NRSG 201 Final Exam V1 | NRSG 201 Med Surg 1 |
Actual Q&A with Rationale (NRSG201 Final Exam) |
Ivy Tech
1. A nurse is assessing a client who has fluid volume deficit. Which of the following findings
should the nurse expect?
A. Distended neck veins
B. Bradycardia
C. Increased skin turgor
D. Orthostatic hypotension
Correct Answer: D
Explanation: The correct answer is Orthostatic hypotension. Fluid volume deficit leads to a
decrease in circulating blood volume, which commonly results in a drop in blood pressure
when changing positions. The nurse should also expect to find tachycardia and delayed
capillary refill in these clients.
2. A client is diagnosed with hyperkalemia. Which of the following EKG changes should the
nurse monitor for?
A. ST segment depression
B. Prominent U waves
C. Peaked T waves
,D. Shortened PR interval
Correct Answer: C
Explanation: The correct answer is Peaked T waves. Hyperkalemia affects cardiac
conduction and typically manifests as tall, peaked T waves and widened QRS complexes on
an EKG. Monitoring for these changes is critical to prevent lethal arrhythmias like
ventricular fibrillation.
3. A nurse is caring for a client with a potassium level of 2.8 mEq/L. Which food should the
nurse encourage the client to consume?
A. Baked potato with skin
B. Apples
C. White bread
D. Angel food cake
Correct Answer: A
Explanation: The correct answer is Baked potato with skin. Potatoes are high in
potassium, providing significant milliequivalents to help correct a deficit. The nurse should
educate the client on incorporating potassium-rich foods like bananas, spinach, and
potatoes into their daily diet.
4. Which assessment finding is a positive Trousseau’s sign indicating hypocalcemia?
A. Carpal spasm when a blood pressure cuff is inflated
, B. Twitching of the facial muscle when the cheek is tapped
C. Numbness and tingling in the toes
D. Hyperactive deep tendon reflexes
Correct Answer: A
Explanation: The correct answer is Carpal spasm when a blood pressure cuff is inflated.
Trousseau’s sign is a classic indicator of neuromuscular irritability associated with low
serum calcium levels. The nurse should observe for the thumb and fingers to adduct and
flex when the cuff pressure exceeds systolic pressure for three minutes.
5. A client’s arterial blood gas (ABG) results are: pH 7.30, PaCO2 50 mm Hg, and HCO3 24
mEq/L. How should the nurse interpret these results?
A. Metabolic Acidosis
B. Metabolic Alkalosis
C. Respiratory Acidosis
D. Respiratory Alkalosis
Correct Answer: C
Explanation: The correct answer is Respiratory Acidosis. The pH is below 7.35 indicating
acidosis, and the PaCO2 is elevated above 45 mm Hg indicating a respiratory cause. This
condition often occurs in patients with COPD or respiratory depression who cannot
effectively exhale carbon dioxide.
Actual Q&A with Rationale (NRSG201 Final Exam) |
Ivy Tech
1. A nurse is assessing a client who has fluid volume deficit. Which of the following findings
should the nurse expect?
A. Distended neck veins
B. Bradycardia
C. Increased skin turgor
D. Orthostatic hypotension
Correct Answer: D
Explanation: The correct answer is Orthostatic hypotension. Fluid volume deficit leads to a
decrease in circulating blood volume, which commonly results in a drop in blood pressure
when changing positions. The nurse should also expect to find tachycardia and delayed
capillary refill in these clients.
2. A client is diagnosed with hyperkalemia. Which of the following EKG changes should the
nurse monitor for?
A. ST segment depression
B. Prominent U waves
C. Peaked T waves
,D. Shortened PR interval
Correct Answer: C
Explanation: The correct answer is Peaked T waves. Hyperkalemia affects cardiac
conduction and typically manifests as tall, peaked T waves and widened QRS complexes on
an EKG. Monitoring for these changes is critical to prevent lethal arrhythmias like
ventricular fibrillation.
3. A nurse is caring for a client with a potassium level of 2.8 mEq/L. Which food should the
nurse encourage the client to consume?
A. Baked potato with skin
B. Apples
C. White bread
D. Angel food cake
Correct Answer: A
Explanation: The correct answer is Baked potato with skin. Potatoes are high in
potassium, providing significant milliequivalents to help correct a deficit. The nurse should
educate the client on incorporating potassium-rich foods like bananas, spinach, and
potatoes into their daily diet.
4. Which assessment finding is a positive Trousseau’s sign indicating hypocalcemia?
A. Carpal spasm when a blood pressure cuff is inflated
, B. Twitching of the facial muscle when the cheek is tapped
C. Numbness and tingling in the toes
D. Hyperactive deep tendon reflexes
Correct Answer: A
Explanation: The correct answer is Carpal spasm when a blood pressure cuff is inflated.
Trousseau’s sign is a classic indicator of neuromuscular irritability associated with low
serum calcium levels. The nurse should observe for the thumb and fingers to adduct and
flex when the cuff pressure exceeds systolic pressure for three minutes.
5. A client’s arterial blood gas (ABG) results are: pH 7.30, PaCO2 50 mm Hg, and HCO3 24
mEq/L. How should the nurse interpret these results?
A. Metabolic Acidosis
B. Metabolic Alkalosis
C. Respiratory Acidosis
D. Respiratory Alkalosis
Correct Answer: C
Explanation: The correct answer is Respiratory Acidosis. The pH is below 7.35 indicating
acidosis, and the PaCO2 is elevated above 45 mm Hg indicating a respiratory cause. This
condition often occurs in patients with COPD or respiratory depression who cannot
effectively exhale carbon dioxide.
