NRSG 110 Exam 2 V1 | NRSG 110 Medical
Surgical Nursing II | Actual Q&A with
Rationale (NRSG110 Exam 2) | Ivy Tech
1. A nurse is caring for a patient with Type 1 Diabetes Mellitus who was administered Regular
insulin at 07:30. At which time should the nurse be most alert for signs of hypoglycemia?
A. 08:00 to 08:30
B. 08:45 to 09:15
C. 16:00 to 18:00
D. 13:00 to 15:00
E. 10:00 to 12:30
F. 19:00 to 21:00
Correct Answer: E
Regular insulin is categorized as short-acting insulin with a peak effect occurring
approximately 2 to 5 hours after subcutaneous injection. Monitoring for hypoglycemia is
critical during this peak period because the insulin concentration in the blood is at its
highest point. Since the dose was given at 07:30, the nurse should expect the maximum
effect to occur between 09:30 and 12:30.
,2. Which assessment finding should the nurse prioritize for a patient diagnosed with hepatic
encephalopathy secondary to cirrhosis?
A. Increased abdominal girth and fluid wave
B. Presence of spider angiomas on the chest
C. Altered mental status and asterixis
D. Generalized pruritus and jaundice
Correct Answer: C
Hepatic encephalopathy is a serious complication of liver failure caused by the
accumulation of ammonia and other neurotoxins in the blood. The hallmark signs include
neurological changes such as confusion, lethargy, and asterixis, also known as a flapping
tremor of the hands. Early identification of these symptoms is vital to prevent progression
to a hepatic coma.
3. A patient is recovering from a subtotal thyroidectomy. Which equipment is most essential
for the nurse to keep at the bedside?
A. Continuous blood pressure monitor
B. Percussion hammer and tuning fork
C. Incentive spirometer and a pillow for splinting
D. Tracheostomy tray and suctioning equipment
Correct Answer: D
, Post-operative thyroidectomy patients are at significant risk for airway obstruction due to
edema, laryngeal nerve damage, or hemorrhage. Keeping a tracheostomy tray at the
bedside ensures that an emergency airway can be established immediately if respiratory
distress occurs. The nurse must also monitor for signs of stridor, which indicates a critical
narrowing of the airway.
4. The nurse is assessing a patient with Diabetes Insipidus. Which clinical manifestation is
most characteristic of this disorder?
A. Large amounts of very dilute urine
B. Hypervolemia and hypertension
C. Elevated urine specific gravity
D. Weight gain and peripheral edema
Correct Answer: A
Diabetes Insipidus is characterized by a deficiency of Antidiuretic Hormone (ADH), which
prevents the kidneys from reabsorbing water. This results in the excretion of massive
quantities of dilute urine, often exceeding 5 to 20 liters per day. Patients will typically
present with severe thirst and a very low urine specific gravity, usually below 1.005.
5. A patient with chronic kidney disease (CKD) has a potassium level of 6.4 mEq/L. Which
medication should the nurse anticipate administering to stabilize the cardiac membrane?
A. Sodium polystyrene sulfonate
B. Furosemide
, C. Regular insulin and Dextrose 50%
D. Calcium gluconate
E. Epoetin alfa
Correct Answer: D
In cases of severe hyperkalemia, calcium gluconate is administered intravenously to
protect the heart from the toxic effects of high potassium. While it does not lower the
potassium level, it stabilizes the cardiac cell membrane to prevent life-threatening
arrhythmias. The nurse should follow this with treatments like insulin or resin exchangers
to actually reduce the serum potassium concentration.
6. The nurse is providing discharge teaching for a patient with a new diagnosis of Cushing’s
syndrome. Which dietary modification should be included?
A. Decrease sodium intake and increase potassium
B. Increase intake of sodium and fat
C. Restrict protein and carbohydrate intake
D. Consume a high-calorie, low-protein diet
Correct Answer: A
Cushing’s syndrome involves an excess of cortisol, which leads to sodium and water
retention as well as potassium depletion. Patients should be taught to limit sodium to
reduce edema and hypertension while increasing potassium-rich foods to counteract
Surgical Nursing II | Actual Q&A with
Rationale (NRSG110 Exam 2) | Ivy Tech
1. A nurse is caring for a patient with Type 1 Diabetes Mellitus who was administered Regular
insulin at 07:30. At which time should the nurse be most alert for signs of hypoglycemia?
