NUR 3300 Exam 3 V2 | NUR 3300 Nursing
Practice II | Q&A with Rationale (NUR3300
Exam 3) | William Paterson University
1. A nurse is reviewing the arterial blood gas (ABG) results for a client with chronic
obstructive pulmonary disease (COPD). The results are: pH 7.30, PaCO2 52 mmHg, and HCO3
26 mEq/L. Which acid-base imbalance does the nurse identify?
A. Respiratory acidosis
B. Metabolic acidosis
C. Respiratory alkalosis
D. Metabolic alkalosis
Answer: A
Rationale: The pH of 7.30 indicates acidosis as it is below the normal range of 7.35 to 7.45.
The PaCO2 of 52 mmHg is elevated, which signifies that the cause is respiratory in origin.
This reflects the hypoventilation and CO2 retention commonly seen in patients with end-
stage COPD.
2. Which clinical manifestation should a nurse expect to find in a client experiencing
hypokalemia (potassium 2.8 mEq/L)?
A. Hyperactive bowel sounds and diarrhea
B. Muscle weakness and cardiac dysrhythmias
,C. Tingling of fingers and toes
D. Positive Chvostek’s sign
Answer: B
Rationale: Hypokalemia affects the electrical conduction of the heart and the contraction
of muscles. Patients with low potassium often present with generalized muscle weakness
and a decrease in gastrointestinal motility. In severe cases, cardiac rhythm changes such as
flattened T-waves or U-waves can be observed on an ECG.
3. During the preoperative assessment, a client tells the nurse they have an allergy to
bananas and avocados. What is the nurse’s priority action?
A. Notify the surgical team of a potential latex allergy
B. Document the food allergy in the diet chart
C. Administer an antihistamine immediately
D. Cancel the surgery until further testing is completed
Answer: A
Rationale: There is a known cross-reactivity between certain fruits like bananas and
avocados and latex protein. The nurse must communicate this risk to the entire surgical
team to ensure a latex-free environment is maintained. This preventive measure is
essential to avoid intraoperative anaphylaxis.
, 4. A client is 2 days postoperative and complains of sudden shortness of breath and chest
pain. The nurse notes the client is tachycardic. Which complication is most likely?
A. Atelectasis
B. Pneumonia
C. Pulmonary embolism
D. Hypovolemic shock
Answer: C
Rationale: Sudden onset of dyspnea and chest pain in a postoperative patient are hallmark
signs of a pulmonary embolism. Postoperative clients are at high risk due to venous stasis
and hypercoagulability. The nurse should stabilize the patient and immediately notify the
healthcare provider for further diagnostics.
5. What is the primary purpose of using an incentive spirometer in a postoperative client?
A. To increase the force of the cough
B. To strengthen the abdominal muscles used for breathing
C. To decrease the need for supplemental oxygen
D. To promote lung expansion and prevent atelectasis
Answer: D
Rationale: Incentive spirometry encourages deep breathing through visual feedback which
helps keep the alveoli open. It is a critical intervention to prevent postoperative atelectasis
Practice II | Q&A with Rationale (NUR3300
Exam 3) | William Paterson University
1. A nurse is reviewing the arterial blood gas (ABG) results for a client with chronic
obstructive pulmonary disease (COPD). The results are: pH 7.30, PaCO2 52 mmHg, and HCO3
26 mEq/L. Which acid-base imbalance does the nurse identify?
A. Respiratory acidosis
B. Metabolic acidosis
C. Respiratory alkalosis
D. Metabolic alkalosis
Answer: A
Rationale: The pH of 7.30 indicates acidosis as it is below the normal range of 7.35 to 7.45.
The PaCO2 of 52 mmHg is elevated, which signifies that the cause is respiratory in origin.
This reflects the hypoventilation and CO2 retention commonly seen in patients with end-
stage COPD.
2. Which clinical manifestation should a nurse expect to find in a client experiencing
hypokalemia (potassium 2.8 mEq/L)?
A. Hyperactive bowel sounds and diarrhea
B. Muscle weakness and cardiac dysrhythmias
,C. Tingling of fingers and toes
D. Positive Chvostek’s sign
Answer: B
Rationale: Hypokalemia affects the electrical conduction of the heart and the contraction
of muscles. Patients with low potassium often present with generalized muscle weakness
and a decrease in gastrointestinal motility. In severe cases, cardiac rhythm changes such as
flattened T-waves or U-waves can be observed on an ECG.
3. During the preoperative assessment, a client tells the nurse they have an allergy to
bananas and avocados. What is the nurse’s priority action?
A. Notify the surgical team of a potential latex allergy
B. Document the food allergy in the diet chart
C. Administer an antihistamine immediately
D. Cancel the surgery until further testing is completed
Answer: A
Rationale: There is a known cross-reactivity between certain fruits like bananas and
avocados and latex protein. The nurse must communicate this risk to the entire surgical
team to ensure a latex-free environment is maintained. This preventive measure is
essential to avoid intraoperative anaphylaxis.
, 4. A client is 2 days postoperative and complains of sudden shortness of breath and chest
pain. The nurse notes the client is tachycardic. Which complication is most likely?
A. Atelectasis
B. Pneumonia
C. Pulmonary embolism
D. Hypovolemic shock
Answer: C
Rationale: Sudden onset of dyspnea and chest pain in a postoperative patient are hallmark
signs of a pulmonary embolism. Postoperative clients are at high risk due to venous stasis
and hypercoagulability. The nurse should stabilize the patient and immediately notify the
healthcare provider for further diagnostics.
5. What is the primary purpose of using an incentive spirometer in a postoperative client?
A. To increase the force of the cough
B. To strengthen the abdominal muscles used for breathing
C. To decrease the need for supplemental oxygen
D. To promote lung expansion and prevent atelectasis
Answer: D
Rationale: Incentive spirometry encourages deep breathing through visual feedback which
helps keep the alveoli open. It is a critical intervention to prevent postoperative atelectasis
