NRSG 201 Final Exam V3 | NRSG 201 Med Surg 1 |
Actual Q&A with Rationale (NRSG201 Final Exam) |
Ivy Tech
1. A nurse is caring for a patient with a potassium level of 2.8 mEq/L. Which clinical
manifestation should the nurse prioritize for assessment?
A. Hyperactive bowel sounds
B. Muscle weakness and cardiac arrhythmias
C. Peaked T waves on ECG
D. Increased muscle tone
Correct Answer: B
Explanation: Hypokalemia is defined as a serum potassium level below 3.5 mEq/L and
significantly affects neuromuscular and cardiac function. Muscle weakness and lethal
cardiac arrhythmias are primary concerns because potassium is essential for maintaining
the resting membrane potential. The nurse must monitor the patient’s heart rhythm and
respiratory status closely to prevent life-threatening complications.
2. When preparing a patient for surgery, the nurse notes the patient is unclear about the risks
of the procedure. What is the most appropriate nursing action?
A. Explain the risks to the patient in detail
B. Proceed with the preoperative checklist
,C. Ask the family to explain the risks to the patient
D. Notify the surgeon that the patient needs further clarification
Correct Answer: D
Explanation: It is the surgeon’s legal responsibility to provide the patient with a detailed
explanation of the risks, benefits, and alternatives of the surgery. The nurse acts as a
witness to the signature and ensures the patient is competent, but cannot provide the
initial informed consent explanation. If the patient expresses confusion, the nurse must
intervene by contacting the surgeon to ensure the patient is fully informed.
3. A patient exhibits Trousseau’s sign and Chvostek’s sign. The nurse expects which
electrolyte imbalance?
A. Hypernatremia
B. Hypocalcemia
C. Hypokalemia
D. Hypermagnesemia
Correct Answer: B
Explanation: Positive Chvostek’s and Trousseau’s signs are classic clinical indicators of
hypocalcemia, which increases neuromuscular irritability. Trousseau’s sign is
characterized by carpal spasms induced by inflating a blood pressure cuff, while Chvostek’s
sign involves facial twitching when the facial nerve is tapped. The nurse should assess for
, these signs in patients at risk, such as those who have undergone thyroid or parathyroid
surgery.
4. Which arterial blood gas (ABG) result is consistent with a patient experiencing metabolic
acidosis?
A. pH 7.48, PaCO2 30, HCO3 24
B. pH 7.28, PaCO2 38, HCO3 18
C. pH 7.35, PaCO2 40, HCO3 22
D. pH 7.50, PaCO2 50, HCO3 30
Correct Answer: B
Explanation: Metabolic acidosis is characterized by a low pH (less than 7.35) and a low
bicarbonate (HCO3) level (less than 22 mEq/L). In this option, the pH of 7.28 and HCO3 of
18 indicate an acidic state caused by a metabolic deficit. The PaCO2 remains near the
normal range, indicating the primary problem is not respiratory in origin.
5. A nurse is assessing a postoperative patient who has become restless and confused. What
is the priority nursing intervention?
A. Administer prescribed PRN pain medication
B. Restrain the patient to prevent injury
C. Document the findings in the medical record
D. Check the patient’s oxygen saturation
Actual Q&A with Rationale (NRSG201 Final Exam) |
Ivy Tech
1. A nurse is caring for a patient with a potassium level of 2.8 mEq/L. Which clinical
manifestation should the nurse prioritize for assessment?
A. Hyperactive bowel sounds
B. Muscle weakness and cardiac arrhythmias
C. Peaked T waves on ECG
D. Increased muscle tone
Correct Answer: B
Explanation: Hypokalemia is defined as a serum potassium level below 3.5 mEq/L and
significantly affects neuromuscular and cardiac function. Muscle weakness and lethal
cardiac arrhythmias are primary concerns because potassium is essential for maintaining
the resting membrane potential. The nurse must monitor the patient’s heart rhythm and
respiratory status closely to prevent life-threatening complications.
2. When preparing a patient for surgery, the nurse notes the patient is unclear about the risks
of the procedure. What is the most appropriate nursing action?
A. Explain the risks to the patient in detail
B. Proceed with the preoperative checklist
,C. Ask the family to explain the risks to the patient
D. Notify the surgeon that the patient needs further clarification
Correct Answer: D
Explanation: It is the surgeon’s legal responsibility to provide the patient with a detailed
explanation of the risks, benefits, and alternatives of the surgery. The nurse acts as a
witness to the signature and ensures the patient is competent, but cannot provide the
initial informed consent explanation. If the patient expresses confusion, the nurse must
intervene by contacting the surgeon to ensure the patient is fully informed.
3. A patient exhibits Trousseau’s sign and Chvostek’s sign. The nurse expects which
electrolyte imbalance?
A. Hypernatremia
B. Hypocalcemia
C. Hypokalemia
D. Hypermagnesemia
Correct Answer: B
Explanation: Positive Chvostek’s and Trousseau’s signs are classic clinical indicators of
hypocalcemia, which increases neuromuscular irritability. Trousseau’s sign is
characterized by carpal spasms induced by inflating a blood pressure cuff, while Chvostek’s
sign involves facial twitching when the facial nerve is tapped. The nurse should assess for
, these signs in patients at risk, such as those who have undergone thyroid or parathyroid
surgery.
4. Which arterial blood gas (ABG) result is consistent with a patient experiencing metabolic
acidosis?
A. pH 7.48, PaCO2 30, HCO3 24
B. pH 7.28, PaCO2 38, HCO3 18
C. pH 7.35, PaCO2 40, HCO3 22
D. pH 7.50, PaCO2 50, HCO3 30
Correct Answer: B
Explanation: Metabolic acidosis is characterized by a low pH (less than 7.35) and a low
bicarbonate (HCO3) level (less than 22 mEq/L). In this option, the pH of 7.28 and HCO3 of
18 indicate an acidic state caused by a metabolic deficit. The PaCO2 remains near the
normal range, indicating the primary problem is not respiratory in origin.
5. A nurse is assessing a postoperative patient who has become restless and confused. What
is the priority nursing intervention?
A. Administer prescribed PRN pain medication
B. Restrain the patient to prevent injury
C. Document the findings in the medical record
D. Check the patient’s oxygen saturation
