,Jersey College NUR 201 Exam 1 | Medical-Surgical Nursing I
(2026) Q&A
1. A nurse is assessing a client with fluid volume excess. Which clinical manifestation
should the nurse expect to observe?
A) Flat neck veins while supine
B) Increased hematocrit levels
C) Full, bounding peripheral pulses
D) Decreased blood pressure
Correct Answer: Full, bounding peripheral pulses
Rationale: Fluid volume excess leads to an increase in circulating blood volume,
which typically manifests as bounding pulses and jugular vein distension. Hematocrit
is usually decreased due to hemodilution, and blood pressure is often elevated, not
decreased.
2. A client is diagnosed with hypokalemia. Which ECG change should the nurse
monitor for?
A) Tall, peaked T waves
B) Presence of U waves
C) Shortened QT interval
D) Widened QRS complex
Correct Answer: Presence of U waves
,Rationale: Hypokalemia often causes the appearance of a U wave and a flattened or
inverted T wave on an ECG, indicating delayed ventricular repolarization. Tall, peaked
T waves are associated with hyperkalemia.
3. Which arterial blood gas (ABG) result supports a diagnosis of respiratory acidosis?
A) pH 7.30, PaCO₂ 50 mm Hg
B) pH 7.50, PaCO₂ 30 mm Hg
C) pH 7.32, HCO₃ 18 mEq/L
D) pH 7.48, HCO₃ 28 mEq/L
Correct Answer: pH 7.30, PaCO₂ 50 mm Hg
Rationale: Respiratory acidosis is characterized by a low pH (below 7.35) and an
elevated PaCO₂ (above 45 mm Hg), indicating CO₂ retention. Option C represents
metabolic acidosis with a low bicarbonate.
4. A preoperative nurse is preparing a client for surgery. What is the nurse's primary
responsibility regarding informed consent?
A) Witnessing the client's signature on the consent form
B) Obtaining the signature of the client for the surgery
C) Explaining the risks and benefits of the procedure
D) Choosing the specific surgical technique to be used
Correct Answer: Witnessing the client's signature on the consent form
Rationale: The nurse's role in informed consent is to witness the client's signature
and verify that the client appears competent to give consent. The surgeon is legally
responsible for explaining the procedure, risks, benefits, and alternatives.
, 5. During surgery, the anesthesiologist notes a sudden rise in end-tidal CO₂ and a
high temperature. Which medication should the nurse anticipate administering?
A) Atropine sulfate
B) Dantrolene sodium
C) Epinephrine
D) Naloxone
Correct Answer: Dantrolene sodium
Rationale: Malignant hyperthermia is a life-threatening complication of general
anesthesia characterized by rapid hypermetabolism, muscle rigidity, and
hyperthermia. Dantrolene sodium is the specific antidote.
6. Which finding is considered an early sign of hypoxia?
A) Cyanosis
B) Bradycardia
C) Restlessness and anxiety
D) Hypotension
Correct Answer: Restlessness and anxiety
Rationale: Restlessness and anxiety are early signs of hypoxia as the body tries to
compensate for decreased oxygen. Cyanosis is a late sign, and bradycardia and
hypotension indicate advanced hypoxia.
7. A patient has a prolonged clotting time. Which vitamin deficiency is most likely
contributing to this finding?
(2026) Q&A
1. A nurse is assessing a client with fluid volume excess. Which clinical manifestation
should the nurse expect to observe?
A) Flat neck veins while supine
B) Increased hematocrit levels
C) Full, bounding peripheral pulses
D) Decreased blood pressure
Correct Answer: Full, bounding peripheral pulses
Rationale: Fluid volume excess leads to an increase in circulating blood volume,
which typically manifests as bounding pulses and jugular vein distension. Hematocrit
is usually decreased due to hemodilution, and blood pressure is often elevated, not
decreased.
2. A client is diagnosed with hypokalemia. Which ECG change should the nurse
monitor for?
A) Tall, peaked T waves
B) Presence of U waves
C) Shortened QT interval
D) Widened QRS complex
Correct Answer: Presence of U waves
,Rationale: Hypokalemia often causes the appearance of a U wave and a flattened or
inverted T wave on an ECG, indicating delayed ventricular repolarization. Tall, peaked
T waves are associated with hyperkalemia.
3. Which arterial blood gas (ABG) result supports a diagnosis of respiratory acidosis?
A) pH 7.30, PaCO₂ 50 mm Hg
B) pH 7.50, PaCO₂ 30 mm Hg
C) pH 7.32, HCO₃ 18 mEq/L
D) pH 7.48, HCO₃ 28 mEq/L
Correct Answer: pH 7.30, PaCO₂ 50 mm Hg
Rationale: Respiratory acidosis is characterized by a low pH (below 7.35) and an
elevated PaCO₂ (above 45 mm Hg), indicating CO₂ retention. Option C represents
metabolic acidosis with a low bicarbonate.
4. A preoperative nurse is preparing a client for surgery. What is the nurse's primary
responsibility regarding informed consent?
A) Witnessing the client's signature on the consent form
B) Obtaining the signature of the client for the surgery
C) Explaining the risks and benefits of the procedure
D) Choosing the specific surgical technique to be used
Correct Answer: Witnessing the client's signature on the consent form
Rationale: The nurse's role in informed consent is to witness the client's signature
and verify that the client appears competent to give consent. The surgeon is legally
responsible for explaining the procedure, risks, benefits, and alternatives.
, 5. During surgery, the anesthesiologist notes a sudden rise in end-tidal CO₂ and a
high temperature. Which medication should the nurse anticipate administering?
A) Atropine sulfate
B) Dantrolene sodium
C) Epinephrine
D) Naloxone
Correct Answer: Dantrolene sodium
Rationale: Malignant hyperthermia is a life-threatening complication of general
anesthesia characterized by rapid hypermetabolism, muscle rigidity, and
hyperthermia. Dantrolene sodium is the specific antidote.
6. Which finding is considered an early sign of hypoxia?
A) Cyanosis
B) Bradycardia
C) Restlessness and anxiety
D) Hypotension
Correct Answer: Restlessness and anxiety
Rationale: Restlessness and anxiety are early signs of hypoxia as the body tries to
compensate for decreased oxygen. Cyanosis is a late sign, and bradycardia and
hypotension indicate advanced hypoxia.
7. A patient has a prolonged clotting time. Which vitamin deficiency is most likely
contributing to this finding?
