NRSG 110 Final Exam V2 | NRSG 110
Medical Surgical Nursing II | Actual Q&A
with Rationale (NRSG110 Final Exam) | Ivy
Tech
1. A nurse is assessing a patient with a history of left-sided heart failure. Which of the
following findings should the nurse expect?
A. Jugular venous distension
B. Crackles in the lungs
C. Dependent edema
D. Hepatosplenomegaly
Correct Answer: B
Left-sided heart failure causes blood to back up into the pulmonary circulation, leading to
pulmonary congestion and crackles. Right-sided heart failure typically manifests as
systemic symptoms like jugular venous distension and peripheral edema. The nurse must
monitor for dyspnea and orthopnea in these patients to prevent respiratory failure.
2. The nurse is evaluating the arterial blood gas (ABG) results for a patient with COPD: pH
7.28, PaCO2 55 mm Hg, and HCO3 26 mEq/L. Which acid-base imbalance is occurring?
A. Metabolic Acidosis
B. Metabolic Alkalosis
,C. Compensated Respiratory Acidosis
D. Respiratory Alkalosis
E. Respiratory Acidosis
Correct Answer: E
The pH is below 7.35, indicating acidosis, and the PaCO2 is elevated above 45 mm Hg,
indicating a respiratory cause. The HCO3 is within the normal range, suggesting that
compensation has not yet occurred. This clinical picture is common in patients with
chronic obstructive pulmonary disease who retain carbon dioxide.
3. A patient is receiving a potassium chloride (KCl) intravenous infusion. Which action by the
nurse is essential for safety?
A. Administer the medication via IV push
B. Use an infusion pump for administration
C. Limit the concentration to 80 mEq/L
D. Check the urine output every 8 hours
Correct Answer: B
Potassium must always be administered via an infusion pump to prevent accidental rapid
bolus, which can cause cardiac arrest. It should never be given by IV push or as a
concentrated bolus. The nurse should also monitor the insertion site for signs of phlebitis
and verify adequate renal function before administration.
, 4. Which clinical manifestation is a hallmark sign of the early stage of hypovolemic shock?
A. Bradycardia
B. Hypertension
C. Increased urine output
D. Tachycardia
Correct Answer: D
Tachycardia is one of the earliest signs of hypovolemic shock as the body attempts to
maintain cardiac output. As blood volume drops, the heart rate increases to compensate for
the reduced stroke volume. The nurse must also look for cold, clammy skin and a
narrowing pulse pressure as shock progresses.
5. A nurse is providing discharge instructions to a patient with peripheral artery disease
(PAD). Which statement should be included?
A. Walk until you feel pain, rest, and then continue walking.
B. Cross your legs at the knees to improve comfort.
C. Apply a heating pad to your feet to improve blood flow.
D. Wear tight-fitting socks to provide compression.
Correct Answer: A
Exercise, specifically walking to the point of pain followed by rest, helps develop collateral
circulation in patients with PAD. Patients should avoid external heat sources because of the
Medical Surgical Nursing II | Actual Q&A
with Rationale (NRSG110 Final Exam) | Ivy
Tech
1. A nurse is assessing a patient with a history of left-sided heart failure. Which of the
following findings should the nurse expect?
A. Jugular venous distension
B. Crackles in the lungs
C. Dependent edema
D. Hepatosplenomegaly
Correct Answer: B
Left-sided heart failure causes blood to back up into the pulmonary circulation, leading to
pulmonary congestion and crackles. Right-sided heart failure typically manifests as
systemic symptoms like jugular venous distension and peripheral edema. The nurse must
monitor for dyspnea and orthopnea in these patients to prevent respiratory failure.
2. The nurse is evaluating the arterial blood gas (ABG) results for a patient with COPD: pH
7.28, PaCO2 55 mm Hg, and HCO3 26 mEq/L. Which acid-base imbalance is occurring?
A. Metabolic Acidosis
B. Metabolic Alkalosis
,C. Compensated Respiratory Acidosis
D. Respiratory Alkalosis
E. Respiratory Acidosis
Correct Answer: E
The pH is below 7.35, indicating acidosis, and the PaCO2 is elevated above 45 mm Hg,
indicating a respiratory cause. The HCO3 is within the normal range, suggesting that
compensation has not yet occurred. This clinical picture is common in patients with
chronic obstructive pulmonary disease who retain carbon dioxide.
3. A patient is receiving a potassium chloride (KCl) intravenous infusion. Which action by the
nurse is essential for safety?
A. Administer the medication via IV push
B. Use an infusion pump for administration
C. Limit the concentration to 80 mEq/L
D. Check the urine output every 8 hours
Correct Answer: B
Potassium must always be administered via an infusion pump to prevent accidental rapid
bolus, which can cause cardiac arrest. It should never be given by IV push or as a
concentrated bolus. The nurse should also monitor the insertion site for signs of phlebitis
and verify adequate renal function before administration.
, 4. Which clinical manifestation is a hallmark sign of the early stage of hypovolemic shock?
A. Bradycardia
B. Hypertension
C. Increased urine output
D. Tachycardia
Correct Answer: D
Tachycardia is one of the earliest signs of hypovolemic shock as the body attempts to
maintain cardiac output. As blood volume drops, the heart rate increases to compensate for
the reduced stroke volume. The nurse must also look for cold, clammy skin and a
narrowing pulse pressure as shock progresses.
5. A nurse is providing discharge instructions to a patient with peripheral artery disease
(PAD). Which statement should be included?
A. Walk until you feel pain, rest, and then continue walking.
B. Cross your legs at the knees to improve comfort.
C. Apply a heating pad to your feet to improve blood flow.
D. Wear tight-fitting socks to provide compression.
Correct Answer: A
Exercise, specifically walking to the point of pain followed by rest, helps develop collateral
circulation in patients with PAD. Patients should avoid external heat sources because of the
