NRSG 110 Exam 3 V3 | NRSG 110 Medical Surgical
Nursing II | Actual Q&A with Rationale (NRSG110
Exam 3) | Ivy Tech
1. A nurse is caring for a client with cirrhosis who presents with confusion and asterixis.
Which of the following medications should the nurse expect the healthcare provider to
prescribe to lower the client’s ammonia levels?
A. Lactulose
B. Spironolactone
C. Furosemide
D. Neomycin
Correct Answer: A
Explanation: Lactulose is administered to clients with hepatic encephalopathy to promote
the excretion of ammonia through the stool. The medication works by acidifying the colon,
which converts ammonia into ammonium, a substance that cannot be reabsorbed into the
bloodstream. The nurse should monitor the client for an increase in bowel movements and
a subsequent improvement in mental status.
2. A client is admitted with an acute exacerbation of COPD. The nurse notes the client is using
pursed-lip breathing. Which of the following describes the primary benefit of this breathing
technique?
A. It increases the rate of breathing to improve oxygenation.
,B. It prevents airway collapse and promotes better gas exchange.
C. It decreases the work of the diaphragm during inspiration.
D. It strengthens the intercostal muscles used for ventilation.
Correct Answer: B
Explanation: Pursed-lip breathing helps to maintain positive pressure in the airways
during exhalation, which prevents the small airways from collapsing. This technique allows
the client to exhale more effectively and reduces the amount of trapped air in the lungs. By
prolonging exhalation, the client can improve overall gas exchange and reduce feelings of
dyspnea.
3. The nurse is providing discharge teaching to a client diagnosed with Gastroesophageal
Reflux Disease (GERD). Which of the following lifestyle modifications should be included in
the teaching? (Select all that apply)
A. Eat three large meals per day to maintain energy levels.
B. Avoid eating within 3 hours of bedtime.
C. Elevate the head of the bed using 6- to 8-inch blocks.
D. Limit intake of caffeine, alcohol, and spicy foods.
E. Sleep in a flat, supine position to align the esophagus.
F. Quit smoking and maintain a healthy weight.
Correct Answer: B, C, D, F
,Explanation: Lifestyle modifications for GERD focus on reducing intra-abdominal pressure
and preventing the reflux of gastric contents. Clients should be encouraged to eat small,
frequent meals and avoid triggers like caffeine and fatty foods that relax the lower
esophageal sphincter. Elevating the head of the bed utilizes gravity to keep stomach acid
from entering the esophagus during sleep.
4. A nurse is assessing a client who has just returned from a cholecystectomy. The client
reports severe pain in the right shoulder. Which action should the nurse take first?
A. Assist the client to ambulate in the hallway.
B. Apply a heating pad to the client’s shoulder.
C. Administer the prescribed opioid analgesic.
D. Place the client in a high-Fowler’s position.
Correct Answer: A
Explanation: Postoperative shoulder pain following a laparoscopic cholecystectomy is
typically caused by the carbon dioxide gas used to insufflate the abdomen during surgery.
Ambulation is the most effective way to help the body reabsorb the gas and alleviate the
referred pain. While pain medication may be used, addressing the underlying cause
through movement is the nursing priority for this specific complication.
, 5. A client with chronic kidney disease (CKD) has a serum potassium level of 6.2 mEq/L. Which
of the following cardiac manifestations is the nurse most likely to observe on the EKG
monitor?
A. Prominent U waves
B. ST-segment depression
C. Widened P waves
D. Tall, peaked T waves
Correct Answer: D
Explanation: Hyperkalemia is a common and dangerous complication of renal failure
because the kidneys are unable to excrete excess potassium. Tall, peaked T waves are a
classic early sign of hyperkalemia on an electrocardiogram. If the potassium level continues
to rise, it can lead to more severe arrhythmias, including a widened QRS complex and
cardiac arrest.
