NUR 390 Exam 1 V3 | NUR 390 Nursing Care of the
Adult I | Actual Q&A with Rationale (NUR390 Exam
1) | Concordia
1. A nurse is reviewing the laboratory results of a patient with a potassium level of 6.4 mEq/L.
Which electrocardiogram change is the most critical for the nurse to monitor?
A. Presence of U waves
B. ST-segment depression
C. Tall, peaked T waves
D. Shortened QT interval
Correct Answer: C
Explanation: Hyperkalemia significantly impacts the repolarization phase of the cardiac
cycle. The emergence of tall, peaked T waves is one of the earliest signs of elevated
potassium levels. Failure to recognize this can lead to lethal dysrhythmias and cardiac
standstill.
2. The nurse is preparing a patient for surgery. Which action is the primary responsibility of
the nurse regarding informed consent?
A. Explaining the risks and benefits of the procedure
B. Obtaining the signature from the next of kin
C. Determining the patient’s surgical risk factors
,D. Witnessing the patient’s signature on the consent form
Correct Answer: D
Explanation: The surgeon is legally responsible for explaining the procedure and its
associated risks. The nurse’s role is to verify that the patient has been informed and to
witness the signing of the document. If the patient expresses confusion, the nurse must
contact the surgeon to provide further clarification.
3. A patient’s arterial blood gas (ABG) results are pH 7.30, PaCO2 52 mmHg, and HCO3 26
mEq/L. How should the nurse interpret these findings?
A. Metabolic acidosis
B. Respiratory alkalosis
C. Metabolic alkalosis
D. Respiratory acidosis
Correct Answer: D
Explanation: A pH below 7.35 indicates acidosis, while a PaCO2 above 45 mmHg indicates
a respiratory cause. Since the bicarbonate level is within the normal range, this represents
uncompensated respiratory acidosis. The nurse should focus on improving the patient’s
ventilation to blow off excess carbon dioxide.
4. Which assessment finding should the nurse prioritize in a patient experiencing acute pain?
A. Elevated heart rate and blood pressure
, B. Self-report of pain intensity
C. Non-verbal cues such as grimacing
D. Reports from family members regarding patient comfort
Correct Answer: B
Explanation: The most reliable indicator of pain is the patient’s self-report. While
physiological signs like vital sign changes occur, they are not specific to pain and can be
absent in chronic conditions. The nurse must accept the patient’s report as the gold
standard for assessment.
5. The nurse assesses a patient for signs of hypocalcemia. Which technique should the nurse
use to check for Trousseau’s sign?
A. Tapping the facial nerve in front of the ear
B. Assessing for hyperactive deep tendon reflexes
C. Palpating for muscle tenderness in the calves
D. Inflating a blood pressure cuff on the upper arm
Correct Answer: D
Explanation: Trousseau’s sign is elicited by occluding arterial blood flow to the arm for
several minutes using a blood pressure cuff. A positive result is indicated by carpal spasm
involving the hand and fingers. This sign is highly sensitive for identifying neuromuscular
irritability related to low calcium levels.
Adult I | Actual Q&A with Rationale (NUR390 Exam
1) | Concordia
1. A nurse is reviewing the laboratory results of a patient with a potassium level of 6.4 mEq/L.
Which electrocardiogram change is the most critical for the nurse to monitor?
A. Presence of U waves
B. ST-segment depression
C. Tall, peaked T waves
D. Shortened QT interval
Correct Answer: C
Explanation: Hyperkalemia significantly impacts the repolarization phase of the cardiac
cycle. The emergence of tall, peaked T waves is one of the earliest signs of elevated
potassium levels. Failure to recognize this can lead to lethal dysrhythmias and cardiac
standstill.
2. The nurse is preparing a patient for surgery. Which action is the primary responsibility of
the nurse regarding informed consent?
A. Explaining the risks and benefits of the procedure
B. Obtaining the signature from the next of kin
C. Determining the patient’s surgical risk factors
,D. Witnessing the patient’s signature on the consent form
Correct Answer: D
Explanation: The surgeon is legally responsible for explaining the procedure and its
associated risks. The nurse’s role is to verify that the patient has been informed and to
witness the signing of the document. If the patient expresses confusion, the nurse must
contact the surgeon to provide further clarification.
3. A patient’s arterial blood gas (ABG) results are pH 7.30, PaCO2 52 mmHg, and HCO3 26
mEq/L. How should the nurse interpret these findings?
A. Metabolic acidosis
B. Respiratory alkalosis
C. Metabolic alkalosis
D. Respiratory acidosis
Correct Answer: D
Explanation: A pH below 7.35 indicates acidosis, while a PaCO2 above 45 mmHg indicates
a respiratory cause. Since the bicarbonate level is within the normal range, this represents
uncompensated respiratory acidosis. The nurse should focus on improving the patient’s
ventilation to blow off excess carbon dioxide.
4. Which assessment finding should the nurse prioritize in a patient experiencing acute pain?
A. Elevated heart rate and blood pressure
, B. Self-report of pain intensity
C. Non-verbal cues such as grimacing
D. Reports from family members regarding patient comfort
Correct Answer: B
Explanation: The most reliable indicator of pain is the patient’s self-report. While
physiological signs like vital sign changes occur, they are not specific to pain and can be
absent in chronic conditions. The nurse must accept the patient’s report as the gold
standard for assessment.
5. The nurse assesses a patient for signs of hypocalcemia. Which technique should the nurse
use to check for Trousseau’s sign?
A. Tapping the facial nerve in front of the ear
B. Assessing for hyperactive deep tendon reflexes
C. Palpating for muscle tenderness in the calves
D. Inflating a blood pressure cuff on the upper arm
Correct Answer: D
Explanation: Trousseau’s sign is elicited by occluding arterial blood flow to the arm for
several minutes using a blood pressure cuff. A positive result is indicated by carpal spasm
involving the hand and fingers. This sign is highly sensitive for identifying neuromuscular
irritability related to low calcium levels.
