PNR 201/PNR201 Exam 2 V2 | Medical-Surgical
Nursing Q&A with Rationale | Fortis College
1. A nurse is assessing a patient with a suspected fluid volume deficit. Which of the following
clinical manifestations should the nurse expect to find?
A. Distended neck veins
B. Dependent edema
C. Increased central venous pressure
D. Orthostatic hypotension
Correct Answer: D
Explanation: Orthostatic hypotension is a classic sign of fluid volume deficit due to
decreased circulating blood volume. Patients often experience a significant drop in blood
pressure when moving from a lying to a standing position. Other signs include poor skin
turgor and dry mucous membranes.
2. When interpreting arterial blood gas (ABG) results, the nurse notes a pH of 7.30, a PaCO2
of 52 mmHg, and an HCO3 of 24 mEq/L. Which imbalance does this represent?
A. Metabolic acidosis
B. Respiratory alkalosis
C. Metabolic alkalosis
D. Respiratory acidosis
,Correct Answer: D
Explanation: A pH below 7.35 indicates acidosis, and a PaCO2 above 45 mmHg indicates a
respiratory cause. Because the bicarbonate level is normal, this is uncompensated
respiratory acidosis. This condition often results from hypoventilation or obstructive lung
diseases.
3. A patient with heart failure is prescribed furosemide. Which electrolyte imbalance is the
patient at greatest risk for developing?
A. Hypokalemia
B. Hypocalcemia
C. Hypernatremia
D. Hyperkalemia
Correct Answer: A
Explanation: Furosemide is a loop diuretic that promotes the excretion of water, sodium,
and potassium. The nurse must monitor for hypokalemia, which can lead to life-threatening
cardiac arrhythmias. Patients are often encouraged to consume potassium-rich foods while
on this medication.
4. A nurse is caring for a patient who has developed Chvostek’s sign. This finding is associated
with which electrolyte abnormality?
A. Hypokalemia
B. Hypermagnesemia
, C. Hypocalcemia
D. Hypernatremia
Correct Answer: C
Explanation: Chvostek’s sign is an abnormal spasm of the facial muscles elicited by
tapping the facial nerve. It is a clinical indicator of hypocalcemia, which increases
neuromuscular excitability. Trousseau’s sign is another common indicator used to assess
for this specific deficiency.
5. Which of the following instructions should a nurse include when teaching a patient about
using a metered-dose inhaler (MDI)?
A. Exhale quickly immediately after inhalation
B. Wait at least 1 minute between puffs of the same medication
C. Inhale as quickly and forcefully as possible
D. Breathe out slowly through the nose during administration
Correct Answer: B
Explanation: Waiting approximately 1 minute between puffs allows the medication to
reach deeper into the bronchial tree. This delay ensures that the first dose has time to
begin bronchodilation before the second dose is administered. Patients should also be
taught to hold their breath for 10 seconds after inhalation.
Nursing Q&A with Rationale | Fortis College
1. A nurse is assessing a patient with a suspected fluid volume deficit. Which of the following
clinical manifestations should the nurse expect to find?
A. Distended neck veins
B. Dependent edema
C. Increased central venous pressure
D. Orthostatic hypotension
Correct Answer: D
Explanation: Orthostatic hypotension is a classic sign of fluid volume deficit due to
decreased circulating blood volume. Patients often experience a significant drop in blood
pressure when moving from a lying to a standing position. Other signs include poor skin
turgor and dry mucous membranes.
2. When interpreting arterial blood gas (ABG) results, the nurse notes a pH of 7.30, a PaCO2
of 52 mmHg, and an HCO3 of 24 mEq/L. Which imbalance does this represent?
A. Metabolic acidosis
B. Respiratory alkalosis
C. Metabolic alkalosis
D. Respiratory acidosis
,Correct Answer: D
Explanation: A pH below 7.35 indicates acidosis, and a PaCO2 above 45 mmHg indicates a
respiratory cause. Because the bicarbonate level is normal, this is uncompensated
respiratory acidosis. This condition often results from hypoventilation or obstructive lung
diseases.
3. A patient with heart failure is prescribed furosemide. Which electrolyte imbalance is the
patient at greatest risk for developing?
A. Hypokalemia
B. Hypocalcemia
C. Hypernatremia
D. Hyperkalemia
Correct Answer: A
Explanation: Furosemide is a loop diuretic that promotes the excretion of water, sodium,
and potassium. The nurse must monitor for hypokalemia, which can lead to life-threatening
cardiac arrhythmias. Patients are often encouraged to consume potassium-rich foods while
on this medication.
4. A nurse is caring for a patient who has developed Chvostek’s sign. This finding is associated
with which electrolyte abnormality?
A. Hypokalemia
B. Hypermagnesemia
, C. Hypocalcemia
D. Hypernatremia
Correct Answer: C
Explanation: Chvostek’s sign is an abnormal spasm of the facial muscles elicited by
tapping the facial nerve. It is a clinical indicator of hypocalcemia, which increases
neuromuscular excitability. Trousseau’s sign is another common indicator used to assess
for this specific deficiency.
5. Which of the following instructions should a nurse include when teaching a patient about
using a metered-dose inhaler (MDI)?
A. Exhale quickly immediately after inhalation
B. Wait at least 1 minute between puffs of the same medication
C. Inhale as quickly and forcefully as possible
D. Breathe out slowly through the nose during administration
Correct Answer: B
Explanation: Waiting approximately 1 minute between puffs allows the medication to
reach deeper into the bronchial tree. This delay ensures that the first dose has time to
begin bronchodilation before the second dose is administered. Patients should also be
taught to hold their breath for 10 seconds after inhalation.
