NSG223/NSG 223 Exam 1 V3 | Medical-
Surgical Nursing II Q&A with Rationale |
Herzing University
1. A patient with chronic obstructive pulmonary disease (COPD) presents with a pH of 7.28,
PaCO2 of 54 mmHg, and HCO3 of 25 mEq/L. Which acid-base imbalance is the patient
experiencing?
A. Metabolic Acidosis
B. Respiratory Alkalosis
C. Respiratory Acidosis
D. Metabolic Alkalosis
Correct Answer: C
Rationale: The pH is below 7.35, indicating acidosis, and the PaCO2 is elevated above 45
mmHg, which points to a respiratory cause. Patients with COPD often retain carbon dioxide
due to impaired gas exchange, leading to this specific imbalance. The bicarbonate level is
currently within the normal range, suggesting that compensation has not yet occurred or is
incomplete.
2. When witnessing a patient sign a surgical consent form, what is the primary responsibility
of the nurse?
A. Verifying that the signature is authentic and the patient is competent.
,B. Explaining the risks and benefits of the surgery to the patient.
C. Answering specific questions about the surgical technique.
D. Deciding if the patient should proceed with the procedure.
Correct Answer: A
Rationale: The nurse’s role in the consent process is to act as a witness to the signature
and ensure the patient is signing voluntarily. It is the surgeon’s legal responsibility to
explain the procedure, its risks, and alternative treatments. If the patient expresses a lack
of understanding, the nurse must notify the surgeon to return and provide further
clarification before the surgery proceeds.
3. A patient is receiving a blood transfusion and begins to complain of back pain, chills, and
shortness of breath. What is the nurse’s priority action?
A. Slow the infusion rate and notify the physician.
B. Stop the infusion immediately and disconnect the tubing.
C. Administer diphenhydramine as ordered.
D. Check the patient’s temperature and blood pressure.
Correct Answer: B
Rationale: These symptoms are classic signs of a hemolytic transfusion reaction, which is a
medical emergency. The nurse must stop the infusion immediately to prevent further
exposure to the incompatible blood. After stopping the infusion, the nurse should maintain
, the IV line with normal saline using new tubing and then notify the healthcare provider and
blood bank.
4. Which electrolyte imbalance should the nurse monitor for in a patient with a potassium
level of 6.2 mEq/L?
A. Hyperkalemia
B. Hypernatremia
C. Hypokalemia
D. Hypocalcemia
Correct Answer: A
Rationale: A potassium level of 6.2 mEq/L is significantly above the normal range of 3.5 to
5.0 mEq/L, indicating hyperkalemia. This condition is dangerous because it can lead to
cardiac dysrhythmias and even cardiac arrest. The nurse must monitor the patient’s EKG
for tall, peaked T waves and prepare for interventions like Kayexalate or insulin
administration.
5. During the intraoperative phase, the ‘time-out’ procedure is performed primarily to:
A. Allow the anesthesia provider to adjust medication levels.
B. Verify the correct patient, site, and procedure before the incision.
C. Ensure the surgical count of sponges and needles is accurate.
D. Provide a break for the surgical team before a long procedure.
Surgical Nursing II Q&A with Rationale |
Herzing University
1. A patient with chronic obstructive pulmonary disease (COPD) presents with a pH of 7.28,
PaCO2 of 54 mmHg, and HCO3 of 25 mEq/L. Which acid-base imbalance is the patient
experiencing?
A. Metabolic Acidosis
B. Respiratory Alkalosis
C. Respiratory Acidosis
D. Metabolic Alkalosis
Correct Answer: C
Rationale: The pH is below 7.35, indicating acidosis, and the PaCO2 is elevated above 45
mmHg, which points to a respiratory cause. Patients with COPD often retain carbon dioxide
due to impaired gas exchange, leading to this specific imbalance. The bicarbonate level is
currently within the normal range, suggesting that compensation has not yet occurred or is
incomplete.
2. When witnessing a patient sign a surgical consent form, what is the primary responsibility
of the nurse?
A. Verifying that the signature is authentic and the patient is competent.
,B. Explaining the risks and benefits of the surgery to the patient.
C. Answering specific questions about the surgical technique.
D. Deciding if the patient should proceed with the procedure.
Correct Answer: A
Rationale: The nurse’s role in the consent process is to act as a witness to the signature
and ensure the patient is signing voluntarily. It is the surgeon’s legal responsibility to
explain the procedure, its risks, and alternative treatments. If the patient expresses a lack
of understanding, the nurse must notify the surgeon to return and provide further
clarification before the surgery proceeds.
3. A patient is receiving a blood transfusion and begins to complain of back pain, chills, and
shortness of breath. What is the nurse’s priority action?
A. Slow the infusion rate and notify the physician.
B. Stop the infusion immediately and disconnect the tubing.
C. Administer diphenhydramine as ordered.
D. Check the patient’s temperature and blood pressure.
Correct Answer: B
Rationale: These symptoms are classic signs of a hemolytic transfusion reaction, which is a
medical emergency. The nurse must stop the infusion immediately to prevent further
exposure to the incompatible blood. After stopping the infusion, the nurse should maintain
, the IV line with normal saline using new tubing and then notify the healthcare provider and
blood bank.
4. Which electrolyte imbalance should the nurse monitor for in a patient with a potassium
level of 6.2 mEq/L?
A. Hyperkalemia
B. Hypernatremia
C. Hypokalemia
D. Hypocalcemia
Correct Answer: A
Rationale: A potassium level of 6.2 mEq/L is significantly above the normal range of 3.5 to
5.0 mEq/L, indicating hyperkalemia. This condition is dangerous because it can lead to
cardiac dysrhythmias and even cardiac arrest. The nurse must monitor the patient’s EKG
for tall, peaked T waves and prepare for interventions like Kayexalate or insulin
administration.
5. During the intraoperative phase, the ‘time-out’ procedure is performed primarily to:
A. Allow the anesthesia provider to adjust medication levels.
B. Verify the correct patient, site, and procedure before the incision.
C. Ensure the surgical count of sponges and needles is accurate.
D. Provide a break for the surgical team before a long procedure.
