NRSG 110 Exam 1 V2 | NRSG 110 Medical Surgical
Nursing II | Actual Q&A with Rationale (NRSG110
Exam 1) | Ivy Tech
1. A nurse is caring for a patient who has been admitted with a serum potassium level of 6.8
mEq/L. Which of the following interventions should the nurse anticipate as a priority to
protect the patient from life-threatening arrhythmias?
A. Administration of oral sodium polystyrene sulfonate (Kayexalate)
B. Initiation of a low-potassium diet
C. Intravenous administration of calcium gluconate
D. Administration of loop diuretics
E. Regular insulin with dextrose 50% intravenously
F. Preparing the patient for emergent hemodialysis
Correct Answer: C
Explanation: Calcium gluconate is administered to antagonize the cardiotoxic effects of
high potassium levels by stabilizing the myocardial cell membrane. While insulin and
Kayexalate help lower serum potassium levels, they do not provide the immediate cardiac
protection required at this critical level. The nurse must prioritize cardiac stability before
focusing on shifting or removing potassium from the body.
,2. The nurse is reviewing the arterial blood gas (ABG) results for a patient with chronic
obstructive pulmonary disease (COPD). The results are: pH 7.32, PaCO2 58 mmHg, and HCO3
30 mEq/L. How should the nurse interpret these findings?
A. Metabolic acidosis, fully compensated
B. Metabolic alkalosis, partially compensated
C. Respiratory alkalosis, uncompensated
D. Respiratory acidosis, partially compensated
Correct Answer: D
Explanation: The pH is below 7.35, indicating acidosis, and the PaCO2 is elevated above 45
mmHg, which points to a respiratory cause. The HCO3 is also elevated above 26 mEq/L,
indicating that the kidneys are attempting to compensate by retaining base. Because the pH
has not yet returned to the normal range, the condition is considered partially
compensated respiratory acidosis.
3. A patient is 24 hours postoperative following abdominal surgery and complains of a
‘popping’ sensation after coughing. Upon assessment, the nurse notes that the wound edges
have separated and a loop of bowel is protruding. Which action should the nurse take first?
A. Cover the protruding organ with sterile dressings moistened with sterile normal saline
B. Place the patient in a high-Fowler’s position
C. Notify the surgeon immediately
D. Attempt to gently push the bowel back into the abdominal cavity
,Correct Answer: A
Explanation: This scenario describes a surgical evisceration, which is a medical
emergency. The priority nursing action is to protect the exposed organs from drying out
and becoming infected by covering them with sterile, saline-soaked dressings. The nurse
should then notify the surgeon and prepare the patient for emergency surgery while
keeping the patient in a low-Fowler’s position with knees bent to reduce abdominal
tension.
4. Which clinical manifestation should the nurse expect to find in a patient experiencing
hypocalcemia?
A. A positive Chvostek’s sign
B. Shortened QT interval on EKG
C. Constipation and kidney stones
D. Depressed deep tendon reflexes
E. Polyuria and polydipsia
Correct Answer: A
Explanation: Hypocalcemia increases neuromuscular excitability, leading to signs such as
Chvostek’s sign (facial twitching when the facial nerve is tapped) and Trousseau’s sign
(carpal spasm with BP cuff inflation). Other findings include tetany, tingling in the
extremities, and a prolonged QT interval. Constipation and shortened QT intervals are
typically associated with hypercalcemia.
, 5. A nurse is preparing to administer a unit of packed red blood cells (PRBCs) to a client with
severe anemia. Which of the following is the most important action for the nurse to perform
before starting the infusion?
A. Verify the patient’s identity and blood product details with another registered nurse
B. Warm the blood to room temperature for 1 hour
C. Administer prophylactic diphenhydramine to prevent an allergic reaction
D. Infuse the blood quickly over the first 15 minutes to ensure stability
Correct Answer: A
Explanation: Verifying the patient’s identity and the blood product against the medical
record and the patient’s ID band with a second nurse is the most critical step in preventing
a hemolytic transfusion reaction. Errors in identification are the leading cause of
transfusion-related deaths. The nurse must also stay with the patient for the first 15
minutes of the infusion to monitor for any adverse reactions.
6. A nurse is teaching a patient about the proper use of an incentive spirometer. Which
statement by the patient indicates an understanding of the procedure?
