PNR 206/PNR206 Exam 1 V3 | Medical-Surgical
Nursing II Q&A with Rationale | Fortis College
1. A patient is admitted with a serum potassium level of 6.2 mEq/L. Which cardiac finding is
the nurse most likely to observe on the ECG monitor?
A. Prominent U waves
B. ST-segment depression
C. Tall, peaked T waves
D. Prolonged PR interval
Correct Answer: C
Explanation: Hyperkalemia, defined as a potassium level above 5.0 mEq/L, directly affects
myocardial conduction. Tall, peaked T waves are a classic early sign of potassium toxicity
on an electrocardiogram. The nurse must prioritize monitoring for these changes to
prevent life-threatening arrhythmias or cardiac arrest.
2. Which clinical manifestation should the nurse expect to find in a patient diagnosed with
hypocalcemia?
A. Negative Chvostek’s sign
B. Trousseau’s sign
C. Muscle flaccidity
D. Hyperglycemia
,Correct Answer: B
Explanation: Hypocalcemia increases neuromuscular excitability, leading to tetany and
involuntary muscle contractions. Trousseau’s sign is elicited by inflating a blood pressure
cuff, which triggers a carpal spasm in affected patients. The nurse should also assess for
Chvostek’s sign by tapping the facial nerve to check for twitching.
3. A patient’s ABG results are pH 7.25, PaCO2 50 mmHg, and HCO3 24 mEq/L. How should the
nurse interpret these findings?
A. Metabolic acidosis
B. Respiratory alkalosis
C. Respiratory acidosis
D. Metabolic alkalosis
Correct Answer: C
Explanation: A pH below 7.35 indicates acidosis, and a PaCO2 above 45 mmHg indicates a
respiratory origin. Since the bicarbonate level is within the normal range, the condition is
uncompensated respiratory acidosis. This state is often seen in patients with
hypoventilation or obstructive lung diseases like COPD.
4. When caring for a patient with left-sided heart failure, which assessment finding is the
nurse most likely to document?
A. Peripheral edema
B. Crackles in the lungs
, C. Jugular venous distention
D. Hepatosplenomegaly
Correct Answer: B
Explanation: Left-sided heart failure causes blood to back up into the pulmonary
circulation, increasing hydrostatic pressure in the lung capillaries. This leads to pulmonary
edema, which manifests clinically as crackles (rales) upon auscultation. The nurse must
monitor for dyspnea and orthopnea as these are primary indicators of worsening
pulmonary congestion.
5. A nurse is teaching a patient about the DASH diet for hypertension. Which food choice
indicates that the patient understands the instructions?
A. Fresh spinach salad with lemon
B. Canned vegetable soup
C. Pickled cucumbers
D. Processed deli meats
Correct Answer: A
Explanation: The DASH (Dietary Approaches to Stop Hypertension) diet emphasizes high
intake of fruits, vegetables, and low-fat dairy while minimizing sodium. Fresh spinach is
naturally low in sodium and high in potassium, which helps lower blood pressure. Canned,
pickled, and processed foods are typically high in sodium and should be avoided by
hypertensive patients.
Nursing II Q&A with Rationale | Fortis College
1. A patient is admitted with a serum potassium level of 6.2 mEq/L. Which cardiac finding is
the nurse most likely to observe on the ECG monitor?
A. Prominent U waves
B. ST-segment depression
C. Tall, peaked T waves
D. Prolonged PR interval
Correct Answer: C
Explanation: Hyperkalemia, defined as a potassium level above 5.0 mEq/L, directly affects
myocardial conduction. Tall, peaked T waves are a classic early sign of potassium toxicity
on an electrocardiogram. The nurse must prioritize monitoring for these changes to
prevent life-threatening arrhythmias or cardiac arrest.
2. Which clinical manifestation should the nurse expect to find in a patient diagnosed with
hypocalcemia?
A. Negative Chvostek’s sign
B. Trousseau’s sign
C. Muscle flaccidity
D. Hyperglycemia
,Correct Answer: B
Explanation: Hypocalcemia increases neuromuscular excitability, leading to tetany and
involuntary muscle contractions. Trousseau’s sign is elicited by inflating a blood pressure
cuff, which triggers a carpal spasm in affected patients. The nurse should also assess for
Chvostek’s sign by tapping the facial nerve to check for twitching.
3. A patient’s ABG results are pH 7.25, PaCO2 50 mmHg, and HCO3 24 mEq/L. How should the
nurse interpret these findings?
A. Metabolic acidosis
B. Respiratory alkalosis
C. Respiratory acidosis
D. Metabolic alkalosis
Correct Answer: C
Explanation: A pH below 7.35 indicates acidosis, and a PaCO2 above 45 mmHg indicates a
respiratory origin. Since the bicarbonate level is within the normal range, the condition is
uncompensated respiratory acidosis. This state is often seen in patients with
hypoventilation or obstructive lung diseases like COPD.
4. When caring for a patient with left-sided heart failure, which assessment finding is the
nurse most likely to document?
A. Peripheral edema
B. Crackles in the lungs
, C. Jugular venous distention
D. Hepatosplenomegaly
Correct Answer: B
Explanation: Left-sided heart failure causes blood to back up into the pulmonary
circulation, increasing hydrostatic pressure in the lung capillaries. This leads to pulmonary
edema, which manifests clinically as crackles (rales) upon auscultation. The nurse must
monitor for dyspnea and orthopnea as these are primary indicators of worsening
pulmonary congestion.
5. A nurse is teaching a patient about the DASH diet for hypertension. Which food choice
indicates that the patient understands the instructions?
A. Fresh spinach salad with lemon
B. Canned vegetable soup
C. Pickled cucumbers
D. Processed deli meats
Correct Answer: A
Explanation: The DASH (Dietary Approaches to Stop Hypertension) diet emphasizes high
intake of fruits, vegetables, and low-fat dairy while minimizing sodium. Fresh spinach is
naturally low in sodium and high in potassium, which helps lower blood pressure. Canned,
pickled, and processed foods are typically high in sodium and should be avoided by
hypertensive patients.
