NUR 155 NURSING FOUNDATIONS
COMPREHENSIVE EXAM REVIEW
(EXAMS 2-4) QUESTIONS AND
ANSWERS
1. A patient presents with a serum potassium level of 6.2 mEq/L. Which cardiac change
should the nurse monitor for most closely on the ECG?
A. Prominent U waves
B. Prolonged PR interval
C. ST-segment depression
D. Tall, peaked T waves
Answer: D
Conceptual Explanation: Hyperkalemia (K+ > 5.0 mEq/L) typically causes tall, peaked T
waves, widened QRS complexes, and potentially cardiac arrest. U waves are associated with
hypokalemia.
2. A client’s arterial blood gas (ABG) results are pH 7.31, PaCO2 50 mmHg, and HCO3 24
mEq/L. How should the nurse interpret these findings?
A. Metabolic acidosis
,B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis
Answer: C
Conceptual Explanation: The pH is low (< 7.35) indicating acidosis. The PaCO2 is high (>
45 mmHg) which matches the acidotic state, identifying it as respiratory. The HCO3 is
normal, indicating no compensation yet.
3. Which assessment finding is a priority for a nurse monitoring a patient receiving a
hypertonic IV solution such as 3% Sodium Chloride?
A. Increased urine output
B. Dry mucous membranes
C. Decreased skin turgor
D. Crackles in the lungs
Answer: D
Conceptual Explanation: Hypertonic solutions draw water into the vascular space,
increasing the risk of fluid volume overload. Crackles indicate pulmonary edema, a serious
complication of fluid overload.
, 4. During the preoperative assessment, a patient reports an allergy to bananas and avocados.
Which action is most important for the nurse to take?
A. Ensure the patient receives an antihistamine before surgery
B. Document the food allergy and proceed with standard care
C. Notify the surgical team to prepare for a latex-free environment
D. Cancel the surgery until an allergy panel is completed
Answer: C
Conceptual Explanation: Cross-reactivity exists between certain foods (bananas,
avocados, kiwis) and latex. A latex allergy can cause anaphylaxis during surgery, so a latex-
free environment is mandatory.
5. A postoperative patient suddenly develops a temperature of 104°F, muscle rigidity, and
tachycardia. Which medication should the nurse anticipate administering immediately?
A. Dantrolene sodium
B. Acetaminophen
C. Naloxone
D. Furosemide
Answer: A
COMPREHENSIVE EXAM REVIEW
(EXAMS 2-4) QUESTIONS AND
ANSWERS
1. A patient presents with a serum potassium level of 6.2 mEq/L. Which cardiac change
should the nurse monitor for most closely on the ECG?
A. Prominent U waves
B. Prolonged PR interval
C. ST-segment depression
D. Tall, peaked T waves
Answer: D
Conceptual Explanation: Hyperkalemia (K+ > 5.0 mEq/L) typically causes tall, peaked T
waves, widened QRS complexes, and potentially cardiac arrest. U waves are associated with
hypokalemia.
2. A client’s arterial blood gas (ABG) results are pH 7.31, PaCO2 50 mmHg, and HCO3 24
mEq/L. How should the nurse interpret these findings?
A. Metabolic acidosis
,B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis
Answer: C
Conceptual Explanation: The pH is low (< 7.35) indicating acidosis. The PaCO2 is high (>
45 mmHg) which matches the acidotic state, identifying it as respiratory. The HCO3 is
normal, indicating no compensation yet.
3. Which assessment finding is a priority for a nurse monitoring a patient receiving a
hypertonic IV solution such as 3% Sodium Chloride?
A. Increased urine output
B. Dry mucous membranes
C. Decreased skin turgor
D. Crackles in the lungs
Answer: D
Conceptual Explanation: Hypertonic solutions draw water into the vascular space,
increasing the risk of fluid volume overload. Crackles indicate pulmonary edema, a serious
complication of fluid overload.
, 4. During the preoperative assessment, a patient reports an allergy to bananas and avocados.
Which action is most important for the nurse to take?
A. Ensure the patient receives an antihistamine before surgery
B. Document the food allergy and proceed with standard care
C. Notify the surgical team to prepare for a latex-free environment
D. Cancel the surgery until an allergy panel is completed
Answer: C
Conceptual Explanation: Cross-reactivity exists between certain foods (bananas,
avocados, kiwis) and latex. A latex allergy can cause anaphylaxis during surgery, so a latex-
free environment is mandatory.
5. A postoperative patient suddenly develops a temperature of 104°F, muscle rigidity, and
tachycardia. Which medication should the nurse anticipate administering immediately?
A. Dantrolene sodium
B. Acetaminophen
C. Naloxone
D. Furosemide
Answer: A
