NUR 2356 EXAM 2 -
MULTIDIMENSIONAL CARE I
QUESTIONS AND VERIFIED ANSWERS
|GRADE A+| JUST RELEASED
1. A patient presents with a serum potassium level of 2.8 mEq/L. Which clinical manifestation
should the nurse prioritize for assessment?
A. Hyperactive bowel sounds
B. Tingling in the fingers and toes
C. Positive Chvostek’s sign
D. Cardiac dysrhythmias and muscle weakness
Answer: D
Conceptual Explanation: Hypokalemia (potassium < 3.5 mEq/L) can lead to life-
threatening cardiac dysrhythmias and significant muscle weakness, which are priority
concerns.
2. Which electrolyte imbalance is a nurse most likely to observe in a patient with a positive
Trousseau’s sign?
A. Hypernatremia
B. Hypokalemia
,C. Hypocalcemia
D. Hypermagnesemia
Answer: C
Conceptual Explanation: Trousseau’s sign (carpal spasm induced by inflating a blood
pressure cuff) is a classic indicator of hypocalcemia and neuromuscular irritability.
3. A patient is admitted with a serum sodium level of 155 mEq/L. Which nursing intervention
is most appropriate?
A. Encourage increased oral fluid intake
B. Administer 3% Sodium Chloride IV
C. Restrict water intake
D. Administer Furosemide to retain sodium
Answer: A
Conceptual Explanation: Hypernatremia indicates a water deficit relative to sodium; the
priority is to provide free water orally or via hypotonic IV fluids to lower the concentration.
4. A patient’s arterial blood gas (ABG) results are: pH 7.30, PaCO2 55 mmHg, and HCO3 24
mEq/L. How should the nurse interpret these findings?
A. Metabolic Acidosis
B. Respiratory Alkalosis
C. Metabolic Alkalosis
, D. Respiratory Acidosis
Answer: D
Conceptual Explanation: A pH below 7.35 indicates acidosis, and a PaCO2 above 45
mmHg indicates a respiratory cause for the acidity.
5. The nurse is caring for a post-operative patient who reports sudden chest pain and
shortness of breath. What is the priority nursing action?
A. Administer the prescribed PRN analgesic
B. Obtain an EKG and notify the physician
C. Apply supplemental oxygen and assess breath sounds
D. Encourage the patient to cough and deep breathe
Answer: C
Conceptual Explanation: Oxygenation is the priority (ABCs) in a potential pulmonary
embolism or respiratory distress situation before diagnostic testing.
6. Which assessment finding would best indicate that a patient is experiencing fluid volume
excess?
A. Tenting of the skin on the forearm
B. Flat neck veins when the head of the bed is at 45 degrees
C. Decreased urine output with high specific gravity
D. Bounding pulse and crackles in the lungs
MULTIDIMENSIONAL CARE I
QUESTIONS AND VERIFIED ANSWERS
|GRADE A+| JUST RELEASED
1. A patient presents with a serum potassium level of 2.8 mEq/L. Which clinical manifestation
should the nurse prioritize for assessment?
A. Hyperactive bowel sounds
B. Tingling in the fingers and toes
C. Positive Chvostek’s sign
D. Cardiac dysrhythmias and muscle weakness
Answer: D
Conceptual Explanation: Hypokalemia (potassium < 3.5 mEq/L) can lead to life-
threatening cardiac dysrhythmias and significant muscle weakness, which are priority
concerns.
2. Which electrolyte imbalance is a nurse most likely to observe in a patient with a positive
Trousseau’s sign?
A. Hypernatremia
B. Hypokalemia
,C. Hypocalcemia
D. Hypermagnesemia
Answer: C
Conceptual Explanation: Trousseau’s sign (carpal spasm induced by inflating a blood
pressure cuff) is a classic indicator of hypocalcemia and neuromuscular irritability.
3. A patient is admitted with a serum sodium level of 155 mEq/L. Which nursing intervention
is most appropriate?
A. Encourage increased oral fluid intake
B. Administer 3% Sodium Chloride IV
C. Restrict water intake
D. Administer Furosemide to retain sodium
Answer: A
Conceptual Explanation: Hypernatremia indicates a water deficit relative to sodium; the
priority is to provide free water orally or via hypotonic IV fluids to lower the concentration.
4. A patient’s arterial blood gas (ABG) results are: pH 7.30, PaCO2 55 mmHg, and HCO3 24
mEq/L. How should the nurse interpret these findings?
A. Metabolic Acidosis
B. Respiratory Alkalosis
C. Metabolic Alkalosis
, D. Respiratory Acidosis
Answer: D
Conceptual Explanation: A pH below 7.35 indicates acidosis, and a PaCO2 above 45
mmHg indicates a respiratory cause for the acidity.
5. The nurse is caring for a post-operative patient who reports sudden chest pain and
shortness of breath. What is the priority nursing action?
A. Administer the prescribed PRN analgesic
B. Obtain an EKG and notify the physician
C. Apply supplemental oxygen and assess breath sounds
D. Encourage the patient to cough and deep breathe
Answer: C
Conceptual Explanation: Oxygenation is the priority (ABCs) in a potential pulmonary
embolism or respiratory distress situation before diagnostic testing.
6. Which assessment finding would best indicate that a patient is experiencing fluid volume
excess?
A. Tenting of the skin on the forearm
B. Flat neck veins when the head of the bed is at 45 degrees
C. Decreased urine output with high specific gravity
D. Bounding pulse and crackles in the lungs