A. I should blow as hard as I can into the mouthpiece
B. The goal is to move the ball up as fast as possible
C. I should use this device at least once every four hours while I am awake
D. I will take a slow, deep breath in and hold it for 3 to 5 seconds
Nursing II | Actual Q&A with Rationale (NRSG110
Exam 1) | Ivy Tech
1. A nurse is caring for a patient who has been admitted with a serum potassium level of 6.8
mEq/L. Which of the following interventions should the nurse anticipate as a priority to
protect the patient from life-threatening arrhythmias?
A. Administration of oral sodium polystyrene sulfonate (Kayexalate)
B. Initiation of a low-potassium diet
C. Intravenous administration of calcium gluconate
D. Administration of loop diuretics
E. Regular insulin with dextrose 50% intravenously
F. Preparing the patient for emergent hemodialysis
Correct Answer: C
Explanation: Calcium gluconate is administered to antagonize the cardiotoxic effects of
high potassium levels by stabilizing the myocardial cell membrane. While insulin and
Kayexalate help lower serum potassium levels, they do not provide the immediate cardiac
protection required at this critical level. The nurse must prioritize cardiac stability before
focusing on shifting or removing potassium from the body.
,2. The nurse is reviewing the arterial blood gas (ABG) results for a patient with chronic
obstructive pulmonary disease (COPD). The results are: pH 7.32, PaCO2 58 mmHg, and HCO3
30 mEq/L. How should the nurse interpret these findings?
A. Metabolic acidosis, fully compensated
B. Metabolic alkalosis, partially compensated
C. Respiratory alkalosis, uncompensated
D. Respiratory acidosis, partially compensated
Correct Answer: D
Explanation: The pH is below 7.35, indicating acidosis, and the PaCO2 is elevated above 45
mmHg, which points to a respiratory cause. The HCO3 is also elevated above 26 mEq/L,
indicating that the kidneys are attempting to compensate by retaining base. Because the pH
has not yet returned to the normal range, the condition is considered partially
compensated respiratory acidosis.
3. A patient is 24 hours postoperative following abdominal surgery and complains of a
‘popping’ sensation after coughing. Upon assessment, the nurse notes that the wound edges
have separated and a loop of bowel is protruding. Which action should the nurse take first?
A. Cover the protruding organ with sterile dressings moistened with sterile normal saline
B. Place the patient in a high-Fowler’s position
C. Notify the surgeon immediately
D. Attempt to gently push the bowel back into the abdominal cavity
,Correct Answer: A
Explanation: This scenario describes a surgical evisceration, which is a medical
emergency. The priority nursing action is to protect the exposed organs from drying out
and becoming infected by covering them with sterile, saline-soaked dressings. The nurse
should then notify the surgeon and prepare the patient for emergency surgery while
keeping the patient in a low-Fowler’s position with knees bent to reduce abdominal
tension.
4. Which clinical manifestation should the nurse expect to find in a patient experiencing
hypocalcemia?
A. A positive Chvostek’s sign
B. Shortened QT interval on EKG
C. Constipation and kidney stones
D. Depressed deep tendon reflexes
E. Polyuria and polydipsia
Correct Answer: A
Explanation: Hypocalcemia increases neuromuscular excitability, leading to signs such as
Chvostek’s sign (facial twitching when the facial nerve is tapped) and Trousseau’s sign
(carpal spasm with BP cuff inflation). Other findings include tetany, tingling in the
extremities, and a prolonged QT interval. Constipation and shortened QT intervals are
typically associated with hypercalcemia.
, 5. A nurse is preparing to administer a unit of packed red blood cells (PRBCs) to a client with
severe anemia. Which of the following is the most important action for the nurse to perform
before starting the infusion?
A. Verify the patient’s identity and blood product details with another registered nurse
B. Warm the blood to room temperature for 1 hour
C. Administer prophylactic diphenhydramine to prevent an allergic reaction
D. Infuse the blood quickly over the first 15 minutes to ensure stability
Correct Answer: A
Explanation: Verifying the patient’s identity and the blood product against the medical
record and the patient’s ID band with a second nurse is the most critical step in preventing
a hemolytic transfusion reaction. Errors in identification are the leading cause of
transfusion-related deaths. The nurse must also stay with the patient for the first 15
minutes of the infusion to monitor for any adverse reactions.
6. A nurse is teaching a patient about the proper use of an incentive spirometer. Which
statement by the patient indicates an understanding of the procedure?
A. I should blow as hard as I can into the mouthpiece
B. The goal is to move the ball up as fast as possible
C. I should use this device at least once every four hours while I am awake
D. I will take a slow, deep breath in and hold it for 3 to 5 seconds
