NRSG 201 Exam 1 V2 | NRSG 201 Med Surg 1 |
Actual Q&A with Rationale (NRSG201 Exam 1) | Ivy
Tech
1. A nurse is caring for a client with a serum potassium level of 6.2 mEq/L. Which of the
following interventions is the priority?
A. Obtaining a 12-lead electrocardiogram (ECG) immediately
B. Administering a dose of potassium-sparing diuretics
C. Encouraging the intake of bananas and orange juice
D. Checking the patient’s blood pressure and pulse
Correct Answer: A
Explanation: Hyperkalemia is a medical emergency that can lead to life-threatening
cardiac dysrhythmias. An ECG is the priority to assess for changes such as peaked T waves
or widened QRS complexes. The nurse must identify cardiac instability before
implementing other treatments like Kayexalate or insulin/dextrose infusions.
2. A client presents to the emergency department with a pH of 7.32, PaCO2 of 52 mmHg, and
HCO3 of 24 mEq/L. The nurse interprets these results as:
A. Uncompensated metabolic acidosis
B. Fully compensated metabolic alkalosis
C. Partially compensated respiratory acidosis
,D. Uncompensated respiratory acidosis
Correct Answer: D
Explanation: The pH is below 7.35, indicating acidosis, while the PaCO2 is elevated above
45 mmHg, indicating a respiratory cause. Since the HCO3 is within the normal range (22-26
mEq/L), no compensation is occurring. This combination defines an uncompensated
respiratory acidosis state, often caused by hypoventilation.
3. Which clinical manifestation would the nurse expect to find in a client experiencing
hypocalcemia?
A. Diminished deep tendon reflexes
B. Polyuria and extreme thirst
C. Positive Trousseau’s and Chvostek’s signs
D. Constipation and muscle weakness
Correct Answer: C
Explanation: Hypocalcemia increases neuromuscular excitability, leading to muscle
twitching and spasms. Trousseau’s sign involves carpal spasm induced by inflating a blood
pressure cuff, while Chvostek’s sign is a facial twitch when tapping the facial nerve. These
findings are classic indicators of low serum calcium levels and require prompt monitoring
for laryngeal spasms.
, 4. During the preoperative assessment, a client reports an allergy to avocados and bananas.
For which complication is this client at increased risk?
A. Malignant hyperthermia
B. Postoperative nausea and vomiting
C. Latex sensitivity or allergy
D. Severe reaction to general anesthesia
Correct Answer: C
Explanation: There is a known cross-reactivity between certain foods like avocados,
bananas, and chestnuts and latex. Clients with these food allergies are at a significantly
higher risk for developing a latex allergy during surgical procedures. The nurse must
document this clearly and ensure a latex-free environment is maintained for the client’s
safety.
5. A postoperative client has not voided for 8 hours since returning to the surgical unit. What
is the nurse’s first action?
A. Insert a straight catheter immediately
B. Perform a bladder scan at the bedside
C. Notify the surgeon regarding potential renal failure
D. Increase the IV fluid rate to stimulate production
Correct Answer: B
Actual Q&A with Rationale (NRSG201 Exam 1) | Ivy
Tech
1. A nurse is caring for a client with a serum potassium level of 6.2 mEq/L. Which of the
following interventions is the priority?
A. Obtaining a 12-lead electrocardiogram (ECG) immediately
B. Administering a dose of potassium-sparing diuretics
C. Encouraging the intake of bananas and orange juice
D. Checking the patient’s blood pressure and pulse
Correct Answer: A
Explanation: Hyperkalemia is a medical emergency that can lead to life-threatening
cardiac dysrhythmias. An ECG is the priority to assess for changes such as peaked T waves
or widened QRS complexes. The nurse must identify cardiac instability before
implementing other treatments like Kayexalate or insulin/dextrose infusions.
2. A client presents to the emergency department with a pH of 7.32, PaCO2 of 52 mmHg, and
HCO3 of 24 mEq/L. The nurse interprets these results as:
A. Uncompensated metabolic acidosis
B. Fully compensated metabolic alkalosis
C. Partially compensated respiratory acidosis
,D. Uncompensated respiratory acidosis
Correct Answer: D
Explanation: The pH is below 7.35, indicating acidosis, while the PaCO2 is elevated above
45 mmHg, indicating a respiratory cause. Since the HCO3 is within the normal range (22-26
mEq/L), no compensation is occurring. This combination defines an uncompensated
respiratory acidosis state, often caused by hypoventilation.
3. Which clinical manifestation would the nurse expect to find in a client experiencing
hypocalcemia?
A. Diminished deep tendon reflexes
B. Polyuria and extreme thirst
C. Positive Trousseau’s and Chvostek’s signs
D. Constipation and muscle weakness
Correct Answer: C
Explanation: Hypocalcemia increases neuromuscular excitability, leading to muscle
twitching and spasms. Trousseau’s sign involves carpal spasm induced by inflating a blood
pressure cuff, while Chvostek’s sign is a facial twitch when tapping the facial nerve. These
findings are classic indicators of low serum calcium levels and require prompt monitoring
for laryngeal spasms.
, 4. During the preoperative assessment, a client reports an allergy to avocados and bananas.
For which complication is this client at increased risk?
A. Malignant hyperthermia
B. Postoperative nausea and vomiting
C. Latex sensitivity or allergy
D. Severe reaction to general anesthesia
Correct Answer: C
Explanation: There is a known cross-reactivity between certain foods like avocados,
bananas, and chestnuts and latex. Clients with these food allergies are at a significantly
higher risk for developing a latex allergy during surgical procedures. The nurse must
document this clearly and ensure a latex-free environment is maintained for the client’s
safety.
5. A postoperative client has not voided for 8 hours since returning to the surgical unit. What
is the nurse’s first action?
A. Insert a straight catheter immediately
B. Perform a bladder scan at the bedside
C. Notify the surgeon regarding potential renal failure
D. Increase the IV fluid rate to stimulate production
Correct Answer: B
