NRSG 110 Exam 3 V1 | NRSG 110 Medical Surgical
Nursing II | Actual Q&A with Rationale (NRSG110
Exam 3) | Ivy Tech
1. A nurse is caring for a client with a suspected fluid volume deficit. Which assessment
finding should the nurse identify as a primary indicator of this condition?
A. Distended neck veins
B. Orthostatic hypotension
C. Bounding pulse
D. Dependent edema
Correct Answer: B
Explanation: Orthostatic hypotension occurs due to a decrease in circulating blood
volume, which lowers blood pressure when changing positions. Distended neck veins and
bounding pulses are typically associated with fluid volume excess rather than deficit. The
nurse should also monitor for increased heart rate and decreased skin turgor in these
clients.
2. A nurse is reviewing the arterial blood gas (ABG) results for a client: pH 7.50, PaCO2 30 mm
Hg, and HCO3 24 mEq/L. The nurse should interpret these results as which of the following?
A. Metabolic alkalosis
B. Metabolic acidosis
,C. Respiratory acidosis
D. Respiratory alkalosis
Correct Answer: D
Explanation: The pH is above 7.45, indicating alkalosis, and the PaCO2 is below 35 mm Hg,
indicating a respiratory cause. Since the bicarbonate level is within the normal range of 22
to 26 mEq/L, this represents uncompensated respiratory alkalosis. This condition is often
caused by hyperventilation, and the nurse should encourage the client to slow their
breathing.
3. A nurse is preparing to administer potassium chloride (KCl) to a client with hypokalemia.
Which action is essential for the nurse to take?
A. Dilute the medication and use an infusion pump
B. Administer the medication via IV bolus
C. Limit the infusion rate to 40 mEq/hr
D. Withhold the medication if the heart rate is below 60/min
Correct Answer: A
Explanation: Potassium chloride must always be diluted and never given as an IV bolus
because rapid infusion can cause fatal cardiac arrest. An infusion pump ensures a
controlled rate of delivery, typically not exceeding 10 mEq/hr in a peripheral line. The
nurse must also monitor the IV site for signs of phlebitis or infiltration during the infusion.
, 4. Which of the following are responsibilities of the nurse regarding informed consent for a
surgical procedure? (Select all that apply)
A. Explaining the risks and benefits of the surgery
B. Discussing alternative treatment options
C. Witnessing the client’s signature on the consent form
D. Verifying the client is competent to provide consent
E. Confirming the client has received all necessary information from the surgeon
Correct Answer: C
Explanation: The nurse’s role is to witness the signature and verify that the client is
competent and understands that the surgeon has provided the necessary information. It is
the surgeon’s responsibility, not the nurse’s, to explain the risks, benefits, and alternatives
of the procedure. If the client has questions about the procedure itself, the nurse must
notify the surgeon to return and provide further clarification.
5. A client is 2 days postoperative following abdominal surgery and reports sudden pain and a
‘popping’ sensation in the incision. The nurse observes the wound has opened and viscera are
protruding. Which action should the nurse take first?
A. Call the surgeon immediately
B. Cover the area with sterile, saline-soaked dressings
C. Place the client in a high-Fowler’s position
Nursing II | Actual Q&A with Rationale (NRSG110
Exam 3) | Ivy Tech
1. A nurse is caring for a client with a suspected fluid volume deficit. Which assessment
finding should the nurse identify as a primary indicator of this condition?
A. Distended neck veins
B. Orthostatic hypotension
C. Bounding pulse
D. Dependent edema
Correct Answer: B
Explanation: Orthostatic hypotension occurs due to a decrease in circulating blood
volume, which lowers blood pressure when changing positions. Distended neck veins and
bounding pulses are typically associated with fluid volume excess rather than deficit. The
nurse should also monitor for increased heart rate and decreased skin turgor in these
clients.
2. A nurse is reviewing the arterial blood gas (ABG) results for a client: pH 7.50, PaCO2 30 mm
Hg, and HCO3 24 mEq/L. The nurse should interpret these results as which of the following?
A. Metabolic alkalosis
B. Metabolic acidosis
,C. Respiratory acidosis
D. Respiratory alkalosis
Correct Answer: D
Explanation: The pH is above 7.45, indicating alkalosis, and the PaCO2 is below 35 mm Hg,
indicating a respiratory cause. Since the bicarbonate level is within the normal range of 22
to 26 mEq/L, this represents uncompensated respiratory alkalosis. This condition is often
caused by hyperventilation, and the nurse should encourage the client to slow their
breathing.
3. A nurse is preparing to administer potassium chloride (KCl) to a client with hypokalemia.
Which action is essential for the nurse to take?
A. Dilute the medication and use an infusion pump
B. Administer the medication via IV bolus
C. Limit the infusion rate to 40 mEq/hr
D. Withhold the medication if the heart rate is below 60/min
Correct Answer: A
Explanation: Potassium chloride must always be diluted and never given as an IV bolus
because rapid infusion can cause fatal cardiac arrest. An infusion pump ensures a
controlled rate of delivery, typically not exceeding 10 mEq/hr in a peripheral line. The
nurse must also monitor the IV site for signs of phlebitis or infiltration during the infusion.
, 4. Which of the following are responsibilities of the nurse regarding informed consent for a
surgical procedure? (Select all that apply)
A. Explaining the risks and benefits of the surgery
B. Discussing alternative treatment options
C. Witnessing the client’s signature on the consent form
D. Verifying the client is competent to provide consent
E. Confirming the client has received all necessary information from the surgeon
Correct Answer: C
Explanation: The nurse’s role is to witness the signature and verify that the client is
competent and understands that the surgeon has provided the necessary information. It is
the surgeon’s responsibility, not the nurse’s, to explain the risks, benefits, and alternatives
of the procedure. If the client has questions about the procedure itself, the nurse must
notify the surgeon to return and provide further clarification.
5. A client is 2 days postoperative following abdominal surgery and reports sudden pain and a
‘popping’ sensation in the incision. The nurse observes the wound has opened and viscera are
protruding. Which action should the nurse take first?
A. Call the surgeon immediately
B. Cover the area with sterile, saline-soaked dressings
C. Place the client in a high-Fowler’s position
