NRSG 100 Exam 4 V2 | NRSG 100 Fundamentals of
Nursing | Actual Q&A with Rationale (NRSG100
Exam 4) | Ivy Tech
1. A nurse is caring for a client who is experiencing respiratory acidosis. Which of the
following conditions is a likely cause of this acid-base imbalance?
A. Hyperventilation
B. Hypoventilation due to COPD
C. Excessive vomiting
D. Aspirin overdose
Correct Answer: B
Explanation: Respiratory acidosis is characterized by an excess of CO2 in the blood due to
inadequate gas exchange. Hypoventilation, often seen in chronic obstructive pulmonary
disease (COPD), leads to the retention of carbon dioxide. The nurse must monitor for signs
of confusion and lethargy as the pH level drops.
2. A nurse is assessing a client with a potassium level of 3.2 mEq/L. Which clinical
manifestation should the nurse expect to find?
A. Hyperactive bowel sounds
B. Peaked T-waves on EKG
C. Muscle weakness and leg cramps
,D. Hypertension
Correct Answer: C
Explanation: A potassium level of 3.2 mEq/L indicates hypokalemia, which affects
neuromuscular function. Clients often present with muscle weakness, fatigue, and
decreased bowel motility. Severe hypokalemia can also lead to dangerous cardiac
arrhythmias that require immediate intervention.
3. Which of the following interventions is a priority for a client with a nursing diagnosis of
‘Risk for Aspiration’ during enteral feedings?
A. Administering feedings while the client is flat
B. Flushing the tube with 100 mL of water
C. Checking the residual volume every 12 hours
D. Elevating the head of the bed to at least 30 to 45 degrees
Correct Answer: D
Explanation: Maintaining the head of the bed at an angle of 30 to 45 degrees prevents
gastric reflux into the esophagus. This positioning is the primary nursing intervention to
reduce the risk of pulmonary aspiration during and after feedings. Proper gastric residual
checks and tube placement verification are also essential safety measures.
4. A client is prescribed a clear liquid diet postoperatively. Which of the following items can
the nurse provide to this client?
A. Vanilla pudding
, B. Apple juice
C. Orange juice with pulp
D. Cream of mushroom soup
Correct Answer: B
Explanation: A clear liquid diet consists of fluids that are transparent and liquid at room
temperature. Apple juice, gelatin, and broth are appropriate choices that provide hydration
without significant residue. This diet is typically used as the first step in transitioning a
patient back to solid foods.
5. A nurse is evaluating a client’s pain. Which of the following is considered the most reliable
indicator of pain intensity?
A. The client’s vital signs
B. The client’s self-report of pain
C. The nurse’s professional judgment
D. Observations of facial grimacing
Correct Answer: B
Explanation: Pain is a subjective experience, and the patient’s self-report is the gold
standard for assessment. While nonverbal cues and physiological changes can suggest pain,
they do not replace the patient’s own description. Nurses should use standardized scales
like the 0-10 numeric scale to quantify this report.
Nursing | Actual Q&A with Rationale (NRSG100
Exam 4) | Ivy Tech
1. A nurse is caring for a client who is experiencing respiratory acidosis. Which of the
following conditions is a likely cause of this acid-base imbalance?
A. Hyperventilation
B. Hypoventilation due to COPD
C. Excessive vomiting
D. Aspirin overdose
Correct Answer: B
Explanation: Respiratory acidosis is characterized by an excess of CO2 in the blood due to
inadequate gas exchange. Hypoventilation, often seen in chronic obstructive pulmonary
disease (COPD), leads to the retention of carbon dioxide. The nurse must monitor for signs
of confusion and lethargy as the pH level drops.
2. A nurse is assessing a client with a potassium level of 3.2 mEq/L. Which clinical
manifestation should the nurse expect to find?
A. Hyperactive bowel sounds
B. Peaked T-waves on EKG
C. Muscle weakness and leg cramps
,D. Hypertension
Correct Answer: C
Explanation: A potassium level of 3.2 mEq/L indicates hypokalemia, which affects
neuromuscular function. Clients often present with muscle weakness, fatigue, and
decreased bowel motility. Severe hypokalemia can also lead to dangerous cardiac
arrhythmias that require immediate intervention.
3. Which of the following interventions is a priority for a client with a nursing diagnosis of
‘Risk for Aspiration’ during enteral feedings?
A. Administering feedings while the client is flat
B. Flushing the tube with 100 mL of water
C. Checking the residual volume every 12 hours
D. Elevating the head of the bed to at least 30 to 45 degrees
Correct Answer: D
Explanation: Maintaining the head of the bed at an angle of 30 to 45 degrees prevents
gastric reflux into the esophagus. This positioning is the primary nursing intervention to
reduce the risk of pulmonary aspiration during and after feedings. Proper gastric residual
checks and tube placement verification are also essential safety measures.
4. A client is prescribed a clear liquid diet postoperatively. Which of the following items can
the nurse provide to this client?
A. Vanilla pudding
, B. Apple juice
C. Orange juice with pulp
D. Cream of mushroom soup
Correct Answer: B
Explanation: A clear liquid diet consists of fluids that are transparent and liquid at room
temperature. Apple juice, gelatin, and broth are appropriate choices that provide hydration
without significant residue. This diet is typically used as the first step in transitioning a
patient back to solid foods.
5. A nurse is evaluating a client’s pain. Which of the following is considered the most reliable
indicator of pain intensity?
A. The client’s vital signs
B. The client’s self-report of pain
C. The nurse’s professional judgment
D. Observations of facial grimacing
Correct Answer: B
Explanation: Pain is a subjective experience, and the patient’s self-report is the gold
standard for assessment. While nonverbal cues and physiological changes can suggest pain,
they do not replace the patient’s own description. Nurses should use standardized scales
like the 0-10 numeric scale to quantify this report.
