NRSG 100 Exam 3 V1 | NRSG 100
Fundamentals of Nursing | Actual Q&A
with Rationale (NRSG100 Exam 3) | Ivy
Tech
1. A nurse is assessing a patient who has a serum potassium level of 3.2 mEq/L. Which clinical
manifestation should the nurse expect to observe?
A. Muscle weakness and leg cramps
B. Tall, peaked T waves on ECG
C. Hyperactive deep tendon reflexes
D. Numbness and tingling in the fingers
Correct Answer: A
Hypokalemia is characterized by a serum potassium level below the normal range, often
leading to muscle weakness or cramps. The heart is highly sensitive to potassium
fluctuations, making cardiac monitoring a priority for these patients. Management includes
identifying the underlying cause and administering supplements as ordered by the
provider.
2. Which arterial blood gas (ABG) result is most consistent with a patient experiencing chronic
obstructive pulmonary disease (COPD)?
A. pH 7.48, PaCO2 30, HCO3 22
,B. pH 7.32, PaCO2 55, HCO3 28
C. pH 7.30, PaCO2 38, HCO3 18
D. pH 7.50, PaCO2 40, HCO3 32
Correct Answer: B
Patients with COPD often experience respiratory acidosis due to the chronic retention of
carbon dioxide. The pH will be below the normal range of 7.35, while the PaCO2 will be
elevated above 45 mmHg. The kidneys may attempt to compensate by increasing the
bicarbonate level over time.
3. A nurse is caring for a patient with a pressure injury that has full-thickness skin loss
involving damage to the subcutaneous tissue, but no visible bone or muscle. How should the
nurse stage this injury?
A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
Correct Answer: C
A Stage 3 pressure injury involves full-thickness skin loss where adipose tissue is visible
in the ulcer. At this stage, fascia, muscle, tendon, ligament, or bone are not exposed. The
, nurse should document the presence of slough or eschar if they are present, though they do
not obscure the depth of the wound.
4. What is the primary purpose of having a patient use an incentive spirometer during the
postoperative period?
A. To increase the strength of the abdominal muscles
B. To promote deep breathing and prevent atelectasis
C. To reduce the need for supplemental oxygen
D. To monitor the patient’s forced expiratory volume
Correct Answer: B
Incentive spirometry is a critical intervention used to encourage patients to take deep,
sustained breaths. This action helps to keep the alveoli open and prevents the collapse of
lung tissue, known as atelectasis. Consistent use is especially important for patients who
have undergone abdominal or thoracic surgery.
5. A nurse enters a room and finds a patient’s surgical wound has eviscerated. What should
be the nurse’s immediate action?
A. Push the protruding organs back into the abdominal cavity
B. Cover the wound with sterile towels moistened with normal saline
C. Apply a dry, sterile pressure dressing to the site
D. Leave the patient to go find the surgical team immediately
Fundamentals of Nursing | Actual Q&A
with Rationale (NRSG100 Exam 3) | Ivy
Tech
1. A nurse is assessing a patient who has a serum potassium level of 3.2 mEq/L. Which clinical
manifestation should the nurse expect to observe?
A. Muscle weakness and leg cramps
B. Tall, peaked T waves on ECG
C. Hyperactive deep tendon reflexes
D. Numbness and tingling in the fingers
Correct Answer: A
Hypokalemia is characterized by a serum potassium level below the normal range, often
leading to muscle weakness or cramps. The heart is highly sensitive to potassium
fluctuations, making cardiac monitoring a priority for these patients. Management includes
identifying the underlying cause and administering supplements as ordered by the
provider.
2. Which arterial blood gas (ABG) result is most consistent with a patient experiencing chronic
obstructive pulmonary disease (COPD)?
A. pH 7.48, PaCO2 30, HCO3 22
,B. pH 7.32, PaCO2 55, HCO3 28
C. pH 7.30, PaCO2 38, HCO3 18
D. pH 7.50, PaCO2 40, HCO3 32
Correct Answer: B
Patients with COPD often experience respiratory acidosis due to the chronic retention of
carbon dioxide. The pH will be below the normal range of 7.35, while the PaCO2 will be
elevated above 45 mmHg. The kidneys may attempt to compensate by increasing the
bicarbonate level over time.
3. A nurse is caring for a patient with a pressure injury that has full-thickness skin loss
involving damage to the subcutaneous tissue, but no visible bone or muscle. How should the
nurse stage this injury?
A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
Correct Answer: C
A Stage 3 pressure injury involves full-thickness skin loss where adipose tissue is visible
in the ulcer. At this stage, fascia, muscle, tendon, ligament, or bone are not exposed. The
, nurse should document the presence of slough or eschar if they are present, though they do
not obscure the depth of the wound.
4. What is the primary purpose of having a patient use an incentive spirometer during the
postoperative period?
A. To increase the strength of the abdominal muscles
B. To promote deep breathing and prevent atelectasis
C. To reduce the need for supplemental oxygen
D. To monitor the patient’s forced expiratory volume
Correct Answer: B
Incentive spirometry is a critical intervention used to encourage patients to take deep,
sustained breaths. This action helps to keep the alveoli open and prevents the collapse of
lung tissue, known as atelectasis. Consistent use is especially important for patients who
have undergone abdominal or thoracic surgery.
5. A nurse enters a room and finds a patient’s surgical wound has eviscerated. What should
be the nurse’s immediate action?
A. Push the protruding organs back into the abdominal cavity
B. Cover the wound with sterile towels moistened with normal saline
C. Apply a dry, sterile pressure dressing to the site
D. Leave the patient to go find the surgical team immediately
