NUR 2356: MULTIDIMENSIONAL CARE I
- EXAM 1 COMPREHENSIVE REVIEW
QUESTIONS AND VERIFIED ANSWERS
|GRADE A+| JUST RELEASED
1. A nurse is caring for a patient with a serum potassium level of 2.8 mEq/L. Which clinical
manifestation should the nurse prioritize for immediate assessment?
A. Increased bowel sounds and diarrhea
B. Tall, peaked T-waves on the EKG
C. Trousseau’s and Chvostek’s signs
D. Cardiac dysrhythmias and muscle weakness
Answer: D
Conceptual Explanation: A potassium level of 2.8 mEq/L indicates hypokalemia. Clinical
manifestations include muscle weakness, leg cramps, and potentially fatal cardiac
dysrhythmias. Peaked T-waves are associated with hyperkalemia, while
Trousseau’s/Chvostek’s signs are for hypocalcemia.
2. Which arterial blood gas (ABG) result should the nurse expect for a patient experiencing
prolonged vomiting and nasogastric suctioning?
A. pH 7.48, PaCO2 42, HCO3 30
,B. pH 7.32, PaCO2 48, HCO3 24
C. pH 7.30, PaCO2 35, HCO3 18
D. pH 7.50, PaCO2 30, HCO3 22
Answer: A
Conceptual Explanation: Prolonged vomiting causes a loss of stomach acid (HCl), leading
to metabolic alkalosis. Option A represents metabolic alkalosis (elevated pH and elevated
HCO3).
3. A patient is scheduled for an elective surgery. During the preoperative assessment, the
patient mentions a family history of sudden high fever during anesthesia. The nurse should
alert the surgical team to prepare for which emergency?
A. Anaphylactic shock
B. Malignant Hyperthermia
C. Hypovolemic shock
D. Autonomic dysreflexia
Answer: B
Conceptual Explanation: Malignant Hyperthermia is a life-threatening hereditary reaction
to volatile anesthetics and succinylcholine, characterized by muscle rigidity and extreme
hyperthermia.
, 4. What is the priority nursing intervention when a patient’s surgical wound shows signs of
evisceration?
A. Push the organs back into the abdominal cavity gently
B. Cover the protruding organs with sterile dressings moistened with sterile normal saline
C. Apply a dry sterile dressing and call the surgeon
D. Place the patient in a High-Fowler’s position
Answer: B
Conceptual Explanation: Evisceration is a medical emergency. The nurse must cover the
organs with sterile, saline-soaked dressings to keep them moist and prevent necrosis while
calling for the surgical team.
5. An elderly patient has a Stage 3 pressure injury on the coccyx. How should the nurse
describe this wound in the documentation?
A. Full-thickness skin loss involving damage to the subcutaneous tissue
B. Non-blanchable erythema of intact skin
C. Partial-thickness loss of dermis presenting as a shallow open ulcer
D. Full-thickness tissue loss with exposed bone, tendon, or muscle
Answer: A
Conceptual Explanation: Stage 3 involves full-thickness skin loss where subcutaneous fat
may be visible, but bone, tendon, or muscle are not exposed (which would be Stage 4).
- EXAM 1 COMPREHENSIVE REVIEW
QUESTIONS AND VERIFIED ANSWERS
|GRADE A+| JUST RELEASED
1. A nurse is caring for a patient with a serum potassium level of 2.8 mEq/L. Which clinical
manifestation should the nurse prioritize for immediate assessment?
A. Increased bowel sounds and diarrhea
B. Tall, peaked T-waves on the EKG
C. Trousseau’s and Chvostek’s signs
D. Cardiac dysrhythmias and muscle weakness
Answer: D
Conceptual Explanation: A potassium level of 2.8 mEq/L indicates hypokalemia. Clinical
manifestations include muscle weakness, leg cramps, and potentially fatal cardiac
dysrhythmias. Peaked T-waves are associated with hyperkalemia, while
Trousseau’s/Chvostek’s signs are for hypocalcemia.
2. Which arterial blood gas (ABG) result should the nurse expect for a patient experiencing
prolonged vomiting and nasogastric suctioning?
A. pH 7.48, PaCO2 42, HCO3 30
,B. pH 7.32, PaCO2 48, HCO3 24
C. pH 7.30, PaCO2 35, HCO3 18
D. pH 7.50, PaCO2 30, HCO3 22
Answer: A
Conceptual Explanation: Prolonged vomiting causes a loss of stomach acid (HCl), leading
to metabolic alkalosis. Option A represents metabolic alkalosis (elevated pH and elevated
HCO3).
3. A patient is scheduled for an elective surgery. During the preoperative assessment, the
patient mentions a family history of sudden high fever during anesthesia. The nurse should
alert the surgical team to prepare for which emergency?
A. Anaphylactic shock
B. Malignant Hyperthermia
C. Hypovolemic shock
D. Autonomic dysreflexia
Answer: B
Conceptual Explanation: Malignant Hyperthermia is a life-threatening hereditary reaction
to volatile anesthetics and succinylcholine, characterized by muscle rigidity and extreme
hyperthermia.
, 4. What is the priority nursing intervention when a patient’s surgical wound shows signs of
evisceration?
A. Push the organs back into the abdominal cavity gently
B. Cover the protruding organs with sterile dressings moistened with sterile normal saline
C. Apply a dry sterile dressing and call the surgeon
D. Place the patient in a High-Fowler’s position
Answer: B
Conceptual Explanation: Evisceration is a medical emergency. The nurse must cover the
organs with sterile, saline-soaked dressings to keep them moist and prevent necrosis while
calling for the surgical team.
5. An elderly patient has a Stage 3 pressure injury on the coccyx. How should the nurse
describe this wound in the documentation?
A. Full-thickness skin loss involving damage to the subcutaneous tissue
B. Non-blanchable erythema of intact skin
C. Partial-thickness loss of dermis presenting as a shallow open ulcer
D. Full-thickness tissue loss with exposed bone, tendon, or muscle
Answer: A
Conceptual Explanation: Stage 3 involves full-thickness skin loss where subcutaneous fat
may be visible, but bone, tendon, or muscle are not exposed (which would be Stage 4).
