NRSG 201 Exam 1 V3 | NRSG 201 Med Surg 1 |
Actual Q&A with Rationale (NRSG201 Exam 1) | Ivy
Tech
1. A nurse is assessing a patient with fluid volume excess. Which clinical manifestation should
the nurse expect to find?
A. Bounding peripheral pulses
B. Flat neck veins when supine
C. Weak, thready pulse
D. Increased serum osmolarity
Correct Answer: A
Explanation: Fluid volume excess leads to an increased vascular volume which results in a
bounding pulse. The nurse should also look for signs such as peripheral edema and jugular
venous distention. Monitoring the patient for crackles in the lungs is a priority to detect
pulmonary edema early.
2. A patient is admitted with a serum potassium level of 6.2 mEq/L. Which intervention is the
nurse’s priority?
A. Administer a potassium-sparing diuretic
B. Obtain a prescription for a low-sodium diet
C. Encourage the intake of orange juice
,D. Place the patient on a cardiac monitor
Correct Answer: D
Explanation: Hyperkalemia poses a significant risk for life-threatening cardiac
arrhythmias. Placing the patient on a cardiac monitor allows the nurse to detect early
changes such as peaked T waves. The nurse must also prepare to administer medications
like sodium polystyrene sulfonate or insulin with dextrose to lower potassium levels.
3. Which assessment finding is most characteristic of hypocalcemia?
A. Diminished deep tendon reflexes
B. Constipation and lethargy
C. Positive Chvostek’s sign
D. Shortened QT interval on ECG
Correct Answer: C
Explanation: Hypocalcemia increases neuromuscular excitability, leading to signs like
Chvostek’s and Trousseau’s signs. A positive Chvostek’s sign is elicited by tapping the facial
nerve, causing a twitch. The nurse should monitor for laryngospasm and seizures as these
are severe complications of low calcium.
4. A patient’s arterial blood gas (ABG) results are: pH 7.31, PaCO2 50 mmHg, and HCO3 24
mEq/L. How should the nurse interpret these results?
A. Metabolic Acidosis
, B. Metabolic Alkalosis
C. Respiratory Alkalosis
D. Respiratory Acidosis
Correct Answer: D
Explanation: The pH is below 7.35, indicating acidosis, and the PaCO2 is elevated above 45
mmHg, indicating a respiratory cause. Since the bicarbonate level is within the normal
range, this represents uncompensated respiratory acidosis. This condition is often seen in
patients with hypoventilation or chronic obstructive pulmonary disease.
5. The nurse is preparing a patient for surgery. Which action is the nurse’s responsibility
regarding informed consent?
A. Explaining the risks and benefits of the procedure
B. Describing alternative treatments to the patient
C. Witnessing the patient’s signature on the consent form
D. Obtaining consent from a family member if the patient is anxious
Correct Answer: C
Explanation: The surgeon is legally responsible for explaining the procedure and its risks
to the patient. The nurse’s role is to witness the signature and ensure the patient is
competent to sign. If the patient expresses a lack of understanding, the nurse must notify
the surgeon to return and provide further clarification.
Actual Q&A with Rationale (NRSG201 Exam 1) | Ivy
Tech
1. A nurse is assessing a patient with fluid volume excess. Which clinical manifestation should
the nurse expect to find?
A. Bounding peripheral pulses
B. Flat neck veins when supine
C. Weak, thready pulse
D. Increased serum osmolarity
Correct Answer: A
Explanation: Fluid volume excess leads to an increased vascular volume which results in a
bounding pulse. The nurse should also look for signs such as peripheral edema and jugular
venous distention. Monitoring the patient for crackles in the lungs is a priority to detect
pulmonary edema early.
2. A patient is admitted with a serum potassium level of 6.2 mEq/L. Which intervention is the
nurse’s priority?
A. Administer a potassium-sparing diuretic
B. Obtain a prescription for a low-sodium diet
C. Encourage the intake of orange juice
,D. Place the patient on a cardiac monitor
Correct Answer: D
Explanation: Hyperkalemia poses a significant risk for life-threatening cardiac
arrhythmias. Placing the patient on a cardiac monitor allows the nurse to detect early
changes such as peaked T waves. The nurse must also prepare to administer medications
like sodium polystyrene sulfonate or insulin with dextrose to lower potassium levels.
3. Which assessment finding is most characteristic of hypocalcemia?
A. Diminished deep tendon reflexes
B. Constipation and lethargy
C. Positive Chvostek’s sign
D. Shortened QT interval on ECG
Correct Answer: C
Explanation: Hypocalcemia increases neuromuscular excitability, leading to signs like
Chvostek’s and Trousseau’s signs. A positive Chvostek’s sign is elicited by tapping the facial
nerve, causing a twitch. The nurse should monitor for laryngospasm and seizures as these
are severe complications of low calcium.
4. A patient’s arterial blood gas (ABG) results are: pH 7.31, PaCO2 50 mmHg, and HCO3 24
mEq/L. How should the nurse interpret these results?
A. Metabolic Acidosis
, B. Metabolic Alkalosis
C. Respiratory Alkalosis
D. Respiratory Acidosis
Correct Answer: D
Explanation: The pH is below 7.35, indicating acidosis, and the PaCO2 is elevated above 45
mmHg, indicating a respiratory cause. Since the bicarbonate level is within the normal
range, this represents uncompensated respiratory acidosis. This condition is often seen in
patients with hypoventilation or chronic obstructive pulmonary disease.
5. The nurse is preparing a patient for surgery. Which action is the nurse’s responsibility
regarding informed consent?
A. Explaining the risks and benefits of the procedure
B. Describing alternative treatments to the patient
C. Witnessing the patient’s signature on the consent form
D. Obtaining consent from a family member if the patient is anxious
Correct Answer: C
Explanation: The surgeon is legally responsible for explaining the procedure and its risks
to the patient. The nurse’s role is to witness the signature and ensure the patient is
competent to sign. If the patient expresses a lack of understanding, the nurse must notify
the surgeon to return and provide further clarification.
