NUR 390 Exam 1 V2 | NUR 390 Nursing Care of the
Adult I | Actual Q&A with Rationale (NUR390 Exam
1) | Concordia
1. A nurse is caring for a client who is post-operative following abdominal surgery. The client
reports a ‘popping’ sensation and the nurse notes that the wound has opened with
protrusion of internal organs. Which of the following actions should the nurse take first?
A. Cover the protruding organs with sterile dressings soaked in sterile normal saline.
B. Attempt to push the organs back into the abdominal cavity.
C. Notify the surgeon immediately and prepare for emergency surgery.
D. Place the client in a high-Fowler’s position to reduce pressure.
Correct Answer: A
Explanation: Wound evisceration is a surgical emergency that requires immediate
protection of the exposed viscera. The nurse must first cover the organs with sterile towels
or dressings moistened with sterile saline to prevent tissue desiccation and infection. The
nurse should then notify the surgeon while keeping the client in a low-Fowler’s position
with knees flexed to minimize abdominal tension. Pushing the organs back in is strictly
contraindicated as it can cause trauma or bowel perforation.
,2. A nurse is reviewing the arterial blood gas (ABG) results for a client with chronic
obstructive pulmonary disease (COPD): pH 7.30, PaCO2 55 mm Hg, HCO3 28 mEq/L. Which of
the following acid-base imbalances is the client experiencing?
A. Compensated Metabolic Acidosis
B. Uncompensated Respiratory Alkalosis
C. Partially Compensated Respiratory Acidosis
D. Fully Compensated Respiratory Acidosis
Correct Answer: C
Explanation: The pH of 7.30 indicates acidosis, and the PaCO2 of 55 mm Hg indicates that
the primary cause is respiratory. The HCO3 level of 28 mEq/L is elevated, which
demonstrates that the kidneys are attempting to compensate by retaining bicarbonate.
Because the pH is still outside the normal range (7.35-7.45), the condition is considered
partially compensated. Full compensation would be indicated only if the pH had returned
to the normal range while the PaCO2 and HCO3 remained abnormal.
3. Which of the following electrolyte imbalances would the nurse expect to find in a client
presenting with a positive Trousseau’s sign and Chvostek’s sign?
A. Hyperkalemia
B. Hypocalcemia
C. Hypernatremia
D. Hypophosphatemia
,Correct Answer: B
Explanation: Hypocalcemia increases neuromuscular excitability, which is clinically
assessed using Trousseau’s and Chvostek’s signs. Trousseau’s sign involves carpal spasms
induced by inflating a blood pressure cuff, while Chvostek’s sign is characterized by facial
twitching when the facial nerve is tapped. The nurse should prioritize monitoring the
client’s airway, as severe hypocalcemia can lead to laryngospasm. Calcium gluconate is the
typical treatment for acute symptomatic hypocalcemia.
4. Select All That Apply (SATA): A nurse is preparing to provide preoperative teaching to a
client scheduled for a total hip arthroplasty. Which of the following topics should be included
in the teaching plan to prevent postoperative complications?
A. Use of the incentive spirometer every 1-2 hours while awake.
B. Importance of early ambulation and leg exercises.
C. The need to maintain NPO status for 24 hours after surgery.
D. Pain management strategies, including the use of a PCA pump.
E. Splinting the incision with a pillow when coughing or deep breathing.
F. Applying heat packs to the surgical site to improve circulation.
Correct Answer: ABDE
Explanation: Effective preoperative teaching focuses on activities that reduce the risk of
atelectasis, pneumonia, and venous thromboembolism. Incentive spirometry, early
ambulation, and splinting are core interventions for physical recovery and respiratory
, health. Pain management education ensures the client understands how to achieve
comfort, which facilitates participation in these recovery activities. NPO status for 24 hours
post-op is not standard, and heat packs are generally avoided immediately post-surgery to
prevent vasodilation and increased bleeding.
5. A client is admitted with severe vomiting and diarrhea for the past 3 days. The nurse notes
poor skin turgor, dry mucous membranes, and a heart rate of 110 bpm. Which fluid and
electrolyte imbalance does the nurse anticipate?
A. Isotonic fluid volume excess
B. Hypermagnesemia
C. Hypovolemia (Fluid volume deficit)
D. Water intoxication
Correct Answer: C
Explanation: The clinical findings of poor skin turgor, tachycardia, and dry mucous
membranes are hallmark signs of hypovolemia or fluid volume deficit. Significant loss of
fluids through the gastrointestinal tract leads to reduced circulating volume and cellular
dehydration. The tachycardia is a compensatory mechanism by the sympathetic nervous
system to maintain cardiac output despite lower blood volume. Nursing care focuses on
fluid replacement, usually with isotonic IV fluids such as 0.9% Normal Saline or Lactated
Ringer’s.