A. 08:00 to 08:30
B. 08:45 to 09:15
C. 16:00 to 18:00
D. 13:00 to 15:00
E. 10:00 to 12:30
F. 19:00 to 21:00
Correct Answer: E
Regular insulin is categorized as short-acting insulin with a peak effect occurring
approximately 2 to 5 hours after subcutaneous injection. Monitoring for hypoglycemia is
critical during this peak period because the insulin concentration in the blood is at its
highest point. Since the dose was given at 07:30, the nurse should expect the maximum
effect to occur between 09:30 and 12:30.
,2. Which assessment finding should the nurse prioritize for a patient diagnosed with hepatic
encephalopathy secondary to cirrhosis?
A. Increased abdominal girth and fluid wave
B. Presence of spider angiomas on the chest
C. Altered mental status and asterixis
D. Generalized pruritus and jaundice
Correct Answer: C
Hepatic encephalopathy is a serious complication of liver failure caused by the
accumulation of ammonia and other neurotoxins in the blood. The hallmark signs include
neurological changes such as confusion, lethargy, and asterixis, also known as a flapping
tremor of the hands. Early identification of these symptoms is vital to prevent progression
to a hepatic coma.
3. A patient is recovering from a subtotal thyroidectomy. Which equipment is most essential
for the nurse to keep at the bedside?
A. Continuous blood pressure monitor
B. Percussion hammer and tuning fork
C. Incentive spirometer and a pillow for splinting
D. Tracheostomy tray and suctioning equipment
Correct Answer: D
, Post-operative thyroidectomy patients are at significant risk for airway obstruction due to
edema, laryngeal nerve damage, or hemorrhage. Keeping a tracheostomy tray at the
bedside ensures that an emergency airway can be established immediately if respiratory
distress occurs. The nurse must also monitor for signs of stridor, which indicates a critical
narrowing of the airway.
4. The nurse is assessing a patient with Diabetes Insipidus. Which clinical manifestation is
most characteristic of this disorder?
A. Large amounts of very dilute urine
B. Hypervolemia and hypertension
C. Elevated urine specific gravity
D. Weight gain and peripheral edema
Correct Answer: A
Diabetes Insipidus is characterized by a deficiency of Antidiuretic Hormone (ADH), which
prevents the kidneys from reabsorbing water. This results in the excretion of massive
quantities of dilute urine, often exceeding 5 to 20 liters per day. Patients will typically
present with severe thirst and a very low urine specific gravity, usually below 1.005.
5. A patient with chronic kidney disease (CKD) has a potassium level of 6.4 mEq/L. Which
medication should the nurse anticipate administering to stabilize the cardiac membrane?
A. Sodium polystyrene sulfonate
B. Furosemide
, C. Regular insulin and Dextrose 50%
D. Calcium gluconate
E. Epoetin alfa
Correct Answer: D
In cases of severe hyperkalemia, calcium gluconate is administered intravenously to
protect the heart from the toxic effects of high potassium. While it does not lower the
potassium level, it stabilizes the cardiac cell membrane to prevent life-threatening
arrhythmias. The nurse should follow this with treatments like insulin or resin exchangers
to actually reduce the serum potassium concentration.
6. The nurse is providing discharge teaching for a patient with a new diagnosis of Cushing’s
syndrome. Which dietary modification should be included?
A. Decrease sodium intake and increase potassium
B. Increase intake of sodium and fat
C. Restrict protein and carbohydrate intake
D. Consume a high-calorie, low-protein diet
Correct Answer: A
Cushing’s syndrome involves an excess of cortisol, which leads to sodium and water
retention as well as potassium depletion. Patients should be taught to limit sodium to
reduce edema and hypertension while increasing potassium-rich foods to counteract
