NRSG 110 Exam 2 V2 | NRSG 110 Medical
Surgical Nursing II | Actual Q&A with
Rationale (NRSG110 Exam 2) | Ivy Tech
1. A nurse is assessing a patient with chronic obstructive pulmonary disease (COPD). Which
clinical finding should the nurse identify as a late sign of hypoxia?
A. Restlessness
B. Tachycardia
C. Cyanosis
D. Hypertension
Correct Answer: C
Cyanosis is considered a late sign of hypoxia because it indicates significant
deoxygenation of hemoglobin. Early signs typically include restlessness, anxiety, and
tachycardia as the body attempts to compensate for lower oxygen levels. The nurse must
monitor for these changes to intervene before the patient’s condition deteriorates further
into respiratory failure.
2. A patient’s potassium level is 6.2 mEq/L. Which of the following nursing interventions are
appropriate for managing hyperkalemia? (Select the best response)
A. Administering a potassium-sparing diuretic
B. Encouraging the intake of bananas and orange juice
,C. Preparing the patient for possible dialysis
D. Administering IV calcium gluconate if prescribed
E. Continuous cardiac monitoring
Correct Answer: E
Hyperkalemia poses a significant risk for cardiac dysrhythmias and cardiac arrest, making
continuous EKG monitoring the highest priority. Levels above 6.0 mEq/L are critical and
require immediate stabilization of the cardiac membrane, often with calcium gluconate.
The nurse should also evaluate the patient for muscle weakness and avoid any further
potassium supplementation.
3. The nurse is caring for a patient whose arterial blood gas (ABG) results are: pH 7.30, PaCO2
52 mm Hg, and HCO3 24 mEq/L. How should the nurse interpret these findings?
A. Metabolic acidosis
B. Respiratory acidosis
C. Respiratory alkalosis
D. Metabolic alkalosis
Correct Answer: B
The pH of 7.30 indicates acidosis, and the elevated PaCO2 of 52 mm Hg identifies the
respiratory system as the cause of the imbalance. Since the bicarbonate level is within the
, normal range, this is uncompensated respiratory acidosis. Common causes include
hypoventilation related to conditions like COPD, pneumonia, or sedation.
4. Which task is the responsibility of the nurse regarding informed consent for a surgical
procedure?
A. Explaining the risks and benefits of the surgery
B. Witnessing the patient’s signature on the consent form
C. Describing alternative treatments available to the patient
D. Detailing the exact steps of the surgical procedure
Correct Answer: B
The nurse’s role in informed consent is primarily to act as a witness to the patient’s
signature and verify that the patient appears competent to give consent. It is the surgeon’s
legal responsibility to explain the procedure, its risks, benefits, and alternatives. If the
patient has further questions, the nurse must notify the surgeon to return and provide
clarification before the patient signs the form.
5. A patient with acute asthma is prescribed Albuterol via nebulizer. What is the primary
intended effect of this medication?
A. Bronchodilation through beta-2 agonism
B. Reduction of airway inflammation
C. Thinning of pulmonary secretions
Surgical Nursing II | Actual Q&A with
Rationale (NRSG110 Exam 2) | Ivy Tech
1. A nurse is assessing a patient with chronic obstructive pulmonary disease (COPD). Which
clinical finding should the nurse identify as a late sign of hypoxia?
A. Restlessness
B. Tachycardia
C. Cyanosis
D. Hypertension
Correct Answer: C
Cyanosis is considered a late sign of hypoxia because it indicates significant
deoxygenation of hemoglobin. Early signs typically include restlessness, anxiety, and
tachycardia as the body attempts to compensate for lower oxygen levels. The nurse must
monitor for these changes to intervene before the patient’s condition deteriorates further
into respiratory failure.
2. A patient’s potassium level is 6.2 mEq/L. Which of the following nursing interventions are
appropriate for managing hyperkalemia? (Select the best response)
A. Administering a potassium-sparing diuretic
B. Encouraging the intake of bananas and orange juice
,C. Preparing the patient for possible dialysis
D. Administering IV calcium gluconate if prescribed
E. Continuous cardiac monitoring
Correct Answer: E
Hyperkalemia poses a significant risk for cardiac dysrhythmias and cardiac arrest, making
continuous EKG monitoring the highest priority. Levels above 6.0 mEq/L are critical and
require immediate stabilization of the cardiac membrane, often with calcium gluconate.
The nurse should also evaluate the patient for muscle weakness and avoid any further
potassium supplementation.
3. The nurse is caring for a patient whose arterial blood gas (ABG) results are: pH 7.30, PaCO2
52 mm Hg, and HCO3 24 mEq/L. How should the nurse interpret these findings?
A. Metabolic acidosis
B. Respiratory acidosis
C. Respiratory alkalosis
D. Metabolic alkalosis
Correct Answer: B
The pH of 7.30 indicates acidosis, and the elevated PaCO2 of 52 mm Hg identifies the
respiratory system as the cause of the imbalance. Since the bicarbonate level is within the
, normal range, this is uncompensated respiratory acidosis. Common causes include
hypoventilation related to conditions like COPD, pneumonia, or sedation.
4. Which task is the responsibility of the nurse regarding informed consent for a surgical
procedure?
A. Explaining the risks and benefits of the surgery
B. Witnessing the patient’s signature on the consent form
C. Describing alternative treatments available to the patient
D. Detailing the exact steps of the surgical procedure
Correct Answer: B
The nurse’s role in informed consent is primarily to act as a witness to the patient’s
signature and verify that the patient appears competent to give consent. It is the surgeon’s
legal responsibility to explain the procedure, its risks, benefits, and alternatives. If the
patient has further questions, the nurse must notify the surgeon to return and provide
clarification before the patient signs the form.
5. A patient with acute asthma is prescribed Albuterol via nebulizer. What is the primary
intended effect of this medication?
A. Bronchodilation through beta-2 agonism
B. Reduction of airway inflammation
C. Thinning of pulmonary secretions
