NRSG 110 Exam 1 V3 | NRSG 110 Medical
Surgical Nursing II | Actual Q&A with
Rationale (NRSG110 Exam 1) | Ivy Tech
1. A client presents to the emergency department with a pH of 7.30, PaCO2 of 52 mmHg, and
HCO3 of 24 mEq/L. Which acid-base imbalance is the client experiencing?
A. Metabolic Acidosis
B. Metabolic Alkalosis
C. Respiratory Alkalosis
D. Respiratory Acidosis
Correct Answer: D
The pH is below 7.35, indicating acidosis. The PaCO2 is elevated above 45 mmHg, which
correlates with the acidic pH, while the HCO3 is within the normal range. This combination
confirms a respiratory origin for the imbalance, often seen in conditions like COPD or
pneumonia.
2. When teaching a client with Chronic Obstructive Pulmonary Disease (COPD) about
breathing techniques, which method should the nurse emphasize to promote carbon dioxide
elimination?
A. Diaphragmatic breathing
B. Deep chest breathing
,C. Pursed-lip breathing
D. Rapid, shallow breathing
Correct Answer: C
Pursed-lip breathing helps to maintain positive pressure in the airways, preventing
alveolar collapse during expiration. This technique prolongs exhalation and assists in the
removal of trapped carbon dioxide. It is a fundamental intervention for managing dyspnea
in obstructive lung diseases.
3. A nurse is assessing a client for signs of left-sided heart failure. Which clinical manifestation
should the nurse expect to find?
A. Jugular venous distention
B. Dependent edema
C. Pulmonary crackles
D. Hepatosplenomegaly
Correct Answer: C
Left-sided heart failure leads to pulmonary congestion because the left ventricle cannot
effectively pump blood into the systemic circulation. This results in fluid backing up into
the lungs, causing crackles, dyspnea, and orthopnea. In contrast, systemic signs like jugular
venous distention and peripheral edema are indicative of right-sided heart failure.
, 4. A client is prescribed Digoxin 0.125 mg daily. Which laboratory value should the nurse
monitor most closely to prevent Digoxin toxicity?
A. Serum Sodium
B. Serum Potassium
C. Serum Calcium
D. Serum Magnesium
Correct Answer: B
Hypokalemia significantly increases the risk of Digoxin toxicity because potassium and
digoxin compete for the same binding sites on the ATPase pump. The nurse must ensure
potassium levels are within the normal range (3.5-5.0 mEq/L) before administration.
Symptoms of toxicity include visual disturbances, nausea, and bradycardia.
5. The nurse is preparing a plan of care for a client who is 24 hours postoperative following
abdominal surgery. Which interventions should be included to prevent pulmonary
complications?
A. Limit fluid intake to prevent circulatory overload
B. Maintain strict bed rest for the first 48 hours
C. Encourage frequent use of the incentive spirometer and early ambulation
D. Perform chest physiotherapy once daily
E. Administer cough suppressants every 4 hours
Surgical Nursing II | Actual Q&A with
Rationale (NRSG110 Exam 1) | Ivy Tech
1. A client presents to the emergency department with a pH of 7.30, PaCO2 of 52 mmHg, and
HCO3 of 24 mEq/L. Which acid-base imbalance is the client experiencing?
A. Metabolic Acidosis
B. Metabolic Alkalosis
C. Respiratory Alkalosis
D. Respiratory Acidosis
Correct Answer: D
The pH is below 7.35, indicating acidosis. The PaCO2 is elevated above 45 mmHg, which
correlates with the acidic pH, while the HCO3 is within the normal range. This combination
confirms a respiratory origin for the imbalance, often seen in conditions like COPD or
pneumonia.
2. When teaching a client with Chronic Obstructive Pulmonary Disease (COPD) about
breathing techniques, which method should the nurse emphasize to promote carbon dioxide
elimination?
A. Diaphragmatic breathing
B. Deep chest breathing
,C. Pursed-lip breathing
D. Rapid, shallow breathing
Correct Answer: C
Pursed-lip breathing helps to maintain positive pressure in the airways, preventing
alveolar collapse during expiration. This technique prolongs exhalation and assists in the
removal of trapped carbon dioxide. It is a fundamental intervention for managing dyspnea
in obstructive lung diseases.
3. A nurse is assessing a client for signs of left-sided heart failure. Which clinical manifestation
should the nurse expect to find?
A. Jugular venous distention
B. Dependent edema
C. Pulmonary crackles
D. Hepatosplenomegaly
Correct Answer: C
Left-sided heart failure leads to pulmonary congestion because the left ventricle cannot
effectively pump blood into the systemic circulation. This results in fluid backing up into
the lungs, causing crackles, dyspnea, and orthopnea. In contrast, systemic signs like jugular
venous distention and peripheral edema are indicative of right-sided heart failure.
, 4. A client is prescribed Digoxin 0.125 mg daily. Which laboratory value should the nurse
monitor most closely to prevent Digoxin toxicity?
A. Serum Sodium
B. Serum Potassium
C. Serum Calcium
D. Serum Magnesium
Correct Answer: B
Hypokalemia significantly increases the risk of Digoxin toxicity because potassium and
digoxin compete for the same binding sites on the ATPase pump. The nurse must ensure
potassium levels are within the normal range (3.5-5.0 mEq/L) before administration.
Symptoms of toxicity include visual disturbances, nausea, and bradycardia.
5. The nurse is preparing a plan of care for a client who is 24 hours postoperative following
abdominal surgery. Which interventions should be included to prevent pulmonary
complications?
A. Limit fluid intake to prevent circulatory overload
B. Maintain strict bed rest for the first 48 hours
C. Encourage frequent use of the incentive spirometer and early ambulation
D. Perform chest physiotherapy once daily
E. Administer cough suppressants every 4 hours
