NRSG 110 Exam 2 V3 | NRSG 110 Medical
Surgical Nursing II | Actual Q&A with
Rationale (NRSG110 Exam 2) | Ivy Tech
1. A client is admitted with an exacerbation of left-sided heart failure. Which clinical
manifestation should the nurse expect to find during the physical assessment?
A. Jugular venous distention
B. Peripheral edema
C. Crackles in the lungs
D. Hepatosplenomegaly
Correct Answer: C
Left-sided heart failure results in pulmonary congestion because the left ventricle is
unable to pump blood effectively into the systemic circulation. This backflow increases
pressure in the pulmonary capillaries, leading to fluid leakage into the alveoli. The presence
of crackles or rales is a primary indicator of this fluid accumulation in the lungs.
2. A nurse is caring for a client with Chronic Obstructive Pulmonary Disease (COPD) who is
receiving oxygen therapy. Which oxygen delivery method should the nurse anticipate for
precise oxygen concentration?
A. Nasal cannula
B. Simple face mask
,C. Venturi mask
D. Partial rebreather mask
Correct Answer: C
The Venturi mask is the most accurate method for delivering a precise concentration of
oxygen to a client. It is particularly useful for COPD patients because it allows for exact
titration of oxygen flow to prevent suppression of the hypoxic drive. Other devices provide
variable concentrations depending on the client’s respiratory rate and depth.
3. A client with Type 1 Diabetes Mellitus is found unconscious and clammy. The fingerstick
blood glucose is 42 mg/dL. What is the priority nursing action?
A. Administer Glucagon IM or Subcutaneously
B. Recheck the blood glucose in 15 minutes
C. Administer 15g of oral carbohydrates
D. Notify the provider immediately
Correct Answer: A
For an unconscious client experiencing severe hypoglycemia, the nurse must quickly
elevate blood glucose levels without the risk of aspiration. Glucagon stimulates the liver to
release glucose and is the standard emergency treatment when intravenous access is
unavailable. Once the client regains consciousness, oral carbohydrates can be provided to
maintain stability.
, 4. The nurse is preparing a client for a scheduled cholecystectomy. Who is responsible for
obtaining the formal informed consent for the surgical procedure?
A. The perioperative nurse
B. The anesthesia provider
C. The surgeon
D. The nurse manager
Correct Answer: C
It is the surgeon’s legal and ethical responsibility to explain the procedure, risks, benefits,
and alternatives to the client. The nurse’s role is typically to witness the client’s signature
and verify that the client is competent to sign. If the nurse realizes the client does not
understand the procedure, the surgeon must be called back to provide further explanation.
5. A nurse is assessing a client for electrolyte imbalances. The client’s potassium level is 3.1
mEq/L. Which EKG findings are consistent with this diagnosis?
A. Prominent U waves
B. Peaked T waves
C. Shortened QT interval
D. Widened QRS complex
E. ST segment elevation
Correct Answer: A
Surgical Nursing II | Actual Q&A with
Rationale (NRSG110 Exam 2) | Ivy Tech
1. A client is admitted with an exacerbation of left-sided heart failure. Which clinical
manifestation should the nurse expect to find during the physical assessment?
A. Jugular venous distention
B. Peripheral edema
C. Crackles in the lungs
D. Hepatosplenomegaly
Correct Answer: C
Left-sided heart failure results in pulmonary congestion because the left ventricle is
unable to pump blood effectively into the systemic circulation. This backflow increases
pressure in the pulmonary capillaries, leading to fluid leakage into the alveoli. The presence
of crackles or rales is a primary indicator of this fluid accumulation in the lungs.
2. A nurse is caring for a client with Chronic Obstructive Pulmonary Disease (COPD) who is
receiving oxygen therapy. Which oxygen delivery method should the nurse anticipate for
precise oxygen concentration?
A. Nasal cannula
B. Simple face mask
,C. Venturi mask
D. Partial rebreather mask
Correct Answer: C
The Venturi mask is the most accurate method for delivering a precise concentration of
oxygen to a client. It is particularly useful for COPD patients because it allows for exact
titration of oxygen flow to prevent suppression of the hypoxic drive. Other devices provide
variable concentrations depending on the client’s respiratory rate and depth.
3. A client with Type 1 Diabetes Mellitus is found unconscious and clammy. The fingerstick
blood glucose is 42 mg/dL. What is the priority nursing action?
A. Administer Glucagon IM or Subcutaneously
B. Recheck the blood glucose in 15 minutes
C. Administer 15g of oral carbohydrates
D. Notify the provider immediately
Correct Answer: A
For an unconscious client experiencing severe hypoglycemia, the nurse must quickly
elevate blood glucose levels without the risk of aspiration. Glucagon stimulates the liver to
release glucose and is the standard emergency treatment when intravenous access is
unavailable. Once the client regains consciousness, oral carbohydrates can be provided to
maintain stability.
, 4. The nurse is preparing a client for a scheduled cholecystectomy. Who is responsible for
obtaining the formal informed consent for the surgical procedure?
A. The perioperative nurse
B. The anesthesia provider
C. The surgeon
D. The nurse manager
Correct Answer: C
It is the surgeon’s legal and ethical responsibility to explain the procedure, risks, benefits,
and alternatives to the client. The nurse’s role is typically to witness the client’s signature
and verify that the client is competent to sign. If the nurse realizes the client does not
understand the procedure, the surgeon must be called back to provide further explanation.
5. A nurse is assessing a client for electrolyte imbalances. The client’s potassium level is 3.1
mEq/L. Which EKG findings are consistent with this diagnosis?
A. Prominent U waves
B. Peaked T waves
C. Shortened QT interval
D. Widened QRS complex
E. ST segment elevation
Correct Answer: A
