NRSG 100 Exam 4 V2 | NRSG 100
Fundamentals of Nursing | Actual Q&A
with Rationale (NRSG100 Exam 4) | Ivy
Tech
1. A nurse is assessing a patient’s peripheral IV site and notes coolness, swelling, and a
sluggish infusion rate. What is the most likely complication?
A. Thrombosis
B. Phlebitis
C. Extravasation
D. Infiltration
Correct Answer: D
Infiltration occurs when non-vesicant IV fluid leaks into the surrounding subcutaneous
tissue, causing coolness and edema. Phlebitis would instead present with warmth and
redness along the vein. The nurse must stop the infusion and elevate the extremity to
promote fluid reabsorption.
2. Which laboratory value should the nurse prioritize when caring for a patient with severe
muscle weakness and cardiac dysrhythmias?
A. Potassium 6.2 mEq/L
B. Sodium 138 mEq/L
,C. Calcium 9.5 mg/dL
D. Magnesium 1.9 mg/dL
Correct Answer: A
A potassium level of 6.2 mEq/L indicates hyperkalemia, which significantly impacts
cardiac electrical conduction. Muscle weakness is a common neuromuscular manifestation
of elevated potassium levels. This condition is a medical emergency that requires
immediate intervention to prevent cardiac arrest.
3. A patient’s arterial blood gas (ABG) results show: pH 7.30, PaCO2 50 mmHg, and HCO3 24
mEq/L. How does the nurse interpret these findings?
A. Respiratory alkalosis
B. Metabolic acidosis
C. Respiratory acidosis
D. Metabolic alkalosis
Correct Answer: C
The pH of 7.30 indicates acidosis, while the elevated PaCO2 of 50 mmHg points to a
respiratory origin. Because the bicarbonate (HCO3) level is within the normal range, the
imbalance is likely uncompensated. The nurse should assess the patient for signs of
hypoventilation or airway obstruction.
, 4. During the preoperative phase, whose primary responsibility is it to obtain the patient’s
signature on the informed consent form?
A. The circulating nurse
B. The anesthesiologist
C. The scrub technician
D. The surgeon
Correct Answer: D
The surgeon is legally responsible for explaining the procedure, risks, and benefits to the
patient before obtaining consent. The nurse’s role is typically to witness the signature and
ensure the patient understands what they are signing. If the patient has questions about
the procedure itself, the nurse must notify the surgeon to return and provide clarification.
5. A nurse is caring for a postoperative patient who has not voided for 8 hours. What is the
priority nursing action?
A. Insert a straight catheter immediately
B. Encourage increased fluid intake
C. Perform a bladder scan
D. Apply heat to the suprapubic area
Correct Answer: C
Fundamentals of Nursing | Actual Q&A
with Rationale (NRSG100 Exam 4) | Ivy
Tech
1. A nurse is assessing a patient’s peripheral IV site and notes coolness, swelling, and a
sluggish infusion rate. What is the most likely complication?
A. Thrombosis
B. Phlebitis
C. Extravasation
D. Infiltration
Correct Answer: D
Infiltration occurs when non-vesicant IV fluid leaks into the surrounding subcutaneous
tissue, causing coolness and edema. Phlebitis would instead present with warmth and
redness along the vein. The nurse must stop the infusion and elevate the extremity to
promote fluid reabsorption.
2. Which laboratory value should the nurse prioritize when caring for a patient with severe
muscle weakness and cardiac dysrhythmias?
A. Potassium 6.2 mEq/L
B. Sodium 138 mEq/L
,C. Calcium 9.5 mg/dL
D. Magnesium 1.9 mg/dL
Correct Answer: A
A potassium level of 6.2 mEq/L indicates hyperkalemia, which significantly impacts
cardiac electrical conduction. Muscle weakness is a common neuromuscular manifestation
of elevated potassium levels. This condition is a medical emergency that requires
immediate intervention to prevent cardiac arrest.
3. A patient’s arterial blood gas (ABG) results show: pH 7.30, PaCO2 50 mmHg, and HCO3 24
mEq/L. How does the nurse interpret these findings?
A. Respiratory alkalosis
B. Metabolic acidosis
C. Respiratory acidosis
D. Metabolic alkalosis
Correct Answer: C
The pH of 7.30 indicates acidosis, while the elevated PaCO2 of 50 mmHg points to a
respiratory origin. Because the bicarbonate (HCO3) level is within the normal range, the
imbalance is likely uncompensated. The nurse should assess the patient for signs of
hypoventilation or airway obstruction.
, 4. During the preoperative phase, whose primary responsibility is it to obtain the patient’s
signature on the informed consent form?
A. The circulating nurse
B. The anesthesiologist
C. The scrub technician
D. The surgeon
Correct Answer: D
The surgeon is legally responsible for explaining the procedure, risks, and benefits to the
patient before obtaining consent. The nurse’s role is typically to witness the signature and
ensure the patient understands what they are signing. If the patient has questions about
the procedure itself, the nurse must notify the surgeon to return and provide clarification.
5. A nurse is caring for a postoperative patient who has not voided for 8 hours. What is the
priority nursing action?
A. Insert a straight catheter immediately
B. Encourage increased fluid intake
C. Perform a bladder scan
D. Apply heat to the suprapubic area
Correct Answer: C
