PNR 201/PNR201 Exam 1 V1 | Medical-Surgical
Nursing Q&A with Rationale | Fortis College
1. A nurse is assessing a client who has been diagnosed with hypovolemia. Which of the
following clinical manifestations should the nurse expect to find?
A. Distended neck veins
B. Bradycardia
C. Increased skin turgor
D. Orthostatic hypotension
Correct Answer: D
Explanation: Hypovolemia results in a decrease in circulating blood volume, leading to
orthostatic hypotension due to inadequate perfusion when changing positions. The nurse
would also expect to see tachycardia as a compensatory mechanism to maintain cardiac
output. Decreased skin turgor and flat neck veins are other classic signs of fluid volume
deficit.
2. A client is admitted with a serum potassium level of 6.2 mEq/L. Which of the following
findings is the priority for the nurse to monitor on the EKG?
A. Prominent U waves
B. Inverted T waves
C. ST-segment depression
,D. Tall, peaked T waves
Correct Answer: D
Explanation: Hyperkalemia, defined as a potassium level above 5.0 mEq/L, significantly
affects cardiac electrical conduction. Tall, peaked T waves are one of the earliest signs of
hyperkalemia and can progress to a widened QRS complex or cardiac arrest. The nurse
must prioritize cardiac monitoring to ensure early detection of life-threatening
arrhythmias.
3. A patient is scheduled for elective surgery. The nurse notes that the patient has not signed
the informed consent form. Which action should the nurse take?
A. Explain the risks and benefits of the procedure to the patient.
B. Sign the consent form as a witness for the patient.
C. Ask the patient’s spouse to sign the consent form.
D. Notify the surgeon that the consent has not been obtained.
Correct Answer: D
Explanation: It is the surgeon’s legal responsibility to explain the procedure, risks,
benefits, and alternatives to obtain informed consent. The nurse’s role is to witness the
signature and ensure the patient understands what they are signing. If consent is missing,
the nurse must contact the surgeon to complete the process before the procedure begins.
, 4. During the intraoperative phase, the surgical team notices the patient’s heart rate and
temperature are rising rapidly, and their muscles are becoming rigid. Which medication
should the nurse prepare?
A. Naloxone
B. Atropine sulfate
C. Dantrolene sodium
D. Epinephrine
Correct Answer: C
Explanation: These symptoms are indicative of Malignant Hyperthermia, a rare but life-
threatening reaction to certain anesthetic agents. Dantrolene sodium is the specific skeletal
muscle relaxant used to treat this metabolic crisis. Immediate intervention is required,
including stopping the anesthetic agents and cooling the patient.
5. A client with metabolic acidosis is likely to demonstrate which of the following respiratory
patterns?
A. Bradypnea
B. Cheyne-Stokes respirations
C. Kussmaul’s respirations
D. Hypoventilation
Correct Answer: C
Nursing Q&A with Rationale | Fortis College
1. A nurse is assessing a client who has been diagnosed with hypovolemia. Which of the
following clinical manifestations should the nurse expect to find?
A. Distended neck veins
B. Bradycardia
C. Increased skin turgor
D. Orthostatic hypotension
Correct Answer: D
Explanation: Hypovolemia results in a decrease in circulating blood volume, leading to
orthostatic hypotension due to inadequate perfusion when changing positions. The nurse
would also expect to see tachycardia as a compensatory mechanism to maintain cardiac
output. Decreased skin turgor and flat neck veins are other classic signs of fluid volume
deficit.
2. A client is admitted with a serum potassium level of 6.2 mEq/L. Which of the following
findings is the priority for the nurse to monitor on the EKG?
A. Prominent U waves
B. Inverted T waves
C. ST-segment depression
,D. Tall, peaked T waves
Correct Answer: D
Explanation: Hyperkalemia, defined as a potassium level above 5.0 mEq/L, significantly
affects cardiac electrical conduction. Tall, peaked T waves are one of the earliest signs of
hyperkalemia and can progress to a widened QRS complex or cardiac arrest. The nurse
must prioritize cardiac monitoring to ensure early detection of life-threatening
arrhythmias.
3. A patient is scheduled for elective surgery. The nurse notes that the patient has not signed
the informed consent form. Which action should the nurse take?
A. Explain the risks and benefits of the procedure to the patient.
B. Sign the consent form as a witness for the patient.
C. Ask the patient’s spouse to sign the consent form.
D. Notify the surgeon that the consent has not been obtained.
Correct Answer: D
Explanation: It is the surgeon’s legal responsibility to explain the procedure, risks,
benefits, and alternatives to obtain informed consent. The nurse’s role is to witness the
signature and ensure the patient understands what they are signing. If consent is missing,
the nurse must contact the surgeon to complete the process before the procedure begins.
, 4. During the intraoperative phase, the surgical team notices the patient’s heart rate and
temperature are rising rapidly, and their muscles are becoming rigid. Which medication
should the nurse prepare?
A. Naloxone
B. Atropine sulfate
C. Dantrolene sodium
D. Epinephrine
Correct Answer: C
Explanation: These symptoms are indicative of Malignant Hyperthermia, a rare but life-
threatening reaction to certain anesthetic agents. Dantrolene sodium is the specific skeletal
muscle relaxant used to treat this metabolic crisis. Immediate intervention is required,
including stopping the anesthetic agents and cooling the patient.
5. A client with metabolic acidosis is likely to demonstrate which of the following respiratory
patterns?
A. Bradypnea
B. Cheyne-Stokes respirations
C. Kussmaul’s respirations
D. Hypoventilation
Correct Answer: C
