NUR 114 Exam 3: Nursing Concepts II Comprehensive Review
Questions and Verified Answers with Explanations |Latest Update
1. A patient’s arterial blood gas (ABG) results show a pH of 7.30, PaCO2 of 52
mmHg, and HCO3 of 24 mEq/L. Which acid-base imbalance is present?
A. Metabolic Acidosis
B. Metabolic Alkalosis
C. Respiratory Acidosis
D. Respiratory Alkalosis
Answer: C
Explanation: The pH is low (acidosis) and the PaCO2 is high (respiratory cause), while the
bicarbonate is normal, indicating uncompensated respiratory acidosis.
2. Which clinical manifestation should the nurse expect to find in a patient with
a potassium level of 2.8 mEq/L?
A. Tall peaked T-waves
B. Muscle weakness and leg cramps
C. Hyperactive bowel sounds
D. Positive Trousseau’s sign
Answer: B
,Explanation: Hypokalemia (low potassium) commonly causes muscle weakness, fatigue,
and leg cramps due to altered nerve and muscle function.
3. What is the primary purpose of the ‘time-out’ procedure in the operating
room?
A. To allow the surgeon to rest before starting
B. To ensure all staff members have had a break
C. To document the start time of the anesthesia
D. To verify the patient identity, surgical site, and procedure
Answer: D
Explanation: The time-out is a critical safety step to prevent wrong-site, wrong-procedure,
and wrong-person surgery.
4. A patient is diagnosed with fluid volume deficit. Which assessment finding is
most consistent with this diagnosis?
A. Distended neck veins
B. Bounding pulse
C. Crackles in the lung bases
D. Orthostatic hypotension
Answer: D
,Explanation: Fluid volume deficit leads to decreased circulating volume, which manifests
as orthostatic hypotension, tachycardia, and poor skin turgor.
5. Which electrolyte imbalance is a patient at risk for if they are experiencing
excessive vomiting?
A. Hypernatremia
B. Respiratory Acidosis
C. Hyperkalemia
D. Metabolic Alkalosis
Answer: D
Explanation: Vomiting results in the loss of gastric hydrochloric acid, leading to an excess
of bicarbonate in the blood (metabolic alkalosis).
6. The nurse is caring for a patient with a calcium level of 7.5 mg/dL. Which sign
should the nurse assess for?
A. Negative Chvostek’s sign
B. Trousseau’s sign
C. Muscle flaccidity
D. Bradycardia
Answer: B
, Explanation: Hypocalcemia is characterized by neuromuscular irritability, including
positive Trousseau’s and Chvostek’s signs.
7. Which oxygen delivery device is capable of delivering the highest
concentration of oxygen (up to 90-100%)?
A. Nasal cannula
B. Non-rebreather mask
C. Venturi mask
D. Simple face mask
Answer: B
Explanation: The non-rebreather mask has a reservoir bag and valves that prevent
exhaled air from mixing with oxygen, allowing for high concentrations.
8. A patient 2 days post-op from abdominal surgery reports a ‘popping’
sensation after coughing, and the nurse observes intestines protruding. What is
the priority action?
A. Cover the area with sterile saline-soaked dressings
B. Push the organs back into the abdomen
C. Apply a tight abdominal binder
D. Administer pain medication immediately
Questions and Verified Answers with Explanations |Latest Update
1. A patient’s arterial blood gas (ABG) results show a pH of 7.30, PaCO2 of 52
mmHg, and HCO3 of 24 mEq/L. Which acid-base imbalance is present?
A. Metabolic Acidosis
B. Metabolic Alkalosis
C. Respiratory Acidosis
D. Respiratory Alkalosis
Answer: C
Explanation: The pH is low (acidosis) and the PaCO2 is high (respiratory cause), while the
bicarbonate is normal, indicating uncompensated respiratory acidosis.
2. Which clinical manifestation should the nurse expect to find in a patient with
a potassium level of 2.8 mEq/L?
A. Tall peaked T-waves
B. Muscle weakness and leg cramps
C. Hyperactive bowel sounds
D. Positive Trousseau’s sign
Answer: B
,Explanation: Hypokalemia (low potassium) commonly causes muscle weakness, fatigue,
and leg cramps due to altered nerve and muscle function.
3. What is the primary purpose of the ‘time-out’ procedure in the operating
room?
A. To allow the surgeon to rest before starting
B. To ensure all staff members have had a break
C. To document the start time of the anesthesia
D. To verify the patient identity, surgical site, and procedure
Answer: D
Explanation: The time-out is a critical safety step to prevent wrong-site, wrong-procedure,
and wrong-person surgery.
4. A patient is diagnosed with fluid volume deficit. Which assessment finding is
most consistent with this diagnosis?
A. Distended neck veins
B. Bounding pulse
C. Crackles in the lung bases
D. Orthostatic hypotension
Answer: D
,Explanation: Fluid volume deficit leads to decreased circulating volume, which manifests
as orthostatic hypotension, tachycardia, and poor skin turgor.
5. Which electrolyte imbalance is a patient at risk for if they are experiencing
excessive vomiting?
A. Hypernatremia
B. Respiratory Acidosis
C. Hyperkalemia
D. Metabolic Alkalosis
Answer: D
Explanation: Vomiting results in the loss of gastric hydrochloric acid, leading to an excess
of bicarbonate in the blood (metabolic alkalosis).
6. The nurse is caring for a patient with a calcium level of 7.5 mg/dL. Which sign
should the nurse assess for?
A. Negative Chvostek’s sign
B. Trousseau’s sign
C. Muscle flaccidity
D. Bradycardia
Answer: B
, Explanation: Hypocalcemia is characterized by neuromuscular irritability, including
positive Trousseau’s and Chvostek’s signs.
7. Which oxygen delivery device is capable of delivering the highest
concentration of oxygen (up to 90-100%)?
A. Nasal cannula
B. Non-rebreather mask
C. Venturi mask
D. Simple face mask
Answer: B
Explanation: The non-rebreather mask has a reservoir bag and valves that prevent
exhaled air from mixing with oxygen, allowing for high concentrations.
8. A patient 2 days post-op from abdominal surgery reports a ‘popping’
sensation after coughing, and the nurse observes intestines protruding. What is
the priority action?
A. Cover the area with sterile saline-soaked dressings
B. Push the organs back into the abdomen
C. Apply a tight abdominal binder
D. Administer pain medication immediately
