NRSG 110 Exam 1 V2 | NRSG 110 Medical
Surgical Nursing II | Actual Q&A with
Rationale (NRSG110 Exam 1) | Ivy Tech
1. A nurse is assessing a patient with chronic obstructive pulmonary disease (COPD). Which
clinical finding should the nurse prioritize as a sign of chronic air trapping?
A. Occasional non-productive cough
B. Presence of fine crackles in the lung bases
C. Oxygen saturation of 94% on room air
D. An increased anteroposterior diameter of the chest
Correct Answer: D
An increased anteroposterior diameter, known as a barrel chest, is a classic sign of chronic
air trapping in COPD patients. This occurs because the lungs are chronically overinflated
with air, causing the rib cage to remain partially expanded. The nurse should recognize this
as a structural change resulting from long-term obstructive disease processes.
2. A patient is admitted with a serum potassium level of 6.2 mEq/L. Which of the following
nursing interventions and assessments are most appropriate?
A. Encourage the consumption of bananas and orange juice
B. Obtain an immediate 12-lead electrocardiogram (ECG)
C. Administer spironolactone as ordered
,D. Monitor for signs of Chvostek’s sign
E. Prepare to administer intravenous calcium gluconate if ordered
F. Assess for tall, peaked T-waves on the cardiac monitor
Correct Answer: B
Hyperkalemia is a medical emergency because it can lead to fatal cardiac dysrhythmias.
The nurse’s priority is to obtain an ECG to assess for cardiac changes such as peaked T-
waves or widened QRS complexes. Interventions like calcium gluconate may follow to
stabilize the myocardium, but assessment via ECG is the critical first step in an acute
setting.
3. A client is diagnosed with Respiratory Acidosis. Which arterial blood gas (ABG) result would
the nurse expect to see?
A. pH 7.50, PaCO2 30 mmHg, HCO3 24 mEq/L
B. pH 7.30, PaCO2 52 mmHg, HCO3 26 mEq/L
C. pH 7.32, PaCO2 35 mmHg, HCO3 18 mEq/L
D. pH 7.48, PaCO2 42 mmHg, HCO3 30 mEq/L
Correct Answer: B
Respiratory acidosis is characterized by a low pH (less than 7.35) and an elevated PaCO2
(greater than 45 mmHg). This condition occurs when the lungs cannot remove enough
, carbon dioxide produced by the body. The nurse must monitor for causes of
hypoventilation such as respiratory depression or airway obstruction.
4. Which teaching point is most important for a patient newly diagnosed with Human
Immunodeficiency Virus (HIV)?
A. HIV can be transmitted through casual contact like hugging.
B. The patient is no longer infectious once ART is started.
C. Antiretroviral therapy (ART) must be taken consistently to prevent viral resistance.
D. A diagnosis of HIV is the same as a diagnosis of AIDS.
Correct Answer: C
Adherence to ART is crucial for suppressing viral load and preventing the development of
drug-resistant strains of HIV. Patients must understand that missing doses can lead to
treatment failure and disease progression. The nurse should emphasize that while ART
reduces transmission risk, it does not make the patient immediately non-infectious until
the viral load is undetectable.
5. A nurse is caring for a patient with right-sided heart failure. Which clinical manifestations
should the nurse expect to observe?
A. Pulmonary edema and crackles
B. Orthopnea and paroxysmal nocturnal dyspnea
C. Jugular venous distention and peripheral edema
Surgical Nursing II | Actual Q&A with
Rationale (NRSG110 Exam 1) | Ivy Tech
1. A nurse is assessing a patient with chronic obstructive pulmonary disease (COPD). Which
clinical finding should the nurse prioritize as a sign of chronic air trapping?
A. Occasional non-productive cough
B. Presence of fine crackles in the lung bases
C. Oxygen saturation of 94% on room air
D. An increased anteroposterior diameter of the chest
Correct Answer: D
An increased anteroposterior diameter, known as a barrel chest, is a classic sign of chronic
air trapping in COPD patients. This occurs because the lungs are chronically overinflated
with air, causing the rib cage to remain partially expanded. The nurse should recognize this
as a structural change resulting from long-term obstructive disease processes.
2. A patient is admitted with a serum potassium level of 6.2 mEq/L. Which of the following
nursing interventions and assessments are most appropriate?
A. Encourage the consumption of bananas and orange juice
B. Obtain an immediate 12-lead electrocardiogram (ECG)
C. Administer spironolactone as ordered
,D. Monitor for signs of Chvostek’s sign
E. Prepare to administer intravenous calcium gluconate if ordered
F. Assess for tall, peaked T-waves on the cardiac monitor
Correct Answer: B
Hyperkalemia is a medical emergency because it can lead to fatal cardiac dysrhythmias.
The nurse’s priority is to obtain an ECG to assess for cardiac changes such as peaked T-
waves or widened QRS complexes. Interventions like calcium gluconate may follow to
stabilize the myocardium, but assessment via ECG is the critical first step in an acute
setting.
3. A client is diagnosed with Respiratory Acidosis. Which arterial blood gas (ABG) result would
the nurse expect to see?
A. pH 7.50, PaCO2 30 mmHg, HCO3 24 mEq/L
B. pH 7.30, PaCO2 52 mmHg, HCO3 26 mEq/L
C. pH 7.32, PaCO2 35 mmHg, HCO3 18 mEq/L
D. pH 7.48, PaCO2 42 mmHg, HCO3 30 mEq/L
Correct Answer: B
Respiratory acidosis is characterized by a low pH (less than 7.35) and an elevated PaCO2
(greater than 45 mmHg). This condition occurs when the lungs cannot remove enough
, carbon dioxide produced by the body. The nurse must monitor for causes of
hypoventilation such as respiratory depression or airway obstruction.
4. Which teaching point is most important for a patient newly diagnosed with Human
Immunodeficiency Virus (HIV)?
A. HIV can be transmitted through casual contact like hugging.
B. The patient is no longer infectious once ART is started.
C. Antiretroviral therapy (ART) must be taken consistently to prevent viral resistance.
D. A diagnosis of HIV is the same as a diagnosis of AIDS.
Correct Answer: C
Adherence to ART is crucial for suppressing viral load and preventing the development of
drug-resistant strains of HIV. Patients must understand that missing doses can lead to
treatment failure and disease progression. The nurse should emphasize that while ART
reduces transmission risk, it does not make the patient immediately non-infectious until
the viral load is undetectable.
5. A nurse is caring for a patient with right-sided heart failure. Which clinical manifestations
should the nurse expect to observe?
A. Pulmonary edema and crackles
B. Orthopnea and paroxysmal nocturnal dyspnea
C. Jugular venous distention and peripheral edema