6. A client is diagnosed with Type 1 Diabetes Mellitus. Which of the following clinical
manifestations are most indicative of Diabetic Ketoacidosis (DKA)? (Select all that apply)
A. Kussmaul respirations
B. Fruity breath odor
C. Severe hypertension
D. Abdominal pain and nausea
Nursing II | Actual Q&A with Rationale (NRSG110
Exam 3) | Ivy Tech
1. A nurse is caring for a client with cirrhosis who presents with confusion and asterixis.
Which of the following medications should the nurse expect the healthcare provider to
prescribe to lower the client’s ammonia levels?
A. Lactulose
B. Spironolactone
C. Furosemide
D. Neomycin
Correct Answer: A
Explanation: Lactulose is administered to clients with hepatic encephalopathy to promote
the excretion of ammonia through the stool. The medication works by acidifying the colon,
which converts ammonia into ammonium, a substance that cannot be reabsorbed into the
bloodstream. The nurse should monitor the client for an increase in bowel movements and
a subsequent improvement in mental status.
2. A client is admitted with an acute exacerbation of COPD. The nurse notes the client is using
pursed-lip breathing. Which of the following describes the primary benefit of this breathing
technique?
A. It increases the rate of breathing to improve oxygenation.
,B. It prevents airway collapse and promotes better gas exchange.
C. It decreases the work of the diaphragm during inspiration.
D. It strengthens the intercostal muscles used for ventilation.
Correct Answer: B
Explanation: Pursed-lip breathing helps to maintain positive pressure in the airways
during exhalation, which prevents the small airways from collapsing. This technique allows
the client to exhale more effectively and reduces the amount of trapped air in the lungs. By
prolonging exhalation, the client can improve overall gas exchange and reduce feelings of
dyspnea.
3. The nurse is providing discharge teaching to a client diagnosed with Gastroesophageal
Reflux Disease (GERD). Which of the following lifestyle modifications should be included in
the teaching? (Select all that apply)
A. Eat three large meals per day to maintain energy levels.
B. Avoid eating within 3 hours of bedtime.
C. Elevate the head of the bed using 6- to 8-inch blocks.
D. Limit intake of caffeine, alcohol, and spicy foods.
E. Sleep in a flat, supine position to align the esophagus.
F. Quit smoking and maintain a healthy weight.
Correct Answer: B, C, D, F
,Explanation: Lifestyle modifications for GERD focus on reducing intra-abdominal pressure
and preventing the reflux of gastric contents. Clients should be encouraged to eat small,
frequent meals and avoid triggers like caffeine and fatty foods that relax the lower
esophageal sphincter. Elevating the head of the bed utilizes gravity to keep stomach acid
from entering the esophagus during sleep.
4. A nurse is assessing a client who has just returned from a cholecystectomy. The client
reports severe pain in the right shoulder. Which action should the nurse take first?
A. Assist the client to ambulate in the hallway.
B. Apply a heating pad to the client’s shoulder.
C. Administer the prescribed opioid analgesic.
D. Place the client in a high-Fowler’s position.
Correct Answer: A
Explanation: Postoperative shoulder pain following a laparoscopic cholecystectomy is
typically caused by the carbon dioxide gas used to insufflate the abdomen during surgery.
Ambulation is the most effective way to help the body reabsorb the gas and alleviate the
referred pain. While pain medication may be used, addressing the underlying cause
through movement is the nursing priority for this specific complication.
, 5. A client with chronic kidney disease (CKD) has a serum potassium level of 6.2 mEq/L. Which
of the following cardiac manifestations is the nurse most likely to observe on the EKG
monitor?
A. Prominent U waves
B. ST-segment depression
C. Widened P waves
D. Tall, peaked T waves
Correct Answer: D
Explanation: Hyperkalemia is a common and dangerous complication of renal failure
because the kidneys are unable to excrete excess potassium. Tall, peaked T waves are a
classic early sign of hyperkalemia on an electrocardiogram. If the potassium level continues
to rise, it can lead to more severe arrhythmias, including a widened QRS complex and
cardiac arrest.
6. A client is diagnosed with Type 1 Diabetes Mellitus. Which of the following clinical
manifestations are most indicative of Diabetic Ketoacidosis (DKA)? (Select all that apply)
A. Kussmaul respirations
B. Fruity breath odor
C. Severe hypertension
D. Abdominal pain and nausea
