NRSG 110 Exam 4 V2 | NRSG 110 Medical
Surgical Nursing II | Actual Q&A with
Rationale (NRSG110 Exam 4) | Ivy Tech
1. A nurse is caring for a client with a history of chronic kidney disease (CKD). Which of the
following laboratory results should the nurse expect to find?
A. Hypokalemia
B. Respiratory alkalosis
C. Hypocalcemia
D. Hypomagnesemia
Correct Answer: C
In chronic kidney disease, the kidneys are unable to activate vitamin D, which is essential
for calcium absorption. This lead to a state of hypocalcemia and a reciprocal increase in
phosphorus levels. The nurse should monitor for signs of bone density loss and provide
phosphate binders as ordered.
2. A client is admitted to the emergency department after a motor vehicle accident. The
nurse observes signs of Cushing’s Triad. Which assessment findings are consistent with this
condition?
A. Tachycardia, hypotension, and tachypnea
B. Bradycardia, hypertension with a widening pulse pressure, and irregular respirations
,C. Bradycardia, hypotension, and irregular respirations
D. Tachycardia, hypertension, and Cheyne-Stokes respirations
E. Hyperthermia, tachycardia, and increased Glasglow Coma Scale score
Correct Answer: B
Cushing’s triad is a late sign of increased intracranial pressure (ICP) that indicates
brainstem compression. It consists of a specific set of vital sign changes: bradycardia,
hypertension with a widening pulse pressure, and irregular or slowed respirations.
Immediate intervention is required to prevent brain herniation and death.
3. A nurse is providing education to a client with glaucoma. Which statement by the client
indicates a need for further teaching regarding the use of eye drops?
A. I will wait 5 minutes between different types of eye drops.
B. I will apply pressure to the inner corner of my eye after instilling the drops.
C. I will avoid touching the tip of the dropper to my eye.
D. I can stop using the drops once my vision improves and my pressure is normal.
Correct Answer: D
Glaucoma is a chronic condition that typically requires lifelong medication to prevent
further vision loss from increased intraocular pressure. Stopping the medication abruptly
can lead to a rapid increase in pressure and permanent blindness. The client must
understand that the medication manages the disease but does not cure it.
, 4. A client is experiencing an acute gout attack. Which of the following medications should
the nurse anticipate the provider will prescribe for acute symptom relief?
A. Allopurinol
B. Colchicine
C. Probenecid
D. Febuxostat
Correct Answer: B
Colchicine is an anti-inflammatory agent used specifically for the treatment of acute gouty
attacks to reduce pain and swelling. Allopurinol and Probenecid are used for long-term
maintenance to lower uric acid levels but are not effective for acute pain. Clients should be
monitored for gastrointestinal side effects such as diarrhea when taking colchicine.
5. Which clinical manifestation is characteristic of a client experiencing autonomic dysreflexia
after a spinal cord injury at the T6 level?
A. Hypotension and tachycardia
B. Pale, cool skin above the level of injury
C. Severe headache and flushing above the level of injury
D. Diarrhea and abdominal cramping
E. Loss of consciousness and seizures
Correct Answer: C
Surgical Nursing II | Actual Q&A with
Rationale (NRSG110 Exam 4) | Ivy Tech
1. A nurse is caring for a client with a history of chronic kidney disease (CKD). Which of the
following laboratory results should the nurse expect to find?
A. Hypokalemia
B. Respiratory alkalosis
C. Hypocalcemia
D. Hypomagnesemia
Correct Answer: C
In chronic kidney disease, the kidneys are unable to activate vitamin D, which is essential
for calcium absorption. This lead to a state of hypocalcemia and a reciprocal increase in
phosphorus levels. The nurse should monitor for signs of bone density loss and provide
phosphate binders as ordered.
2. A client is admitted to the emergency department after a motor vehicle accident. The
nurse observes signs of Cushing’s Triad. Which assessment findings are consistent with this
condition?
A. Tachycardia, hypotension, and tachypnea
B. Bradycardia, hypertension with a widening pulse pressure, and irregular respirations
,C. Bradycardia, hypotension, and irregular respirations
D. Tachycardia, hypertension, and Cheyne-Stokes respirations
E. Hyperthermia, tachycardia, and increased Glasglow Coma Scale score
Correct Answer: B
Cushing’s triad is a late sign of increased intracranial pressure (ICP) that indicates
brainstem compression. It consists of a specific set of vital sign changes: bradycardia,
hypertension with a widening pulse pressure, and irregular or slowed respirations.
Immediate intervention is required to prevent brain herniation and death.
3. A nurse is providing education to a client with glaucoma. Which statement by the client
indicates a need for further teaching regarding the use of eye drops?
A. I will wait 5 minutes between different types of eye drops.
B. I will apply pressure to the inner corner of my eye after instilling the drops.
C. I will avoid touching the tip of the dropper to my eye.
D. I can stop using the drops once my vision improves and my pressure is normal.
Correct Answer: D
Glaucoma is a chronic condition that typically requires lifelong medication to prevent
further vision loss from increased intraocular pressure. Stopping the medication abruptly
can lead to a rapid increase in pressure and permanent blindness. The client must
understand that the medication manages the disease but does not cure it.
, 4. A client is experiencing an acute gout attack. Which of the following medications should
the nurse anticipate the provider will prescribe for acute symptom relief?
A. Allopurinol
B. Colchicine
C. Probenecid
D. Febuxostat
Correct Answer: B
Colchicine is an anti-inflammatory agent used specifically for the treatment of acute gouty
attacks to reduce pain and swelling. Allopurinol and Probenecid are used for long-term
maintenance to lower uric acid levels but are not effective for acute pain. Clients should be
monitored for gastrointestinal side effects such as diarrhea when taking colchicine.
5. Which clinical manifestation is characteristic of a client experiencing autonomic dysreflexia
after a spinal cord injury at the T6 level?
A. Hypotension and tachycardia
B. Pale, cool skin above the level of injury
C. Severe headache and flushing above the level of injury
D. Diarrhea and abdominal cramping
E. Loss of consciousness and seizures
Correct Answer: C
