NUR 201/NUR201 Exam 2 V3 | Medical-Surgical
Nursing I Q&A with Rationale | Fortis College
1. A nurse is assessing a client who is post-operative Day 1 following abdominal surgery.
Which finding is the most sensitive indicator that the client is developing an early
complication of atelectasis?
A. Decreased oxygen saturation
B. Diminished breath sounds at the bases
C. Productive cough with yellow sputum
D. Increased temperature
Correct Answer: B
Explanation: Atelectasis occurs when the alveoli collapse, commonly due to shallow
breathing after surgery. Diminished breath sounds at the lung bases are the earliest clinical
sign of this condition. While oxygen saturation may eventually drop, it is often a later
finding compared to auscultation changes.
2. A client presents with a potassium level of 2.8 mEq/L. Which cardiac rhythm change should
the nurse expect to see on the EKG monitor?
A. Tall peaked T waves
B. Widened QRS complex
C. Prominent U waves
,D. Shortened PR interval
Correct Answer: C
Explanation: Hypokalemia typically results in the presence of U waves and flat or inverted
T waves. High potassium levels, conversely, cause tall peaked T waves. Monitoring for these
changes is critical to prevent lethal arrhythmias such as ventricular tachycardia.
3. Which electrolyte imbalance is a client at highest risk for when receiving multiple units of
packed red blood cells rapidly?
A. Hypokalemia
B. Hypernatremia
C. Hypocalcemia
D. Hypermagnesemia
Correct Answer: C
Explanation: Blood products are preserved with citrate, which can bind to the client’s
calcium. This leads to a decrease in ionized calcium levels, causing hypocalcemia. The nurse
should monitor for symptoms like tetany or a positive Chvostek’s sign during massive
transfusions.
4. A client has a pH of 7.30, PaCO2 of 52 mmHg, and HCO3 of 26 mEq/L. How should the nurse
interpret these arterial blood gas results?
A. Metabolic Acidosis
, B. Respiratory Alkalosis
C. Respiratory Acidosis
D. Metabolic Alkalosis
Correct Answer: C
Explanation: The pH is below the normal range (7.35-7.45), indicating acidosis. The PaCO2
is elevated above 45 mmHg, which points to a respiratory cause for the acidic pH. Because
the bicarbonate level is within normal range, this is uncompensated respiratory acidosis.
5. During the intraoperative phase, the scrub nurse notices a break in sterile technique. What
is the most appropriate immediate action?
A. Point out the break and correct the contamination immediately
B. Document the incident in the patient’s record
C. Notify the surgeon at the end of the procedure
D. Wait for the circulating nurse to see it
Correct Answer: A
Explanation: Maintenance of the sterile field is the responsibility of all surgical team
members. Any break in technique must be addressed instantly to prevent surgical site
infections. Delaying correction increases the risk of microbial contamination to the
patient’s wound.
Nursing I Q&A with Rationale | Fortis College
1. A nurse is assessing a client who is post-operative Day 1 following abdominal surgery.
Which finding is the most sensitive indicator that the client is developing an early
complication of atelectasis?
A. Decreased oxygen saturation
B. Diminished breath sounds at the bases
C. Productive cough with yellow sputum
D. Increased temperature
Correct Answer: B
Explanation: Atelectasis occurs when the alveoli collapse, commonly due to shallow
breathing after surgery. Diminished breath sounds at the lung bases are the earliest clinical
sign of this condition. While oxygen saturation may eventually drop, it is often a later
finding compared to auscultation changes.
2. A client presents with a potassium level of 2.8 mEq/L. Which cardiac rhythm change should
the nurse expect to see on the EKG monitor?
A. Tall peaked T waves
B. Widened QRS complex
C. Prominent U waves
,D. Shortened PR interval
Correct Answer: C
Explanation: Hypokalemia typically results in the presence of U waves and flat or inverted
T waves. High potassium levels, conversely, cause tall peaked T waves. Monitoring for these
changes is critical to prevent lethal arrhythmias such as ventricular tachycardia.
3. Which electrolyte imbalance is a client at highest risk for when receiving multiple units of
packed red blood cells rapidly?
A. Hypokalemia
B. Hypernatremia
C. Hypocalcemia
D. Hypermagnesemia
Correct Answer: C
Explanation: Blood products are preserved with citrate, which can bind to the client’s
calcium. This leads to a decrease in ionized calcium levels, causing hypocalcemia. The nurse
should monitor for symptoms like tetany or a positive Chvostek’s sign during massive
transfusions.
4. A client has a pH of 7.30, PaCO2 of 52 mmHg, and HCO3 of 26 mEq/L. How should the nurse
interpret these arterial blood gas results?
A. Metabolic Acidosis
, B. Respiratory Alkalosis
C. Respiratory Acidosis
D. Metabolic Alkalosis
Correct Answer: C
Explanation: The pH is below the normal range (7.35-7.45), indicating acidosis. The PaCO2
is elevated above 45 mmHg, which points to a respiratory cause for the acidic pH. Because
the bicarbonate level is within normal range, this is uncompensated respiratory acidosis.
5. During the intraoperative phase, the scrub nurse notices a break in sterile technique. What
is the most appropriate immediate action?
A. Point out the break and correct the contamination immediately
B. Document the incident in the patient’s record
C. Notify the surgeon at the end of the procedure
D. Wait for the circulating nurse to see it
Correct Answer: A
Explanation: Maintenance of the sterile field is the responsibility of all surgical team
members. Any break in technique must be addressed instantly to prevent surgical site
infections. Delaying correction increases the risk of microbial contamination to the
patient’s wound.
