PNR 201/PNR201 Exam 1 V1 | Medical-
Surgical Nursing Q&A with Rationale |
Fortis College
1. A nurse is caring for a patient who has a potassium level of 2.8 mEq/L. Which of the
following findings should the nurse expect?
A. Prominent U waves on ECG
B. Hyperactive bowel sounds
C. Muscle tetany and tremors
D. Tall, peaked T waves
Correct Answer: A
Expert Explanation: Hypokalemia is defined as a serum potassium level below 3.5 mEq/L
and can cause cardiac dysrhythmias. The presence of U waves is a classic
electrocardiogram change associated with low potassium levels. The nurse must monitor
the patient closely for potential cardiac arrest and muscle weakness.
2. A patient is admitted with metabolic acidosis. Which of the following arterial blood gas
(ABG) results supports this diagnosis?
A. pH 7.30, PaCO2 38, HCO3 18
B. pH 7.48, PaCO2 30, HCO3 23
C. pH 7.32, PaCO2 50, HCO3 26
,D. pH 7.50, PaCO2 40, HCO3 30
Correct Answer: A
Expert Explanation: Metabolic acidosis is characterized by a low pH and a low
bicarbonate level. In this case, the pH of 7.30 indicates acidosis and the HCO3 of 18 is below
the normal range of 22 to 26 mEq/L. This condition often results from renal failure,
diabetic ketoacidosis, or severe diarrhea.
3. The nurse is preparing a patient for surgery. Which action is the primary responsibility of
the nurse regarding informed consent?
A. Witnessing the patient sign the consent form
B. Describing alternative treatments to the patient
C. Explaining the risks and benefits of the procedure
D. Obtaining the patient’s medical history for the surgeon
Correct Answer: A
Expert Explanation: The nurse’s role in the informed consent process is to act as a witness
to the patient’s signature. It is the surgeon’s legal responsibility to explain the procedure,
risks, and benefits to the patient. The nurse ensures that the patient appears competent
and has signed the document voluntarily.
4. A patient in the PACU is experiencing a drop in blood pressure and an increased heart rate.
What should be the nurse’s priority action?
A. Administer pain medication
, B. Increase the IV fluid rate
C. Assess for signs of hemorrhage
D. Encourage deep breathing exercises
Correct Answer: C
Expert Explanation: Tachycardia and hypotension are early clinical indicators of post-
operative hemorrhage or shock. The nurse must immediately assess the surgical site and
drains for excessive bleeding. Prompt identification of circulatory collapse is vital for
patient survival in the immediate post-operative period.
5. Which electrolyte imbalance is most commonly associated with a positive Chvostek’s sign?
A. Hypocalcemia
B. Hypermagnesemia
C. Hyponatremia
D. Hyperkalemia
Correct Answer: A
Expert Explanation: Chvostek’s sign is an indication of neuromuscular irritability caused
by low serum calcium levels. It is elicited by tapping the facial nerve in front of the ear,
which results in twitching of the facial muscles. This finding necessitates immediate
reporting and potential calcium replacement therapy.
Surgical Nursing Q&A with Rationale |
Fortis College
1. A nurse is caring for a patient who has a potassium level of 2.8 mEq/L. Which of the
following findings should the nurse expect?
A. Prominent U waves on ECG
B. Hyperactive bowel sounds
C. Muscle tetany and tremors
D. Tall, peaked T waves
Correct Answer: A
Expert Explanation: Hypokalemia is defined as a serum potassium level below 3.5 mEq/L
and can cause cardiac dysrhythmias. The presence of U waves is a classic
electrocardiogram change associated with low potassium levels. The nurse must monitor
the patient closely for potential cardiac arrest and muscle weakness.
2. A patient is admitted with metabolic acidosis. Which of the following arterial blood gas
(ABG) results supports this diagnosis?
A. pH 7.30, PaCO2 38, HCO3 18
B. pH 7.48, PaCO2 30, HCO3 23
C. pH 7.32, PaCO2 50, HCO3 26
,D. pH 7.50, PaCO2 40, HCO3 30
Correct Answer: A
Expert Explanation: Metabolic acidosis is characterized by a low pH and a low
bicarbonate level. In this case, the pH of 7.30 indicates acidosis and the HCO3 of 18 is below
the normal range of 22 to 26 mEq/L. This condition often results from renal failure,
diabetic ketoacidosis, or severe diarrhea.
3. The nurse is preparing a patient for surgery. Which action is the primary responsibility of
the nurse regarding informed consent?
A. Witnessing the patient sign the consent form
B. Describing alternative treatments to the patient
C. Explaining the risks and benefits of the procedure
D. Obtaining the patient’s medical history for the surgeon
Correct Answer: A
Expert Explanation: The nurse’s role in the informed consent process is to act as a witness
to the patient’s signature. It is the surgeon’s legal responsibility to explain the procedure,
risks, and benefits to the patient. The nurse ensures that the patient appears competent
and has signed the document voluntarily.
4. A patient in the PACU is experiencing a drop in blood pressure and an increased heart rate.
What should be the nurse’s priority action?
A. Administer pain medication
, B. Increase the IV fluid rate
C. Assess for signs of hemorrhage
D. Encourage deep breathing exercises
Correct Answer: C
Expert Explanation: Tachycardia and hypotension are early clinical indicators of post-
operative hemorrhage or shock. The nurse must immediately assess the surgical site and
drains for excessive bleeding. Prompt identification of circulatory collapse is vital for
patient survival in the immediate post-operative period.
5. Which electrolyte imbalance is most commonly associated with a positive Chvostek’s sign?
A. Hypocalcemia
B. Hypermagnesemia
C. Hyponatremia
D. Hyperkalemia
Correct Answer: A
Expert Explanation: Chvostek’s sign is an indication of neuromuscular irritability caused
by low serum calcium levels. It is elicited by tapping the facial nerve in front of the ear,
which results in twitching of the facial muscles. This finding necessitates immediate
reporting and potential calcium replacement therapy.
