NRSG 201 Exam 2 V3 | NRSG 201 Med
Surg 1 | Actual Q&A with Rationale
(NRSG201 Exam 2) | Ivy Tech
1. A nurse is providing preoperative teaching to a client. Which statement by the client
indicates an understanding of the use of incentive spirometry?
A. I should breathe out forcefully into the device.
B. I will take a deep breath and hold it for 3 to 5 seconds before exhaling.
C. I only need to use this if I develop a cough.
D. I will use the device once every 4 hours while awake.
Correct Answer: B
The correct technique for incentive spirometry involves a slow, deep inhalation to
maximum capacity followed by a breath hold. This maneuver helps to expand the alveoli
and prevent postoperative atelectasis. The patient should aim to perform this exercise 10
times every hour while awake.
2. Which of the following electrolyte imbalances is most closely associated with the presence
of Chvostek’s sign and Trousseau’s sign?
A. Hypocalcemia
B. Hyponatremia
C. Hyperkalemia
,D. Hypomagnesemia
Correct Answer: A
Hypocalcemia increases neuromuscular irritability, leading to signs such as tetany and
muscle twitching. Chvostek’s sign is elicited by tapping the facial nerve, while Trousseau’s
sign is a carpal spasm induced by inflating a blood pressure cuff. The nurse must monitor
for these signs in patients who have undergone thyroid or parathyroid surgery.
3. 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. Respiratory Acidosis
B. Metabolic Acidosis
C. Respiratory Alkalosis
D. Metabolic Alkalosis
Correct Answer: A
A pH of 7.30 indicates acidosis, and a PaCO2 of 52 mmHg indicates that the cause is
respiratory in nature. Because the bicarbonate level is within the normal range, the
condition is currently uncompensated. This pattern is commonly seen in patients with
hypoventilation or COPD exacerbations.
4. A nurse is caring for a client who is 2 hours postoperative. Which of the following is the
priority assessment?
A. Urine output and catheter drainage
, B. Pain level and last analgesic dose
C. Airway patency and oxygen saturation
D. Surgical dressing integrity
Correct Answer: C
According to the ABC (Airway, Breathing, Circulation) priority framework, airway
management is always the first priority in the immediate postoperative period. Anesthesia
and sedation can depress the respiratory drive and cause airway obstruction. Ensuring
adequate oxygenation is vital to preventing tissue hypoxia and other complications.
5. The nurse is assessing a client with fluid volume excess. Which clinical manifestation
should the nurse expect to find?
A. Flattened neck veins
B. Distended neck veins (JVD)
C. Decreased blood pressure
D. Dry mucous membranes
Correct Answer: B
Fluid volume excess leads to an increase in intravascular pressure, which manifests as
jugular venous distention. Other common signs include peripheral edema, crackles in the
lungs, and weight gain. The nurse should monitor the patient’s daily weight and restrict
sodium intake as ordered.
Surg 1 | Actual Q&A with Rationale
(NRSG201 Exam 2) | Ivy Tech
1. A nurse is providing preoperative teaching to a client. Which statement by the client
indicates an understanding of the use of incentive spirometry?
A. I should breathe out forcefully into the device.
B. I will take a deep breath and hold it for 3 to 5 seconds before exhaling.
C. I only need to use this if I develop a cough.
D. I will use the device once every 4 hours while awake.
Correct Answer: B
The correct technique for incentive spirometry involves a slow, deep inhalation to
maximum capacity followed by a breath hold. This maneuver helps to expand the alveoli
and prevent postoperative atelectasis. The patient should aim to perform this exercise 10
times every hour while awake.
2. Which of the following electrolyte imbalances is most closely associated with the presence
of Chvostek’s sign and Trousseau’s sign?
A. Hypocalcemia
B. Hyponatremia
C. Hyperkalemia
,D. Hypomagnesemia
Correct Answer: A
Hypocalcemia increases neuromuscular irritability, leading to signs such as tetany and
muscle twitching. Chvostek’s sign is elicited by tapping the facial nerve, while Trousseau’s
sign is a carpal spasm induced by inflating a blood pressure cuff. The nurse must monitor
for these signs in patients who have undergone thyroid or parathyroid surgery.
3. 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. Respiratory Acidosis
B. Metabolic Acidosis
C. Respiratory Alkalosis
D. Metabolic Alkalosis
Correct Answer: A
A pH of 7.30 indicates acidosis, and a PaCO2 of 52 mmHg indicates that the cause is
respiratory in nature. Because the bicarbonate level is within the normal range, the
condition is currently uncompensated. This pattern is commonly seen in patients with
hypoventilation or COPD exacerbations.
4. A nurse is caring for a client who is 2 hours postoperative. Which of the following is the
priority assessment?
A. Urine output and catheter drainage
, B. Pain level and last analgesic dose
C. Airway patency and oxygen saturation
D. Surgical dressing integrity
Correct Answer: C
According to the ABC (Airway, Breathing, Circulation) priority framework, airway
management is always the first priority in the immediate postoperative period. Anesthesia
and sedation can depress the respiratory drive and cause airway obstruction. Ensuring
adequate oxygenation is vital to preventing tissue hypoxia and other complications.
5. The nurse is assessing a client with fluid volume excess. Which clinical manifestation
should the nurse expect to find?
A. Flattened neck veins
B. Distended neck veins (JVD)
C. Decreased blood pressure
D. Dry mucous membranes
Correct Answer: B
Fluid volume excess leads to an increase in intravascular pressure, which manifests as
jugular venous distention. Other common signs include peripheral edema, crackles in the
lungs, and weight gain. The nurse should monitor the patient’s daily weight and restrict
sodium intake as ordered.
