NSG 3130 EXAM 1: FUNDAMENTAL
CONCEPTS & SKILLS FOR NURSING
PRACTICE II
1. A patient presents with a serum potassium level of 6.2 mEq/L. Which electrocardiogram
(ECG) change should the nurse prioritize for immediate intervention?
A. Tall, peaked T waves
B. Prominent U waves
C. Shortened PR interval
D. ST-segment depression
Answer: A
Conceptual Explanation: Hyperkalemia (potassium > 5.0 mEq/L) typically manifests on
an ECG as tall, peaked T waves. Prominent U waves and ST-segment depression are
characteristic of hypokalemia.
2. When assessing a patient for hypocalcemia, the nurse inflates a blood pressure cuff on the
patient’s arm and observes carpal spasms. How should the nurse document this finding?
A. Positive Babinski sign
,B. Positive Trousseau’s sign
C. Positive Chvostek’s sign
D. Positive Homans’ sign
Answer: B
Conceptual Explanation: Trousseau’s sign is a clinical indicator of hypocalcemia,
characterized by carpal spasm induced by inflating a BP cuff. Chvostek’s sign involves facial
twitching when the facial nerve is tapped.
3. The nurse is caring for a patient with a serum sodium level of 128 mEq/L. Which nursing
intervention is the most appropriate?
A. Encouraging increased water intake
B. Administering a prescribed diuretic
C. Providing a low-sodium diet
D. Implementing seizure precautions
Answer: D
Conceptual Explanation: Hyponatremia (sodium < 135 mEq/L) can lead to cerebral
edema and increased intracranial pressure, putting the patient at high risk for seizures.
Water restriction, not increase, is often indicated.
, 4. A patient with chronic obstructive pulmonary disease (COPD) is receiving oxygen via a
nasal cannula at 2 L/min. Which physiological stimulus primarily drives this patient’s
respiratory effort?
A. Increased carbon dioxide levels
B. Decreased pH levels
C. Low arterial oxygen levels
D. Increased bicarbonate levels
Answer: C
Conceptual Explanation: In chronic hypercapnia (like COPD), the central chemoreceptors
become desensitized to CO2. The primary respiratory drive shifts to the peripheral
chemoreceptors, which respond to low oxygen levels (hypoxic drive).
5. The nurse observes a small area of skin on the patient’s sacrum that is reddened and does
not blanch when pressed, but the skin remains intact. Which stage of pressure injury should
the nurse document?
A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
Answer: A
CONCEPTS & SKILLS FOR NURSING
PRACTICE II
1. A patient presents with a serum potassium level of 6.2 mEq/L. Which electrocardiogram
(ECG) change should the nurse prioritize for immediate intervention?
A. Tall, peaked T waves
B. Prominent U waves
C. Shortened PR interval
D. ST-segment depression
Answer: A
Conceptual Explanation: Hyperkalemia (potassium > 5.0 mEq/L) typically manifests on
an ECG as tall, peaked T waves. Prominent U waves and ST-segment depression are
characteristic of hypokalemia.
2. When assessing a patient for hypocalcemia, the nurse inflates a blood pressure cuff on the
patient’s arm and observes carpal spasms. How should the nurse document this finding?
A. Positive Babinski sign
,B. Positive Trousseau’s sign
C. Positive Chvostek’s sign
D. Positive Homans’ sign
Answer: B
Conceptual Explanation: Trousseau’s sign is a clinical indicator of hypocalcemia,
characterized by carpal spasm induced by inflating a BP cuff. Chvostek’s sign involves facial
twitching when the facial nerve is tapped.
3. The nurse is caring for a patient with a serum sodium level of 128 mEq/L. Which nursing
intervention is the most appropriate?
A. Encouraging increased water intake
B. Administering a prescribed diuretic
C. Providing a low-sodium diet
D. Implementing seizure precautions
Answer: D
Conceptual Explanation: Hyponatremia (sodium < 135 mEq/L) can lead to cerebral
edema and increased intracranial pressure, putting the patient at high risk for seizures.
Water restriction, not increase, is often indicated.
, 4. A patient with chronic obstructive pulmonary disease (COPD) is receiving oxygen via a
nasal cannula at 2 L/min. Which physiological stimulus primarily drives this patient’s
respiratory effort?
A. Increased carbon dioxide levels
B. Decreased pH levels
C. Low arterial oxygen levels
D. Increased bicarbonate levels
Answer: C
Conceptual Explanation: In chronic hypercapnia (like COPD), the central chemoreceptors
become desensitized to CO2. The primary respiratory drive shifts to the peripheral
chemoreceptors, which respond to low oxygen levels (hypoxic drive).
5. The nurse observes a small area of skin on the patient’s sacrum that is reddened and does
not blanch when pressed, but the skin remains intact. Which stage of pressure injury should
the nurse document?
A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
Answer: A
