correct Answer: A
Explanation: Hyponatremia, defined as a serum sodium level below 135 mEq/L, can cause
cerebral edema and increased intracranial pressure. The nurse’s priority is to protect the
patient from potential seizures and monitor for changes in mental status that indicate
worsening status. Increasing fluid intake would further dilute the sodium levels, which is
contraindicated in this situation.
2. The nurse is caring for a patient who has developed a positive Chvostek’s sign. Which
electrolyte imbalance should the nurse document?
A. Hyperkalemia
B. Hypocalcemia
C. Hypernatremia
,D. Hypomagnesemia
Correct Answer: B
Explanation: Chvostek’s sign is a clinical indicator of hypocalcemia, characterized by facial
twitching when the facial nerve is tapped. This occurs because low calcium levels increase
neuromuscular irritability and excitability. The nurse should also assess for Trousseau’s
sign and prepare to administer calcium gluconate as prescribed.
3. 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. Metabolic Acidosis
B. Respiratory Alkalosis
C. Respiratory Acidosis
D. Metabolic Alkalosis
Correct Answer: C
Explanation: The pH of 7.30 indicates acidosis (below 7.35), and the elevated PaCO2 of 52
mmHg indicates a respiratory cause (above 45 mmHg). Because the bicarbonate (HCO3) is
within the normal range of 22-26 mEq/L, this is an uncompensated respiratory acidosis.
This condition often results from hypoventilation or obstructive lung diseases.
4. Which of the following is the nurse’s primary responsibility when a patient is signing an
informed consent for surgery?
A. Explaining the risks and benefits of the surgical procedure
, B. Describing the alternative treatments available to the patient
C. Obtaining the consent if the surgeon is too busy
D. Witnessing the patient’s signature and ensuring they are competent
Correct Answer: D
Explanation: The nurse acts as a witness to the patient’s signature on the informed
consent form, verifying that the signature is authentic and the patient is of sound mind. It is
the surgeon’s legal responsibility to explain the procedure, risks, and alternatives. If the
patient has questions about the surgery itself, the nurse must contact the surgeon to clarify
them.
5. A postoperative patient develops a temperature of 104°F, muscle rigidity, and tachycardia
shortly after the administration of general anesthesia. What is the immediate priority action?
A. Increase the flow rate of the IV fluids
B. Apply cooling blankets to the patient’s skin
C. Administer IV Dantrolene as prescribed
D. Perform a set of cultures for suspected sepsis
Correct Answer: C
Explanation: These symptoms are classic indicators of Malignant Hyperthermia, a life-
threatening pharmacogenetic disorder triggered by certain anesthetic agents. Dantrolene
