PNR 201/PNR201 Exam 1 V2 | Medical-Surgical
Nursing Q&A with Rationale | Fortis College
1. A nurse is assessing a patient with a fluid volume deficit. Which clinical manifestation
should the nurse expect to find?
A. Distended neck veins
B. Orthostatic hypotension
C. Bounding pulse
D. Dependent edema
Correct Answer: B
Explanation: Orthostatic hypotension occurs because there is insufficient intravascular
volume to maintain blood pressure when changing positions. The body compensates for
low volume by increasing the heart rate, but the pressure still drops. Other signs of deficit
include poor skin turgor and dry mucous membranes.
2. Which laboratory value is most indicative of a patient experiencing hypokalemia?
A. Serum Sodium 130 mEq/L
B. Serum Potassium 5.5 mEq/L
C. Serum Potassium 3.2 mEq/L
D. Serum Sodium 148 mEq/L
Correct Answer: C
,Explanation: The normal range for serum potassium is 3.5 to 5.0 mEq/L. A value of 3.2
mEq/L is below the normal range, indicating hypokalemia which can lead to cardiac
dysrhythmias. The nurse must monitor the patient’s EKG and notify the provider for
replacement therapy.
3. The nurse is caring for a patient scheduled for surgery. Who is legally responsible for
obtaining the patient’s informed consent?
A. The scrub nurse
B. The surgeon
C. The circulating nurse
D. The nurse manager
Correct Answer: B
Explanation: The surgeon is legally responsible for explaining the procedure, risks,
benefits, and alternatives to the patient. The nurse’s role is typically to witness the
signature and ensure the patient understands what was explained. If the patient has
questions about the surgery itself, the nurse must call the surgeon back to speak with the
patient.
4. During the preoperative assessment, a patient reports a history of latex allergy. What is the
priority nursing action?
A. Document the allergy in the chart only
B. Administer an antihistamine immediately
, C. Notify the surgical team and pharmacy
D. Place a red allergy band on the patient
Correct Answer: C
Explanation: A latex allergy requires immediate communication with the entire surgical
team to ensure a latex-free environment is maintained. This prevents life-threatening
anaphylactic reactions during the procedure. The nurse should also flag the medical record
and apply an allergy identification band.
5. A patient is 12 hours postoperative following abdominal surgery. The nurse notes that the
patient has not voided. What is the first action the nurse should take?
A. Insert a straight catheter
B. Encourage oral fluid intake
C. Increase IV fluid rate
D. Perform a bladder scan
Correct Answer: D
Explanation: A bladder scan is a non-invasive way to determine the amount of urine held
in the bladder. Postoperative urinary retention is common due to anesthesia and narcotics.
Assessing the bladder volume first allows the nurse to determine if catheterization is
necessary based on facility protocols.
Nursing Q&A with Rationale | Fortis College
1. A nurse is assessing a patient with a fluid volume deficit. Which clinical manifestation
should the nurse expect to find?
A. Distended neck veins
B. Orthostatic hypotension
C. Bounding pulse
D. Dependent edema
Correct Answer: B
Explanation: Orthostatic hypotension occurs because there is insufficient intravascular
volume to maintain blood pressure when changing positions. The body compensates for
low volume by increasing the heart rate, but the pressure still drops. Other signs of deficit
include poor skin turgor and dry mucous membranes.
2. Which laboratory value is most indicative of a patient experiencing hypokalemia?
A. Serum Sodium 130 mEq/L
B. Serum Potassium 5.5 mEq/L
C. Serum Potassium 3.2 mEq/L
D. Serum Sodium 148 mEq/L
Correct Answer: C
,Explanation: The normal range for serum potassium is 3.5 to 5.0 mEq/L. A value of 3.2
mEq/L is below the normal range, indicating hypokalemia which can lead to cardiac
dysrhythmias. The nurse must monitor the patient’s EKG and notify the provider for
replacement therapy.
3. The nurse is caring for a patient scheduled for surgery. Who is legally responsible for
obtaining the patient’s informed consent?
A. The scrub nurse
B. The surgeon
C. The circulating nurse
D. The nurse manager
Correct Answer: B
Explanation: The surgeon is legally responsible for explaining the procedure, risks,
benefits, and alternatives to the patient. The nurse’s role is typically to witness the
signature and ensure the patient understands what was explained. If the patient has
questions about the surgery itself, the nurse must call the surgeon back to speak with the
patient.
4. During the preoperative assessment, a patient reports a history of latex allergy. What is the
priority nursing action?
A. Document the allergy in the chart only
B. Administer an antihistamine immediately
, C. Notify the surgical team and pharmacy
D. Place a red allergy band on the patient
Correct Answer: C
Explanation: A latex allergy requires immediate communication with the entire surgical
team to ensure a latex-free environment is maintained. This prevents life-threatening
anaphylactic reactions during the procedure. The nurse should also flag the medical record
and apply an allergy identification band.
5. A patient is 12 hours postoperative following abdominal surgery. The nurse notes that the
patient has not voided. What is the first action the nurse should take?
A. Insert a straight catheter
B. Encourage oral fluid intake
C. Increase IV fluid rate
D. Perform a bladder scan
Correct Answer: D
Explanation: A bladder scan is a non-invasive way to determine the amount of urine held
in the bladder. Postoperative urinary retention is common due to anesthesia and narcotics.
Assessing the bladder volume first allows the nurse to determine if catheterization is
necessary based on facility protocols.
