PNR 201/PNR201 Exam 1 V3 | Medical-Surgical
Nursing Q&A with Rationale | Fortis College
1. A nurse is assessing a patient with a fluid volume excess. Which of the following clinical
manifestations should the nurse expect to find?
A. Tachycardia and weak pulses
B. Decreased skin turgor and dry mucous membranes
C. Distended neck veins and crackles
D. Orthostatic hypotension
Correct Answer: C
Explanation: Fluid volume excess results in an overhydration of the vascular and
interstitial spaces, leading to increased venous pressure and pulmonary congestion.
Distended neck veins occur because the heart cannot effectively pump the extra volume,
while crackles indicate fluid in the alveolar spaces. The nurse must prioritize monitoring
respiratory status to prevent complications like pulmonary edema.
2. A patient is diagnosed with hypokalemia. Which of the following assessment findings is
most consistent with this electrolyte imbalance?
A. Hyperactive bowel sounds
B. Positive Trousseau’s sign
C. Peaked T waves on ECG
,D. Muscle weakness and leg cramps
Correct Answer: D
Explanation: Potassium is essential for muscle contraction and nerve conduction, and low
levels often lead to muscle fatigue and cramping. Patients with hypokalemia typically
present with sluggish bowel sounds and potentially dangerous cardiac arrhythmias. The
nurse should advocate for potassium supplementation and continuous cardiac monitoring
to ensure patient safety.
3. The nurse is caring for a patient who has been vomiting for 24 hours. Which acid-base
imbalance is the patient at greatest risk for developing?
A. Metabolic alkalosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Respiratory acidosis
Correct Answer: A
Explanation: Gastric secretions are highly acidic, and losing them through vomiting leads
to an excess of bicarbonate in the blood. This shift in pH results in metabolic alkalosis as
the body loses hydrochloric acid. The nurse should monitor the patient’s electrolyte levels
and prepare to administer intravenous fluids to restore balance.
, 4. Before a patient undergoes a surgical procedure, the nurse must ensure that the informed
consent is signed. What is the primary role of the nurse in this process?
A. Explaining the risks and benefits of the surgery
B. Witnessing the patient’s signature on the consent form
C. Determining the patient’s surgical competence
D. Obtaining the medical history for the surgeon
Correct Answer: B
Explanation: The nurse serves as a witness to ensure that the patient is signing the
document voluntarily and appears to be competent. It is the surgeon’s responsibility to
explain the actual procedure, risks, and alternatives to the patient. If the patient expresses
confusion, the nurse must notify the surgeon to provide further clarification before the
procedure proceeds.
5. Which of the following is an early sign of malignant hyperthermia during general
anesthesia?
A. Muscle rigidity
B. Bradycardia
C. Hypothermia
D. Decrease in end-tidal carbon dioxide
Correct Answer: A
Nursing Q&A with Rationale | Fortis College
1. A nurse is assessing a patient with a fluid volume excess. Which of the following clinical
manifestations should the nurse expect to find?
A. Tachycardia and weak pulses
B. Decreased skin turgor and dry mucous membranes
C. Distended neck veins and crackles
D. Orthostatic hypotension
Correct Answer: C
Explanation: Fluid volume excess results in an overhydration of the vascular and
interstitial spaces, leading to increased venous pressure and pulmonary congestion.
Distended neck veins occur because the heart cannot effectively pump the extra volume,
while crackles indicate fluid in the alveolar spaces. The nurse must prioritize monitoring
respiratory status to prevent complications like pulmonary edema.
2. A patient is diagnosed with hypokalemia. Which of the following assessment findings is
most consistent with this electrolyte imbalance?
A. Hyperactive bowel sounds
B. Positive Trousseau’s sign
C. Peaked T waves on ECG
,D. Muscle weakness and leg cramps
Correct Answer: D
Explanation: Potassium is essential for muscle contraction and nerve conduction, and low
levels often lead to muscle fatigue and cramping. Patients with hypokalemia typically
present with sluggish bowel sounds and potentially dangerous cardiac arrhythmias. The
nurse should advocate for potassium supplementation and continuous cardiac monitoring
to ensure patient safety.
3. The nurse is caring for a patient who has been vomiting for 24 hours. Which acid-base
imbalance is the patient at greatest risk for developing?
A. Metabolic alkalosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Respiratory acidosis
Correct Answer: A
Explanation: Gastric secretions are highly acidic, and losing them through vomiting leads
to an excess of bicarbonate in the blood. This shift in pH results in metabolic alkalosis as
the body loses hydrochloric acid. The nurse should monitor the patient’s electrolyte levels
and prepare to administer intravenous fluids to restore balance.
, 4. Before a patient undergoes a surgical procedure, the nurse must ensure that the informed
consent is signed. What is the primary role of the nurse in this process?
A. Explaining the risks and benefits of the surgery
B. Witnessing the patient’s signature on the consent form
C. Determining the patient’s surgical competence
D. Obtaining the medical history for the surgeon
Correct Answer: B
Explanation: The nurse serves as a witness to ensure that the patient is signing the
document voluntarily and appears to be competent. It is the surgeon’s responsibility to
explain the actual procedure, risks, and alternatives to the patient. If the patient expresses
confusion, the nurse must notify the surgeon to provide further clarification before the
procedure proceeds.
5. Which of the following is an early sign of malignant hyperthermia during general
anesthesia?
A. Muscle rigidity
B. Bradycardia
C. Hypothermia
D. Decrease in end-tidal carbon dioxide
Correct Answer: A
