NRSG 110 Exam 1 V1 | NRSG 110 Medical
Surgical Nursing II | Actual Q&A with
Rationale (NRSG110 Exam 1) | Ivy Tech
1. A patient’s arterial blood gas (ABG) results are pH 7.28, PaCO2 55 mm Hg, and HCO3 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
The pH level of 7.28 is below the normal range of 7.35 to 7.45, indicating acidosis. The
PaCO2 is elevated at 55 mm Hg, which is above the normal range of 35 to 45 mm Hg,
indicating a respiratory cause. Because the HCO3 is within the normal range of 22 to 26
mEq/L, this is an uncompensated respiratory acidosis typical of hypoventilation.
2. Which clinical manifestations should the nurse monitor for in a patient with a serum
potassium level of 6.2 mEq/L? (Select all that apply)
A. Cardiac dysrhythmias
B. Muscle weakness
C. Tall, peaked T waves
,D. Paresthesia
E. Abdominal cramping
F. All of the above
Correct Answer: F
A serum potassium level of 6.2 mEq/L indicates hyperkalemia, which significantly impacts
neuromuscular and cardiac function. Patients may exhibit peaked T waves on an ECG,
muscle weakness, and gastrointestinal symptoms like cramping. It is critical for the nurse
to monitor for cardiac arrest as high potassium levels interfere with myocardial
conduction.
3. A patient is admitted with severe vomiting and diarrhea. Which intravenous fluid should
the nurse anticipate administering to replace fluid volume in the intravascular space?
A. 0.45% Sodium Chloride
B. 0.9% Sodium Chloride
C. 3% Sodium Chloride
D. Dextrose 5% in Water (D5W)
Correct Answer: B
Isotonic solutions like 0.9% Sodium Chloride (Normal Saline) remain in the intravascular
compartment, making them the treatment of choice for extracellular fluid volume deficit.
This solution expands the volume of the blood without causing fluid shifts into or out of the
, cells. The nurse must monitor for fluid overload signs like crackles or edema during rapid
resuscitation.
4. During a physical assessment, the nurse taps the patient’s facial nerve in front of the ear
and observes a spasm of the lip and cheek. How should the nurse document this finding?
A. Positive Chvostek’s sign
B. Negative Allen’s test
C. Positive Trousseau’s sign
D. Positive Homans’ sign
Correct Answer: A
A positive Chvostek’s sign is an indication of hypocalcemia or hypomagnesemia, reflecting
neuromuscular irritability. This test involves tapping the facial nerve and observing for
involuntary twitching of the facial muscles. This finding necessitates immediate reporting
to the healthcare provider to prevent potential tetany or seizures.
5. A postoperative patient is ordered to use an incentive spirometer. What is the primary
purpose of this intervention?
A. To increase oxygen saturation quickly
B. To reduce the risk of deep vein thrombosis
C. To prevent atelectasis and promote lung expansion
D. To manage postoperative pain
Surgical Nursing II | Actual Q&A with
Rationale (NRSG110 Exam 1) | Ivy Tech
1. A patient’s arterial blood gas (ABG) results are pH 7.28, PaCO2 55 mm Hg, and HCO3 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
The pH level of 7.28 is below the normal range of 7.35 to 7.45, indicating acidosis. The
PaCO2 is elevated at 55 mm Hg, which is above the normal range of 35 to 45 mm Hg,
indicating a respiratory cause. Because the HCO3 is within the normal range of 22 to 26
mEq/L, this is an uncompensated respiratory acidosis typical of hypoventilation.
2. Which clinical manifestations should the nurse monitor for in a patient with a serum
potassium level of 6.2 mEq/L? (Select all that apply)
A. Cardiac dysrhythmias
B. Muscle weakness
C. Tall, peaked T waves
,D. Paresthesia
E. Abdominal cramping
F. All of the above
Correct Answer: F
A serum potassium level of 6.2 mEq/L indicates hyperkalemia, which significantly impacts
neuromuscular and cardiac function. Patients may exhibit peaked T waves on an ECG,
muscle weakness, and gastrointestinal symptoms like cramping. It is critical for the nurse
to monitor for cardiac arrest as high potassium levels interfere with myocardial
conduction.
3. A patient is admitted with severe vomiting and diarrhea. Which intravenous fluid should
the nurse anticipate administering to replace fluid volume in the intravascular space?
A. 0.45% Sodium Chloride
B. 0.9% Sodium Chloride
C. 3% Sodium Chloride
D. Dextrose 5% in Water (D5W)
Correct Answer: B
Isotonic solutions like 0.9% Sodium Chloride (Normal Saline) remain in the intravascular
compartment, making them the treatment of choice for extracellular fluid volume deficit.
This solution expands the volume of the blood without causing fluid shifts into or out of the
, cells. The nurse must monitor for fluid overload signs like crackles or edema during rapid
resuscitation.
4. During a physical assessment, the nurse taps the patient’s facial nerve in front of the ear
and observes a spasm of the lip and cheek. How should the nurse document this finding?
A. Positive Chvostek’s sign
B. Negative Allen’s test
C. Positive Trousseau’s sign
D. Positive Homans’ sign
Correct Answer: A
A positive Chvostek’s sign is an indication of hypocalcemia or hypomagnesemia, reflecting
neuromuscular irritability. This test involves tapping the facial nerve and observing for
involuntary twitching of the facial muscles. This finding necessitates immediate reporting
to the healthcare provider to prevent potential tetany or seizures.
5. A postoperative patient is ordered to use an incentive spirometer. What is the primary
purpose of this intervention?
A. To increase oxygen saturation quickly
B. To reduce the risk of deep vein thrombosis
C. To prevent atelectasis and promote lung expansion
D. To manage postoperative pain
