NUR 201/NUR201 Exam 4 V2 | Medical-Surgical
Nursing I Q&A with Rationale | Fortis College
1. A patient with Type 1 Diabetes Mellitus presents to the emergency department with
Kussmaul respirations, a blood glucose of 540 mg/dL, and a fruity breath odor. Which acid-
base imbalance does the nurse anticipate?
A. Metabolic Acidosis
B. Respiratory Alkalosis
C. Metabolic Alkalosis
D. Respiratory Acidosis
Correct Answer: A
Explanation: The patient is demonstrating classic signs of Diabetic Ketoacidosis (DKA),
which leads to metabolic acidosis due to the accumulation of ketones. Kussmaul
respirations are the body’s compensatory mechanism to blow off excess carbon dioxide
and reduce acidity. The elevated glucose level and fruity breath further support the
diagnosis of DKA rather than a respiratory issue.
2. A nurse is caring for a patient who is 24 hours post-thyroidectomy. The patient reports
tingling in the fingertips and around the mouth. Which action should the nurse take first?
A. Assess for Chvostek’s sign
B. Administer a dose of levothyroxine
,C. Encourage deep breathing exercises
D. Check the patient’s blood pressure
Correct Answer: A
Explanation: Tingling in the extremities and circumoral area are early signs of
hypocalcemia, which can occur if the parathyroid glands are accidentally damaged or
removed during a thyroidectomy. Chvostek’s sign is a clinical indicator of hypocalcemia
that involves facial twitching when the facial nerve is tapped. The nurse must identify this
promptly to prevent laryngospasm or seizures.
3. A patient diagnosed with Chronic Kidney Disease (CKD) is prescribed a low-protein diet.
What is the primary rationale for this dietary restriction?
A. To prevent the buildup of nitrogenous waste products
B. To increase the glomerular filtration rate
C. To reduce the risk of hyperkalemia
D. To manage hypertension associated with CKD
Correct Answer: A
Explanation: In patients with impaired renal function, the kidneys cannot effectively
excrete urea and other waste products derived from protein metabolism. Restricting
dietary protein helps minimize the accumulation of blood urea nitrogen (BUN) and other
toxins. This intervention slows the progression of renal failure and reduces uremic
symptoms.
, 4. A nurse is assessing a patient with a history of cirrhosis. The nurse notes that the patient
has flapping tremors of the hands when the arms are extended. How should the nurse
document this finding?
A. Positive Murphy’s sign
B. Positive Cullen’s sign
C. Trousseau’s sign
D. Asterixis
Correct Answer: D
Explanation: Asterixis, also known as liver flap, is a hallmark sign of hepatic
encephalopathy resulting from high ammonia levels. It is assessed by having the patient
extend their arms and dorsiflex the wrists, observing for a rhythmic flapping motion. The
nurse should report this finding immediately as it indicates worsening liver function and
neurological status.
5. Which of the following laboratory results is most indicative of acute pancreatitis?
A. Decreased white blood cell count
B. Elevated serum amylase and lipase
C. Elevated serum calcium
D. Decreased serum bilirubin
Correct Answer: B
Nursing I Q&A with Rationale | Fortis College
1. A patient with Type 1 Diabetes Mellitus presents to the emergency department with
Kussmaul respirations, a blood glucose of 540 mg/dL, and a fruity breath odor. Which acid-
base imbalance does the nurse anticipate?
A. Metabolic Acidosis
B. Respiratory Alkalosis
C. Metabolic Alkalosis
D. Respiratory Acidosis
Correct Answer: A
Explanation: The patient is demonstrating classic signs of Diabetic Ketoacidosis (DKA),
which leads to metabolic acidosis due to the accumulation of ketones. Kussmaul
respirations are the body’s compensatory mechanism to blow off excess carbon dioxide
and reduce acidity. The elevated glucose level and fruity breath further support the
diagnosis of DKA rather than a respiratory issue.
2. A nurse is caring for a patient who is 24 hours post-thyroidectomy. The patient reports
tingling in the fingertips and around the mouth. Which action should the nurse take first?
A. Assess for Chvostek’s sign
B. Administer a dose of levothyroxine
,C. Encourage deep breathing exercises
D. Check the patient’s blood pressure
Correct Answer: A
Explanation: Tingling in the extremities and circumoral area are early signs of
hypocalcemia, which can occur if the parathyroid glands are accidentally damaged or
removed during a thyroidectomy. Chvostek’s sign is a clinical indicator of hypocalcemia
that involves facial twitching when the facial nerve is tapped. The nurse must identify this
promptly to prevent laryngospasm or seizures.
3. A patient diagnosed with Chronic Kidney Disease (CKD) is prescribed a low-protein diet.
What is the primary rationale for this dietary restriction?
A. To prevent the buildup of nitrogenous waste products
B. To increase the glomerular filtration rate
C. To reduce the risk of hyperkalemia
D. To manage hypertension associated with CKD
Correct Answer: A
Explanation: In patients with impaired renal function, the kidneys cannot effectively
excrete urea and other waste products derived from protein metabolism. Restricting
dietary protein helps minimize the accumulation of blood urea nitrogen (BUN) and other
toxins. This intervention slows the progression of renal failure and reduces uremic
symptoms.
, 4. A nurse is assessing a patient with a history of cirrhosis. The nurse notes that the patient
has flapping tremors of the hands when the arms are extended. How should the nurse
document this finding?
A. Positive Murphy’s sign
B. Positive Cullen’s sign
C. Trousseau’s sign
D. Asterixis
Correct Answer: D
Explanation: Asterixis, also known as liver flap, is a hallmark sign of hepatic
encephalopathy resulting from high ammonia levels. It is assessed by having the patient
extend their arms and dorsiflex the wrists, observing for a rhythmic flapping motion. The
nurse should report this finding immediately as it indicates worsening liver function and
neurological status.
5. Which of the following laboratory results is most indicative of acute pancreatitis?
A. Decreased white blood cell count
B. Elevated serum amylase and lipase
C. Elevated serum calcium
D. Decreased serum bilirubin
Correct Answer: B
