NUR 201/NUR201 Exam 2 V2 | Medical-Surgical
Nursing I Q&A with Rationale | Fortis College
1. A patient is scheduled for surgery in the morning. Which action by the nurse is most
important regarding the patient’s informed consent?
A. Explaining the risks and benefits of the surgical procedure to the patient.
B. Witnessing the patient’s signature on the consent form.
C. Ensuring the patient understands the surgical procedure before signing.
D. Obtaining the consent from the patient’s next of kin if they are anxious.
Correct Answer: B
Explanation: The nurse’s primary role in informed consent is to witness the patient’s
signature. It is the surgeon’s responsibility to explain the risks, benefits, and alternatives of
the procedure. If the nurse identifies that the patient does not understand the surgery, the
nurse must notify the surgeon before the patient signs the form.
2. A nurse is reviewing the arterial blood gas (ABG) results of a patient: pH 7.30, PaCO2 55
mmHg, and HCO3 26 mEq/L. How should the nurse interpret these results?
A. Respiratory Acidosis
B. Metabolic Alkalosis
C. Respiratory Alkalosis
D. Metabolic Acidosis
,Correct Answer: A
Explanation: The pH is below 7.35, indicating acidosis, and the PaCO2 is elevated above 45
mmHg, indicating a respiratory cause. Since the bicarbonate level is within the normal
range, the condition is uncompensated respiratory acidosis. This state is common in
patients with hypoventilation or COPD.
3. A patient is 2 days postoperative following abdominal surgery and reports sudden chest
pain and shortness of breath. Which action should the nurse take first?
A. Administer the prescribed PRN pain medication.
B. Encourage the patient to use the incentive spirometer.
C. Assess the patient’s oxygen saturation and lung sounds.
D. Call the surgeon to report the change in status.
Correct Answer: C
Explanation: Sudden chest pain and dyspnea in a postoperative patient are classic signs of
a pulmonary embolism. The nurse must first assess the patient’s physiological status,
including vital signs and lung sounds, to gather necessary data. Following assessment,
oxygen should be applied and the provider notified immediately.
4. The nurse is caring for a patient with a potassium level of 6.2 mEq/L. Which cardiac
monitor finding is most consistent with this lab value?
A. Prominent U waves
B. ST-segment depression
, C. Tall, peaked T waves
D. Widened QRS complex with a short PR interval
Correct Answer: C
Explanation: Hyperkalemia, defined as a potassium level above 5.0 mEq/L, typically
manifests on an EKG as tall, peaked T waves. As the level increases further, the QRS
complex may widen and the P wave may disappear. This is a medical emergency that
requires immediate intervention to prevent cardiac arrest.
5. During a 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 potential latex allergy.
B. Document the food allergy in the patient’s chart.
C. Inform the dietician to provide a latex-free meal.
D. Ask the patient if they have ever had a reaction to seafood.
Correct Answer: A
Explanation: There is a known cross-sensitivity between certain foods, such as bananas,
avocados, and kiwi, and latex. Patients with these food allergies are at a higher risk for a
latex allergy during surgery. The nurse must communicate this risk to the entire surgical
team to ensure a latex-free environment.
Nursing I Q&A with Rationale | Fortis College
1. A patient is scheduled for surgery in the morning. Which action by the nurse is most
important regarding the patient’s informed consent?
A. Explaining the risks and benefits of the surgical procedure to the patient.
B. Witnessing the patient’s signature on the consent form.
C. Ensuring the patient understands the surgical procedure before signing.
D. Obtaining the consent from the patient’s next of kin if they are anxious.
Correct Answer: B
Explanation: The nurse’s primary role in informed consent is to witness the patient’s
signature. It is the surgeon’s responsibility to explain the risks, benefits, and alternatives of
the procedure. If the nurse identifies that the patient does not understand the surgery, the
nurse must notify the surgeon before the patient signs the form.
2. A nurse is reviewing the arterial blood gas (ABG) results of a patient: pH 7.30, PaCO2 55
mmHg, and HCO3 26 mEq/L. How should the nurse interpret these results?
A. Respiratory Acidosis
B. Metabolic Alkalosis
C. Respiratory Alkalosis
D. Metabolic Acidosis
,Correct Answer: A
Explanation: The pH is below 7.35, indicating acidosis, and the PaCO2 is elevated above 45
mmHg, indicating a respiratory cause. Since the bicarbonate level is within the normal
range, the condition is uncompensated respiratory acidosis. This state is common in
patients with hypoventilation or COPD.
3. A patient is 2 days postoperative following abdominal surgery and reports sudden chest
pain and shortness of breath. Which action should the nurse take first?
A. Administer the prescribed PRN pain medication.
B. Encourage the patient to use the incentive spirometer.
C. Assess the patient’s oxygen saturation and lung sounds.
D. Call the surgeon to report the change in status.
Correct Answer: C
Explanation: Sudden chest pain and dyspnea in a postoperative patient are classic signs of
a pulmonary embolism. The nurse must first assess the patient’s physiological status,
including vital signs and lung sounds, to gather necessary data. Following assessment,
oxygen should be applied and the provider notified immediately.
4. The nurse is caring for a patient with a potassium level of 6.2 mEq/L. Which cardiac
monitor finding is most consistent with this lab value?
A. Prominent U waves
B. ST-segment depression
, C. Tall, peaked T waves
D. Widened QRS complex with a short PR interval
Correct Answer: C
Explanation: Hyperkalemia, defined as a potassium level above 5.0 mEq/L, typically
manifests on an EKG as tall, peaked T waves. As the level increases further, the QRS
complex may widen and the P wave may disappear. This is a medical emergency that
requires immediate intervention to prevent cardiac arrest.
5. During a 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 potential latex allergy.
B. Document the food allergy in the patient’s chart.
C. Inform the dietician to provide a latex-free meal.
D. Ask the patient if they have ever had a reaction to seafood.
Correct Answer: A
Explanation: There is a known cross-sensitivity between certain foods, such as bananas,
avocados, and kiwi, and latex. Patients with these food allergies are at a higher risk for a
latex allergy during surgery. The nurse must communicate this risk to the entire surgical
team to ensure a latex-free environment.
