PNR 201/PNR201 Exam 3 V1 | Medical-Surgical
Nursing Q&A with Rationale | Fortis College
1. A nurse is reviewing the laboratory results of a client with a potassium level of 2.8 mEq/L.
Which clinical manifestation should the nurse expect to find during the assessment?
A. Hyperactive bowel sounds
B. Tall peaked T waves
C. Positive Trousseau sign
D. Prominent U waves on EKG
Correct Answer: D
Explanation: A potassium level of 2.8 mEq/L is diagnostic of hypokalemia, which typically
manifests with cardiac changes like U waves. This condition results in decreased
neuromuscular excitability, leading to muscle weakness and potential respiratory
compromise. The other options, such as peaked T waves, are associated with hyperkalemia,
not hypokalemia.
2. A client is admitted with a pH of 7.30, a PaCO2 of 52 mmHg, and an HCO3 of 24 mEq/L.
How should the nurse interpret these arterial blood gas (ABG) results?
A. Metabolic Acidosis
B. Respiratory Alkalosis
C. Respiratory Acidosis
,D. Metabolic Alkalosis
Correct Answer: C
Explanation: The pH is below 7.35, indicating acidosis, and the PaCO2 is elevated above 45
mmHg, which points to a respiratory cause. The bicarbonate level is within the normal
range, suggesting that compensation has not yet occurred. The nurse should monitor the
patient for signs of hypoventilation or airway obstruction.
3. A nurse is providing discharge teaching for a client who has a new prescription for
spironolactone (Aldactone). Which statement by the client indicates a need for further
instruction?
A. “I need to have my blood work checked regularly.”
B. “I should report any muscle weakness to my doctor.”
C. “I will avoid eating excessive amounts of bananas.”
D. “I will use a salt substitute to reduce my sodium intake.”
Correct Answer: D
Explanation: Spironolactone is a potassium-sparing diuretic, and salt substitutes often
contain high levels of potassium chloride. Using these substitutes puts the client at a high
risk for developing life-threatening hyperkalemia. The nurse must ensure the client
understands the importance of avoiding potassium-rich sources while on this medication.
, 4. Which assessment finding should the nurse anticipate in a client experiencing fluid volume
deficit?
A. Distended neck veins
B. Orthostatic hypotension
C. Increased blood pressure
D. Crackles on lung auscultation
Correct Answer: B
Explanation: Fluid volume deficit leads to a decrease in circulating blood volume, which
commonly results in orthostatic hypotension and tachycardia. The body attempts to
compensate by increasing the heart rate to maintain cardiac output despite the low
volume. Distended neck veins and crackles are signs of fluid volume excess, which is the
opposite condition.
5. A client with chronic kidney disease (CKD) is prescribed sevelamer (Renagel). The nurse
understands this medication is administered for which purpose?
A. To treat metabolic alkalosis
B. To decrease serum potassium levels
C. To increase hemoglobin levels
D. To lower serum phosphorus levels
Correct Answer: D
Nursing Q&A with Rationale | Fortis College
1. A nurse is reviewing the laboratory results of a client with a potassium level of 2.8 mEq/L.
Which clinical manifestation should the nurse expect to find during the assessment?
A. Hyperactive bowel sounds
B. Tall peaked T waves
C. Positive Trousseau sign
D. Prominent U waves on EKG
Correct Answer: D
Explanation: A potassium level of 2.8 mEq/L is diagnostic of hypokalemia, which typically
manifests with cardiac changes like U waves. This condition results in decreased
neuromuscular excitability, leading to muscle weakness and potential respiratory
compromise. The other options, such as peaked T waves, are associated with hyperkalemia,
not hypokalemia.
2. A client is admitted with a pH of 7.30, a PaCO2 of 52 mmHg, and an HCO3 of 24 mEq/L.
How should the nurse interpret these arterial blood gas (ABG) results?
A. Metabolic Acidosis
B. Respiratory Alkalosis
C. Respiratory Acidosis
,D. Metabolic Alkalosis
Correct Answer: C
Explanation: The pH is below 7.35, indicating acidosis, and the PaCO2 is elevated above 45
mmHg, which points to a respiratory cause. The bicarbonate level is within the normal
range, suggesting that compensation has not yet occurred. The nurse should monitor the
patient for signs of hypoventilation or airway obstruction.
3. A nurse is providing discharge teaching for a client who has a new prescription for
spironolactone (Aldactone). Which statement by the client indicates a need for further
instruction?
A. “I need to have my blood work checked regularly.”
B. “I should report any muscle weakness to my doctor.”
C. “I will avoid eating excessive amounts of bananas.”
D. “I will use a salt substitute to reduce my sodium intake.”
Correct Answer: D
Explanation: Spironolactone is a potassium-sparing diuretic, and salt substitutes often
contain high levels of potassium chloride. Using these substitutes puts the client at a high
risk for developing life-threatening hyperkalemia. The nurse must ensure the client
understands the importance of avoiding potassium-rich sources while on this medication.
, 4. Which assessment finding should the nurse anticipate in a client experiencing fluid volume
deficit?
A. Distended neck veins
B. Orthostatic hypotension
C. Increased blood pressure
D. Crackles on lung auscultation
Correct Answer: B
Explanation: Fluid volume deficit leads to a decrease in circulating blood volume, which
commonly results in orthostatic hypotension and tachycardia. The body attempts to
compensate by increasing the heart rate to maintain cardiac output despite the low
volume. Distended neck veins and crackles are signs of fluid volume excess, which is the
opposite condition.
5. A client with chronic kidney disease (CKD) is prescribed sevelamer (Renagel). The nurse
understands this medication is administered for which purpose?
A. To treat metabolic alkalosis
B. To decrease serum potassium levels
C. To increase hemoglobin levels
D. To lower serum phosphorus levels
Correct Answer: D
