NSG 3130 Exam 3 V3 | NSG 3130
Fundamental Concepts & Skills for
Nursing Practice II | Actual Q&A with
Rationale (NSG3130 Exam 3) | Galen
College of Nursing
1. A nurse is assessing a patient who is 48 hours post-operative and has not had a bowel
movement. The nurse notes hypoactive bowel sounds and abdominal distension. Which
action should the nurse take first?
A. Administer a prescribed stimulant laxative.
B. Insert a nasogastric tube to low suction.
C. Request an order for a cleansing enema.
D. Ambulate the patient in the hallway.
Answer: D
Rationale: Early ambulation is the most effective nursing intervention to stimulate
peristalsis in the post-operative period. It is a non-invasive measure that promotes the
return of bowel function. Pharmacological interventions are generally reserved if mobility
does not resolve the issue.
2. A patient’s arterial blood gas (ABG) results are: pH 7.30, PaCO2 52 mmHg, and HCO3 26
mEq/L. How should the nurse interpret these findings?
A. Metabolic Acidosis
,B. Respiratory Acidosis
C. Respiratory Alkalosis
D. Metabolic Alkalosis
Answer: B
Rationale: The pH is below the normal range of 7.35-7.45, indicating acidosis. The PaCO2
is elevated above 45 mmHg, which identifies the respiratory system as the cause of the
imbalance. The bicarbonate (HCO3) is within the normal range, confirming it is not
metabolic in origin.
3. Which clinical manifestation should the nurse expect to find in a patient with a serum
potassium level of 2.8 mEq/L?
A. Hyperactive deep tendon reflexes
B. Diarrhea and abdominal cramping
C. Peaked T-waves on an EKG
D. Muscle weakness and leg cramps
Answer: D
Rationale: Hypokalemia, defined as potassium less than 3.5 mEq/L, commonly manifests
as muscle weakness and cramps. It can also cause cardiac dysrhythmias and decreased
bowel motility. Peaked T-waves and hyperactive reflexes are more commonly associated
with hyperkalemia.
, 4. A nurse is preparing to administer a cleansing enema to a patient. In which position should
the nurse place the patient?
A. Right lateral position with knees flexed
B. Dorsal recumbent position
C. High-Fowler’s position
D. Left Sims’ position
Answer: D
Rationale: The left Sims’ position allows the enema solution to flow by gravity into the
sigmoid colon and rectum. This position follows the natural anatomy of the colon for better
distribution. It also provides comfort and safety for the patient during the procedure.
5. A patient is scheduled for surgery and the nurse is reviewing the informed consent. What is
the nurse’s primary responsibility regarding the consent form?
A. Explain the risks and benefits of the procedure.
B. Ensure the surgeon has provided all necessary information.
C. Witness the patient’s signature on the form.
D. Decide if the patient is mentally competent.
Answer: C
Rationale: The nurse’s role is to act as a witness to the signature, confirming that the
patient signed the document voluntarily. It is the surgeon’s responsibility to explain the
Fundamental Concepts & Skills for
Nursing Practice II | Actual Q&A with
Rationale (NSG3130 Exam 3) | Galen
College of Nursing
1. A nurse is assessing a patient who is 48 hours post-operative and has not had a bowel
movement. The nurse notes hypoactive bowel sounds and abdominal distension. Which
action should the nurse take first?
A. Administer a prescribed stimulant laxative.
B. Insert a nasogastric tube to low suction.
C. Request an order for a cleansing enema.
D. Ambulate the patient in the hallway.
Answer: D
Rationale: Early ambulation is the most effective nursing intervention to stimulate
peristalsis in the post-operative period. It is a non-invasive measure that promotes the
return of bowel function. Pharmacological interventions are generally reserved if mobility
does not resolve the issue.
2. A patient’s arterial blood gas (ABG) results are: pH 7.30, PaCO2 52 mmHg, and HCO3 26
mEq/L. How should the nurse interpret these findings?
A. Metabolic Acidosis
,B. Respiratory Acidosis
C. Respiratory Alkalosis
D. Metabolic Alkalosis
Answer: B
Rationale: The pH is below the normal range of 7.35-7.45, indicating acidosis. The PaCO2
is elevated above 45 mmHg, which identifies the respiratory system as the cause of the
imbalance. The bicarbonate (HCO3) is within the normal range, confirming it is not
metabolic in origin.
3. Which clinical manifestation should the nurse expect to find in a patient with a serum
potassium level of 2.8 mEq/L?
A. Hyperactive deep tendon reflexes
B. Diarrhea and abdominal cramping
C. Peaked T-waves on an EKG
D. Muscle weakness and leg cramps
Answer: D
Rationale: Hypokalemia, defined as potassium less than 3.5 mEq/L, commonly manifests
as muscle weakness and cramps. It can also cause cardiac dysrhythmias and decreased
bowel motility. Peaked T-waves and hyperactive reflexes are more commonly associated
with hyperkalemia.
, 4. A nurse is preparing to administer a cleansing enema to a patient. In which position should
the nurse place the patient?
A. Right lateral position with knees flexed
B. Dorsal recumbent position
C. High-Fowler’s position
D. Left Sims’ position
Answer: D
Rationale: The left Sims’ position allows the enema solution to flow by gravity into the
sigmoid colon and rectum. This position follows the natural anatomy of the colon for better
distribution. It also provides comfort and safety for the patient during the procedure.
5. A patient is scheduled for surgery and the nurse is reviewing the informed consent. What is
the nurse’s primary responsibility regarding the consent form?
A. Explain the risks and benefits of the procedure.
B. Ensure the surgeon has provided all necessary information.
C. Witness the patient’s signature on the form.
D. Decide if the patient is mentally competent.
Answer: C
Rationale: The nurse’s role is to act as a witness to the signature, confirming that the
patient signed the document voluntarily. It is the surgeon’s responsibility to explain the
