NSG223/NSG 223 Exam 2 V3 | Medical-
Surgical Nursing II Q&A with Rationale |
Herzing University
1. A nurse is caring for a client with a pH of 7.28, PaCO2 of 52 mmHg, and HCO3 of 24 mEq/L.
Which acid-base imbalance does the nurse identify?
A. Respiratory Acidosis
B. Metabolic Acidosis
C. Metabolic Alkalosis
D. Respiratory Alkalosis
Correct Answer: A
Rationale: The low pH indicates acidosis, while the elevated PaCO2 level above 45 mmHg
points to a respiratory origin. Because the bicarbonate level is within the normal range, this
is uncompensated respiratory acidosis. The nurse must monitor the client’s respiratory
rate and depth to assess for worsening hypoventilation.
2. Which clinical manifestation should the nurse expect to find in a client diagnosed with
right-sided heart failure?
A. Pulmonary crackles
B. Orthopnea
C. Frothy pink sputum
,D. Jugular venous distention
Correct Answer: D
Rationale: Right-sided heart failure results in systemic venous congestion because the
right ventricle is unable to pump blood effectively into the pulmonary circulation. This
leads to symptoms such as jugular venous distention, peripheral edema, and hepatomegaly.
Symptoms like crackles and pink sputum are characteristic of left-sided heart failure and
pulmonary congestion.
3. A client is prescribed furosemide for the management of fluid volume excess. Which
electrolyte imbalance is the priority for the nurse to monitor?
A. Hypokalemia
B. Hypocalcemia
C. Hyperkalemia
D. Hypernatremia
Correct Answer: A
Rationale: Furosemide is a loop diuretic that causes the excretion of sodium, water, and
potassium. Hypokalemia is a significant risk that can lead to life-threatening cardiac
dysrhythmias. The nurse must monitor serum potassium levels and encourage the intake of
potassium-rich foods or supplements as ordered.
, 4. A client presents to the emergency department with a sudden onset of shortness of breath
and chest pain that worsens on inspiration. What is the nurse’s priority action?
A. Apply supplemental oxygen
B. Obtain a 12-lead ECG
C. Administer an oral analgesic
D. Perform a complete skin assessment
Correct Answer: A
Rationale: Sudden dyspnea and pleuritic chest pain are hallmark signs of a pulmonary
embolism. The nurse’s immediate priority is to maintain oxygenation and stabilize the
client’s respiratory status. Following oxygen administration, the nurse would then proceed
with further diagnostic testing and physician notification.
5. A nurse is reviewing the laboratory results for a client with chronic kidney disease. Which
finding is most consistent with this diagnosis?
A. Decreased serum creatinine
B. Increased glomerular filtration rate (GFR)
C. Decreased hemoglobin and hematocrit
D. Decreased serum potassium
Correct Answer: C
Surgical Nursing II Q&A with Rationale |
Herzing University
1. A nurse is caring for a client with a pH of 7.28, PaCO2 of 52 mmHg, and HCO3 of 24 mEq/L.
Which acid-base imbalance does the nurse identify?
A. Respiratory Acidosis
B. Metabolic Acidosis
C. Metabolic Alkalosis
D. Respiratory Alkalosis
Correct Answer: A
Rationale: The low pH indicates acidosis, while the elevated PaCO2 level above 45 mmHg
points to a respiratory origin. Because the bicarbonate level is within the normal range, this
is uncompensated respiratory acidosis. The nurse must monitor the client’s respiratory
rate and depth to assess for worsening hypoventilation.
2. Which clinical manifestation should the nurse expect to find in a client diagnosed with
right-sided heart failure?
A. Pulmonary crackles
B. Orthopnea
C. Frothy pink sputum
,D. Jugular venous distention
Correct Answer: D
Rationale: Right-sided heart failure results in systemic venous congestion because the
right ventricle is unable to pump blood effectively into the pulmonary circulation. This
leads to symptoms such as jugular venous distention, peripheral edema, and hepatomegaly.
Symptoms like crackles and pink sputum are characteristic of left-sided heart failure and
pulmonary congestion.
3. A client is prescribed furosemide for the management of fluid volume excess. Which
electrolyte imbalance is the priority for the nurse to monitor?
A. Hypokalemia
B. Hypocalcemia
C. Hyperkalemia
D. Hypernatremia
Correct Answer: A
Rationale: Furosemide is a loop diuretic that causes the excretion of sodium, water, and
potassium. Hypokalemia is a significant risk that can lead to life-threatening cardiac
dysrhythmias. The nurse must monitor serum potassium levels and encourage the intake of
potassium-rich foods or supplements as ordered.
, 4. A client presents to the emergency department with a sudden onset of shortness of breath
and chest pain that worsens on inspiration. What is the nurse’s priority action?
A. Apply supplemental oxygen
B. Obtain a 12-lead ECG
C. Administer an oral analgesic
D. Perform a complete skin assessment
Correct Answer: A
Rationale: Sudden dyspnea and pleuritic chest pain are hallmark signs of a pulmonary
embolism. The nurse’s immediate priority is to maintain oxygenation and stabilize the
client’s respiratory status. Following oxygen administration, the nurse would then proceed
with further diagnostic testing and physician notification.
5. A nurse is reviewing the laboratory results for a client with chronic kidney disease. Which
finding is most consistent with this diagnosis?
A. Decreased serum creatinine
B. Increased glomerular filtration rate (GFR)
C. Decreased hemoglobin and hematocrit
D. Decreased serum potassium
Correct Answer: C