Adult I | Actual Q&A with Rationale (NUR390 Exam
1) | Concordia
1. A nurse is caring for a client who is post-operative following abdominal surgery. The client
reports a ‘popping’ sensation and the nurse notes that the wound has opened with
protrusion of internal organs. Which of the following actions should the nurse take first?
A. Cover the protruding organs with sterile dressings soaked in sterile normal saline.
B. Attempt to push the organs back into the abdominal cavity.
C. Notify the surgeon immediately and prepare for emergency surgery.
D. Place the client in a high-Fowler’s position to reduce pressure.
Correct Answer: A
Explanation: Wound evisceration is a surgical emergency that requires immediate
protection of the exposed viscera. The nurse must first cover the organs with sterile towels
or dressings moistened with sterile saline to prevent tissue desiccation and infection. The
nurse should then notify the surgeon while keeping the client in a low-Fowler’s position
with knees flexed to minimize abdominal tension. Pushing the organs back in is strictly
contraindicated as it can cause trauma or bowel perforation.
,2. A nurse is reviewing the arterial blood gas (ABG) results for a client with chronic
obstructive pulmonary disease (COPD): pH 7.30, PaCO2 55 mm Hg, HCO3 28 mEq/L. Which of
the following acid-base imbalances is the client experiencing?
A. Compensated Metabolic Acidosis
B. Uncompensated Respiratory Alkalosis
C. Partially Compensated Respiratory Acidosis
D. Fully Compensated Respiratory Acidosis
Correct Answer: C
Explanation: The pH of 7.30 indicates acidosis, and the PaCO2 of 55 mm Hg indicates that
the primary cause is respiratory. The HCO3 level of 28 mEq/L is elevated, which
demonstrates that the kidneys are attempting to compensate by retaining bicarbonate.
Because the pH is still outside the normal range (7.35-7.45), the condition is considered
partially compensated. Full compensation would be indicated only if the pH had returned
to the normal range while the PaCO2 and HCO3 remained abnormal.
3. Which of the following electrolyte imbalances would the nurse expect to find in a client
presenting with a positive Trousseau’s sign and Chvostek’s sign?
A. Hyperkalemia
B. Hypocalcemia
C. Hypernatremia
D. Hypophosphatemia
,Correct Answer: B
Explanation: Hypocalcemia increases neuromuscular excitability, which is clinically
assessed using Trousseau’s and Chvostek’s signs. Trousseau’s sign involves carpal spasms
induced by inflating a blood pressure cuff, while Chvostek’s sign is characterized by facial
twitching when the facial nerve is tapped. The nurse should prioritize monitoring the
client’s airway, as severe hypocalcemia can lead to laryngospasm. Calcium gluconate is the
typical treatment for acute symptomatic hypocalcemia.
4. Select All That Apply (SATA): A nurse is preparing to provide preoperative teaching to a
client scheduled for a total hip arthroplasty. Which of the following topics should be included
in the teaching plan to prevent postoperative complications?
A. Use of the incentive spirometer every 1-2 hours while awake.
B. Importance of early ambulation and leg exercises.
C. The need to maintain NPO status for 24 hours after surgery.
D. Pain management strategies, including the use of a PCA pump.
E. Splinting the incision with a pillow when coughing or deep breathing.
F. Applying heat packs to the surgical site to improve circulation.
Correct Answer: ABDE
Explanation: Effective preoperative teaching focuses on activities that reduce the risk of
atelectasis, pneumonia, and venous thromboembolism. Incentive spirometry, early
ambulation, and splinting are core interventions for physical recovery and respiratory
, health. Pain management education ensures the client understands how to achieve
comfort, which facilitates participation in these recovery activities. NPO status for 24 hours
post-op is not standard, and heat packs are generally avoided immediately post-surgery to
prevent vasodilation and increased bleeding.
5. A client is admitted with severe vomiting and diarrhea for the past 3 days. The nurse notes
poor skin turgor, dry mucous membranes, and a heart rate of 110 bpm. Which fluid and
electrolyte imbalance does the nurse anticipate?
A. Isotonic fluid volume excess
B. Hypermagnesemia
C. Hypovolemia (Fluid volume deficit)
D. Water intoxication
Correct Answer: C
Explanation: The clinical findings of poor skin turgor, tachycardia, and dry mucous
membranes are hallmark signs of hypovolemia or fluid volume deficit. Significant loss of
fluids through the gastrointestinal tract leads to reduced circulating volume and cellular
dehydration. The tachycardia is a compensatory mechanism by the sympathetic nervous
system to maintain cardiac output despite lower blood volume. Nursing care focuses on
fluid replacement, usually with isotonic IV fluids such as 0.9% Normal Saline or Lactated
Ringer’s.
