NUR 114 Nursing Concepts II - Exam 2 Questions and Verified Answers
with Explanations |Latest Update
1. A patient’s arterial blood gas (ABG) results are: pH 7.30, PaCO2 55
mmHg, and HCO3 24 mEq/L. Which acid-base imbalance does this
represent?
A. Metabolic Acidosis
B. Metabolic Alkalosis
C. Respiratory Acidosis
D. Respiratory Alkalosis
Answer: C
Explanation: The pH is low (acidosis), the PaCO2 is high (respiratory component), and the
HCO3 is normal, indicating uncompensated respiratory acidosis.
2. Which electrolyte imbalance is most closely associated with the presence of
peaked T waves on an EKG?
A. Hyponatremia
B. Hypokalemia
C. Hypercalcemia
,D. Hyperkalemia
Answer: D
Explanation: Hyperkalemia (high potassium) causes characteristic EKG changes, including
tall, peaked T waves, which can progress to cardiac arrest.
3. A nurse is caring for a patient with a calcium level of 7.5 mg/dL. Which clinical
sign should the nurse monitor for?
A. Trousseau’s sign
B. Absent deep tendon reflexes
C. Polyuria
D. Constipation
Answer: A
Explanation: Trousseau’s sign (carpal spasm induced by inflating a blood pressure cuff) is
a classic indicator of hypocalcemia (low calcium).
4. When witnessing a patient sign an informed consent for surgery, what is the
nurse’s primary responsibility?
A. Explaining the risks and benefits of the procedure
B. Deciding if the patient should undergo the surgery
C. Describing alternative treatments to the patient
,D. Ensuring the patient is signing the form voluntarily
Answer: D
Explanation: The nurse’s role is to witness the signature, ensure the patient is competent,
and verify that the signature is voluntary. Explaining the surgery is the surgeon’s role.
5. A patient is 2 hours post-operative. The nurse notes the surgical dressing is
saturated with bright red blood. What is the priority nursing action?
A. Reinforce the dressing and notify the surgeon
B. Change the dressing immediately
C. Document the findings in the electronic health record
D. Apply a heating pad to the area to promote vasoconstriction
Answer: A
Explanation: Excessive bright red blood (sanguineous drainage) shortly after surgery
indicates hemorrhage; the nurse should reinforce the dressing to provide pressure and
notify the provider.
6. Which IV fluid is considered isotonic and commonly used for fluid volume
replacement?
A. 0.45% Sodium Chloride
B. 3% Sodium Chloride
, C. 0.9% Sodium Chloride
D. Dextrose 10% in Water
Answer: C
Explanation: 0.9% Sodium Chloride (Normal Saline) and Lactated Ringer’s are common
isotonic solutions that stay in the intravascular space.
7. During the intraoperative phase, what is the purpose of the ‘Time-Out’
procedure?
A. To allow the surgeon to rest before beginning
B. To check if the anesthesia equipment is working
C. To verify the correct patient, site, and procedure
D. To allow family members to visit the patient
Answer: C
Explanation: The ‘Time-Out’ is a safety protocol performed immediately before the
incision to ensure all team members agree on the patient identity, site, and procedure.
8. A patient with hyperventilation due to anxiety is likely to develop which acid-
base imbalance?
A. Respiratory Acidosis
B. Metabolic Acidosis
with Explanations |Latest Update
1. A patient’s arterial blood gas (ABG) results are: pH 7.30, PaCO2 55
mmHg, and HCO3 24 mEq/L. Which acid-base imbalance does this
represent?
A. Metabolic Acidosis
B. Metabolic Alkalosis
C. Respiratory Acidosis
D. Respiratory Alkalosis
Answer: C
Explanation: The pH is low (acidosis), the PaCO2 is high (respiratory component), and the
HCO3 is normal, indicating uncompensated respiratory acidosis.
2. Which electrolyte imbalance is most closely associated with the presence of
peaked T waves on an EKG?
A. Hyponatremia
B. Hypokalemia
C. Hypercalcemia
,D. Hyperkalemia
Answer: D
Explanation: Hyperkalemia (high potassium) causes characteristic EKG changes, including
tall, peaked T waves, which can progress to cardiac arrest.
3. A nurse is caring for a patient with a calcium level of 7.5 mg/dL. Which clinical
sign should the nurse monitor for?
A. Trousseau’s sign
B. Absent deep tendon reflexes
C. Polyuria
D. Constipation
Answer: A
Explanation: Trousseau’s sign (carpal spasm induced by inflating a blood pressure cuff) is
a classic indicator of hypocalcemia (low calcium).
4. When witnessing a patient sign an informed consent for surgery, what is the
nurse’s primary responsibility?
A. Explaining the risks and benefits of the procedure
B. Deciding if the patient should undergo the surgery
C. Describing alternative treatments to the patient
,D. Ensuring the patient is signing the form voluntarily
Answer: D
Explanation: The nurse’s role is to witness the signature, ensure the patient is competent,
and verify that the signature is voluntary. Explaining the surgery is the surgeon’s role.
5. A patient is 2 hours post-operative. The nurse notes the surgical dressing is
saturated with bright red blood. What is the priority nursing action?
A. Reinforce the dressing and notify the surgeon
B. Change the dressing immediately
C. Document the findings in the electronic health record
D. Apply a heating pad to the area to promote vasoconstriction
Answer: A
Explanation: Excessive bright red blood (sanguineous drainage) shortly after surgery
indicates hemorrhage; the nurse should reinforce the dressing to provide pressure and
notify the provider.
6. Which IV fluid is considered isotonic and commonly used for fluid volume
replacement?
A. 0.45% Sodium Chloride
B. 3% Sodium Chloride
, C. 0.9% Sodium Chloride
D. Dextrose 10% in Water
Answer: C
Explanation: 0.9% Sodium Chloride (Normal Saline) and Lactated Ringer’s are common
isotonic solutions that stay in the intravascular space.
7. During the intraoperative phase, what is the purpose of the ‘Time-Out’
procedure?
A. To allow the surgeon to rest before beginning
B. To check if the anesthesia equipment is working
C. To verify the correct patient, site, and procedure
D. To allow family members to visit the patient
Answer: C
Explanation: The ‘Time-Out’ is a safety protocol performed immediately before the
incision to ensure all team members agree on the patient identity, site, and procedure.
8. A patient with hyperventilation due to anxiety is likely to develop which acid-
base imbalance?
A. Respiratory Acidosis
B. Metabolic Acidosis
