NUR 425 Exam 3: Medical Surgical V2 - Arizona College
Updated and Latest Questions and Correct Answers with
Rationale
1. A patient’s arterial blood gas (ABG) results show pH 7.30, PaCO2 52 mmHg, and HCO3 24 mEq/L. Which
acid-base imbalance is the patient experiencing?
A. Respiratory Acidosis
B. Metabolic Acidosis
C. Metabolic Alkalosis
D. Respiratory Alkalosis
Ans: A
Explanation: Respiratory acidosis is identified by a low pH combined with an elevated PaCO2 level. This
condition typically occurs when the lungs are unable to remove enough carbon dioxide produced by the
body. The nurse should assess the patient for signs of hypoventilation or underlying airway obstruction.
Interventions are primarily focused on improving alveolar ventilation and addressing the root cause of
the respiratory failure. Ongoing monitoring of the patient’s respiratory status and repeat ABGs are
necessary to evaluate treatment effectiveness.
2. Which clinical manifestation should a nurse expect to find in a patient diagnosed with right-sided heart
failure?
A. Crackles in the lungs
B. Dyspnea on exertion
C. Peripheral edema
D. Orthopnea
,Ans: C
Explanation: Right-sided heart failure leads to systemic venous congestion because the right ventricle
cannot pump blood efficiently. This congestion results in fluid backing up into the systemic circulation,
causing edema in the lower extremities. The nurse may also observe jugular venous distension and
hepatomegaly during the physical assessment. Monitoring daily weights is a critical nursing intervention
to track fluid retention and the effectiveness of diuretic therapy. Providing patient education on sodium
restriction can help manage the clinical symptoms of this condition.
3. A nurse is caring for a post-operative patient who suddenly reports sharp chest pain and shortness of
breath. Which complication should be suspected first?
A. Atelectasis
B. Myocardial Infarction
C. Pulmonary Embolism
D. Pneumonia
Ans: C
Explanation: A pulmonary embolism is a life-threatening complication that often presents with sudden
onset chest pain and dyspnea. Post-operative patients are at high risk due to immobility and potential
venous stasis leading to deep vein thrombosis. The nurse should immediately assess the patient’s oxygen
saturation and notify the rapid response team. Providing supplemental oxygen and maintaining the
patient on bed rest are essential initial steps. Diagnostic testing such as a CT pulmonary angiogram is
typically required to confirm the presence of a clot.
4. Which electrolyte imbalance is most likely to cause the presence of U-waves on an electrocardiogram
(ECG)?
A. Hyperkalemia
, B. Hypercalcemia
C. Hypokalemia
D. Hyponatremia
Ans: C
Explanation: Hypokalemia is characterized by a serum potassium level below the normal range of 3.5 to
5.0 mEq/L. Low potassium levels can significantly affect cardiac conduction, leading to the appearance of
U-waves on the ECG. The nurse should monitor the patient for muscle weakness and cardiac
dysrhythmias which are common in this state. Potassium replacement therapy should be administered
carefully via oral or intravenous routes as prescribed. Educating the patient on potassium-rich foods like
bananas and potatoes can prevent future occurrences of this imbalance.
5. A patient is receiving a blood transfusion and begins to experience chills, fever, and lower back pain.
What is the nurse’s priority action?
A. Slow the infusion rate
B. Stop the transfusion immediately
C. Administer diphenhydramine
D. Check the patient’s temperature
Ans: B
Explanation: The presence of fever, chills, and back pain during a transfusion suggests an acute
hemolytic reaction. The nurse must stop the transfusion immediately to prevent further administration
of incompatible blood. After stopping the blood, the nurse should maintain the IV line with normal saline
using new tubing. Notifying the physician and the blood bank is necessary to initiate the transfusion
Updated and Latest Questions and Correct Answers with
Rationale
1. A patient’s arterial blood gas (ABG) results show pH 7.30, PaCO2 52 mmHg, and HCO3 24 mEq/L. Which
acid-base imbalance is the patient experiencing?
A. Respiratory Acidosis
B. Metabolic Acidosis
C. Metabolic Alkalosis
D. Respiratory Alkalosis
Ans: A
Explanation: Respiratory acidosis is identified by a low pH combined with an elevated PaCO2 level. This
condition typically occurs when the lungs are unable to remove enough carbon dioxide produced by the
body. The nurse should assess the patient for signs of hypoventilation or underlying airway obstruction.
Interventions are primarily focused on improving alveolar ventilation and addressing the root cause of
the respiratory failure. Ongoing monitoring of the patient’s respiratory status and repeat ABGs are
necessary to evaluate treatment effectiveness.
2. Which clinical manifestation should a nurse expect to find in a patient diagnosed with right-sided heart
failure?
A. Crackles in the lungs
B. Dyspnea on exertion
C. Peripheral edema
D. Orthopnea
,Ans: C
Explanation: Right-sided heart failure leads to systemic venous congestion because the right ventricle
cannot pump blood efficiently. This congestion results in fluid backing up into the systemic circulation,
causing edema in the lower extremities. The nurse may also observe jugular venous distension and
hepatomegaly during the physical assessment. Monitoring daily weights is a critical nursing intervention
to track fluid retention and the effectiveness of diuretic therapy. Providing patient education on sodium
restriction can help manage the clinical symptoms of this condition.
3. A nurse is caring for a post-operative patient who suddenly reports sharp chest pain and shortness of
breath. Which complication should be suspected first?
A. Atelectasis
B. Myocardial Infarction
C. Pulmonary Embolism
D. Pneumonia
Ans: C
Explanation: A pulmonary embolism is a life-threatening complication that often presents with sudden
onset chest pain and dyspnea. Post-operative patients are at high risk due to immobility and potential
venous stasis leading to deep vein thrombosis. The nurse should immediately assess the patient’s oxygen
saturation and notify the rapid response team. Providing supplemental oxygen and maintaining the
patient on bed rest are essential initial steps. Diagnostic testing such as a CT pulmonary angiogram is
typically required to confirm the presence of a clot.
4. Which electrolyte imbalance is most likely to cause the presence of U-waves on an electrocardiogram
(ECG)?
A. Hyperkalemia
, B. Hypercalcemia
C. Hypokalemia
D. Hyponatremia
Ans: C
Explanation: Hypokalemia is characterized by a serum potassium level below the normal range of 3.5 to
5.0 mEq/L. Low potassium levels can significantly affect cardiac conduction, leading to the appearance of
U-waves on the ECG. The nurse should monitor the patient for muscle weakness and cardiac
dysrhythmias which are common in this state. Potassium replacement therapy should be administered
carefully via oral or intravenous routes as prescribed. Educating the patient on potassium-rich foods like
bananas and potatoes can prevent future occurrences of this imbalance.
5. A patient is receiving a blood transfusion and begins to experience chills, fever, and lower back pain.
What is the nurse’s priority action?
A. Slow the infusion rate
B. Stop the transfusion immediately
C. Administer diphenhydramine
D. Check the patient’s temperature
Ans: B
Explanation: The presence of fever, chills, and back pain during a transfusion suggests an acute
hemolytic reaction. The nurse must stop the transfusion immediately to prevent further administration
of incompatible blood. After stopping the blood, the nurse should maintain the IV line with normal saline
using new tubing. Notifying the physician and the blood bank is necessary to initiate the transfusion
