NRSG 110 Exam 1 V1 | NRSG 110 Medical Surgical
Nursing II | Actual Q&A with Rationale (NRSG110
Exam 1) | Ivy Tech
1. A nurse is reviewing the laboratory results of a client who has a serum potassium level of
2.9 mEq/L. Which of the following findings should the nurse expect?
A. Tachycardia and hypertension
B. Heightened T waves on the EKG
C. Hyperactive deep tendon reflexes
D. Abdominal distention and hypoactive bowel sounds
Correct Answer: D
Explanation: Hypokalemia, defined as a serum potassium below 3.5 mEq/L, leads to
decreased smooth muscle contraction in the gastrointestinal tract. This often results in
abdominal distention, constipation, or even paralytic ileus. The nurse must monitor for
these gastrointestinal manifestations alongside cardiac changes to ensure patient safety.
2. The surgical nurse is preparing a client for a procedure. Which of the following is a primary
responsibility of the nurse regarding informed consent?
A. Witnessing the client’s signature on the consent form
B. Describing alternative treatments available to the client
C. Explaining the risks and benefits of the surgery
,D. Obtaining consent from a family member if the client is anxious
Correct Answer: A
Explanation: The nurse’s role in informed consent is primarily that of a witness to the
client’s voluntary signature and to ensure the client is competent. It is the surgeon’s legal
responsibility to explain the procedure, risks, and alternatives. If the client does not
understand the procedure, the nurse must notify the surgeon before the client signs the
form.
3. A client is diagnosed with a stage II malignant tumor. The nurse understands that this
staging is based on which of the following criteria?
A. The size of the tumor and the extent of local spread
B. The degree of cell differentiation
C. The presence of distant metastases
D. The specific organ of origin
Correct Answer: A
Explanation: Staging of cancer involves determining the size of the tumor and whether it
has invaded nearby tissues or lymph nodes. Clinical staging differs from grading, which
looks at how much the cells resemble the parent tissue under a microscope. Knowing the
stage helps the healthcare team determine the most effective treatment plan and prognosis
for the client.
, 4. A client’s arterial blood gas (ABG) results are: pH 7.31, PaCO2 50 mm Hg, and HCO3 25
mEq/L. How should the nurse interpret these findings?
A. Metabolic acidosis
B. Respiratory alkalosis
C. Metabolic alkalosis
D. Respiratory acidosis
Correct Answer: D
Explanation: The pH is below the normal range of 7.35 to 7.45, indicating acidosis. The
PaCO2 is elevated above the normal range of 35 to 45 mm Hg, which indicates the cause is
respiratory in nature. Because the bicarbonate is within the normal range, this represents
uncompensated respiratory acidosis commonly seen in conditions like COPD or
hypoventilation.
5. A nurse is providing teaching to a client scheduled for an external radiation therapy. Which
of the following instructions should the nurse include?
A. Wash off the ink markings on the skin daily
B. Use a heating pad to soothe the treatment area
C. Avoid exposure to sunlight in the treated area
D. Apply scented lotions to prevent skin dryness
Correct Answer: C
Nursing II | Actual Q&A with Rationale (NRSG110
Exam 1) | Ivy Tech
1. A nurse is reviewing the laboratory results of a client who has a serum potassium level of
2.9 mEq/L. Which of the following findings should the nurse expect?
A. Tachycardia and hypertension
B. Heightened T waves on the EKG
C. Hyperactive deep tendon reflexes
D. Abdominal distention and hypoactive bowel sounds
Correct Answer: D
Explanation: Hypokalemia, defined as a serum potassium below 3.5 mEq/L, leads to
decreased smooth muscle contraction in the gastrointestinal tract. This often results in
abdominal distention, constipation, or even paralytic ileus. The nurse must monitor for
these gastrointestinal manifestations alongside cardiac changes to ensure patient safety.
2. The surgical nurse is preparing a client for a procedure. Which of the following is a primary
responsibility of the nurse regarding informed consent?
A. Witnessing the client’s signature on the consent form
B. Describing alternative treatments available to the client
C. Explaining the risks and benefits of the surgery
,D. Obtaining consent from a family member if the client is anxious
Correct Answer: A
Explanation: The nurse’s role in informed consent is primarily that of a witness to the
client’s voluntary signature and to ensure the client is competent. It is the surgeon’s legal
responsibility to explain the procedure, risks, and alternatives. If the client does not
understand the procedure, the nurse must notify the surgeon before the client signs the
form.
3. A client is diagnosed with a stage II malignant tumor. The nurse understands that this
staging is based on which of the following criteria?
A. The size of the tumor and the extent of local spread
B. The degree of cell differentiation
C. The presence of distant metastases
D. The specific organ of origin
Correct Answer: A
Explanation: Staging of cancer involves determining the size of the tumor and whether it
has invaded nearby tissues or lymph nodes. Clinical staging differs from grading, which
looks at how much the cells resemble the parent tissue under a microscope. Knowing the
stage helps the healthcare team determine the most effective treatment plan and prognosis
for the client.
, 4. A client’s arterial blood gas (ABG) results are: pH 7.31, PaCO2 50 mm Hg, and HCO3 25
mEq/L. How should the nurse interpret these findings?
A. Metabolic acidosis
B. Respiratory alkalosis
C. Metabolic alkalosis
D. Respiratory acidosis
Correct Answer: D
Explanation: The pH is below the normal range of 7.35 to 7.45, indicating acidosis. The
PaCO2 is elevated above the normal range of 35 to 45 mm Hg, which indicates the cause is
respiratory in nature. Because the bicarbonate is within the normal range, this represents
uncompensated respiratory acidosis commonly seen in conditions like COPD or
hypoventilation.
5. A nurse is providing teaching to a client scheduled for an external radiation therapy. Which
of the following instructions should the nurse include?
A. Wash off the ink markings on the skin daily
B. Use a heating pad to soothe the treatment area
C. Avoid exposure to sunlight in the treated area
D. Apply scented lotions to prevent skin dryness
Correct Answer: C
