NURS 201 Quiz 1 V2 | NURS 201 Medical
Surgical Nursing | Actual Q&A with
Rationale (NURS201 Quiz 1) | West Coast
University
1. A patient is admitted with a serum potassium level of 6.4 mEq/L. Which clinical
manifestation should the nurse monitor for most closely?
A. Cardiac dysrhythmias and peaked T-waves
B. Decreased deep tendon reflexes
C. Hyperactive bowel sounds
D. Increased urinary output
Answer: A
Rationale: The patient’s potassium level is significantly elevated above the normal range of
3.5 to 5.0 mEq/L. Hyperkalemia poses a severe risk to cardiac stability because it affects
the repolarization phase of the cardiac action potential. The nurse must prioritize ECG
monitoring to detect life-threatening dysrhythmias such as ventricular fibrillation or heart
block.
2. A client’s arterial blood gas (ABG) results are: pH 7.28, PaCO2 52 mmHg, and HCO3 24
mEq/L. How should the nurse interpret these findings?
A. Metabolic Acidosis
,B. Respiratory Acidosis
C. Respiratory Alkalosis
D. Metabolic Alkalosis
Answer: B
Rationale: The pH of 7.28 indicates acidosis as it is below the normal range of 7.35 to 7.45.
The PaCO2 is elevated at 52 mmHg, which is above the normal range of 35 to 45 mmHg,
indicating a respiratory cause. Since the bicarbonate level is within the normal range, the
condition is identified as uncompensated respiratory acidosis.
3. When assessing a patient with hypocalcemia, the nurse notes a contraction of facial
muscles when tapping over the facial nerve. This is documented as:
A. Trousseau’s sign
B. Kernig’s sign
C. Chvostek’s sign
D. Babinski’s sign
Answer: C
Rationale: Chvostek’s sign is a clinical indicator of hypocalcemia or hypomagnesemia
characterized by abnormal spasms of the facial muscles. It is elicited by tapping the facial
nerve just in front of the ear. The presence of this sign suggests neuromuscular irritability
that requires immediate clinical intervention.
, 4. A nurse is preparing a patient for surgery. The patient states, ‘I am not really sure what the
doctor is going to do.’ What is the nurse’s priority action?
A. Explain the surgical procedure to the patient in detail
B. Tell the patient not to worry because the surgeon is highly skilled
C. Have the patient sign the consent form and document the conversation
D. Notify the surgeon that the patient needs further clarification
Answer: D
Rationale: The nurse’s primary role in the informed consent process is to witness the
patient’s signature and verify that they appear competent. If the patient expresses a lack of
understanding regarding the procedure, it is the surgeon’s legal responsibility to provide
the necessary explanation. The nurse must advocate for the patient by contacting the
surgeon to ensure the patient is fully informed before proceeding.
5. Which intravenous fluid should the nurse anticipate administering to a patient
experiencing hypovolemic shock?
A. 0.45% Sodium Chloride
B. 5% Dextrose in Water (D5W)
C. 3% Sodium Chloride
D. 0.9% Sodium Chloride
Answer: D
Surgical Nursing | Actual Q&A with
Rationale (NURS201 Quiz 1) | West Coast
University
1. A patient is admitted with a serum potassium level of 6.4 mEq/L. Which clinical
manifestation should the nurse monitor for most closely?
A. Cardiac dysrhythmias and peaked T-waves
B. Decreased deep tendon reflexes
C. Hyperactive bowel sounds
D. Increased urinary output
Answer: A
Rationale: The patient’s potassium level is significantly elevated above the normal range of
3.5 to 5.0 mEq/L. Hyperkalemia poses a severe risk to cardiac stability because it affects
the repolarization phase of the cardiac action potential. The nurse must prioritize ECG
monitoring to detect life-threatening dysrhythmias such as ventricular fibrillation or heart
block.
2. A client’s arterial blood gas (ABG) results are: pH 7.28, PaCO2 52 mmHg, and HCO3 24
mEq/L. How should the nurse interpret these findings?
A. Metabolic Acidosis
,B. Respiratory Acidosis
C. Respiratory Alkalosis
D. Metabolic Alkalosis
Answer: B
Rationale: The pH of 7.28 indicates acidosis as it is below the normal range of 7.35 to 7.45.
The PaCO2 is elevated at 52 mmHg, which is above the normal range of 35 to 45 mmHg,
indicating a respiratory cause. Since the bicarbonate level is within the normal range, the
condition is identified as uncompensated respiratory acidosis.
3. When assessing a patient with hypocalcemia, the nurse notes a contraction of facial
muscles when tapping over the facial nerve. This is documented as:
A. Trousseau’s sign
B. Kernig’s sign
C. Chvostek’s sign
D. Babinski’s sign
Answer: C
Rationale: Chvostek’s sign is a clinical indicator of hypocalcemia or hypomagnesemia
characterized by abnormal spasms of the facial muscles. It is elicited by tapping the facial
nerve just in front of the ear. The presence of this sign suggests neuromuscular irritability
that requires immediate clinical intervention.
, 4. A nurse is preparing a patient for surgery. The patient states, ‘I am not really sure what the
doctor is going to do.’ What is the nurse’s priority action?
A. Explain the surgical procedure to the patient in detail
B. Tell the patient not to worry because the surgeon is highly skilled
C. Have the patient sign the consent form and document the conversation
D. Notify the surgeon that the patient needs further clarification
Answer: D
Rationale: The nurse’s primary role in the informed consent process is to witness the
patient’s signature and verify that they appear competent. If the patient expresses a lack of
understanding regarding the procedure, it is the surgeon’s legal responsibility to provide
the necessary explanation. The nurse must advocate for the patient by contacting the
surgeon to ensure the patient is fully informed before proceeding.
5. Which intravenous fluid should the nurse anticipate administering to a patient
experiencing hypovolemic shock?
A. 0.45% Sodium Chloride
B. 5% Dextrose in Water (D5W)
C. 3% Sodium Chloride
D. 0.9% Sodium Chloride
Answer: D
