NRSG 110 Final Exam V1 | NRSG 110 Medical
Surgical Nursing II | Actual Q&A with Rationale
(NRSG110 Final Exam) | Ivy Tech
1. A patient with heart failure is prescribed digoxin (Lanoxin). Which clinical manifestation
should the nurse identify as an early sign of digoxin toxicity?
A. Anorexia and nausea
B. Increased appetite
C. Hypertension
D. Tachycardia
E. Constipation
Correct Answer: A
Explanation: Gastrointestinal distress including anorexia, nausea, and vomiting are often
the earliest signs of digoxin toxicity. The nurse must monitor for these symptoms along
with visual disturbances like yellow-green halos. It is also critical to monitor serum
potassium levels because hypokalemia potentiates the effects of digoxin.
2. The nurse is caring for a patient who is 24 hours post-op after a total hip replacement.
Which assessment finding requires immediate intervention?
A. Pain level of 4 on a 1-10 scale
B. Sudden shortness of breath and chest pain
,C. Small amount of serosanguinous drainage on the dressing
D. Limited range of motion in the affected hip
Correct Answer: B
Explanation: Sudden onset of respiratory distress and chest pain in a post-operative
patient suggests a pulmonary embolism, which is a life-threatening complication. The
nurse should immediately apply oxygen and notify the healthcare provider. While pain and
limited mobility are expected, they do not take priority over cardiovascular and respiratory
stability.
3. A patient is admitted with a diagnosis of Acute Respiratory Distress Syndrome (ARDS).
Which arterial blood gas (ABG) result would the nurse expect to see in the early stages?
A. pH 7.30, PaCO2 50, HCO3 26
B. pH 7.48, PaCO2 30, HCO3 22
C. pH 7.35, PaCO2 40, HCO3 24
D. pH 7.25, PaCO2 35, HCO3 18
Correct Answer: B
Explanation: In the early stages of ARDS, the patient typically hyperventilates to
compensate for hypoxia, leading to respiratory alkalosis. This is characterized by a high pH
and a low PaCO2 level. As the condition progresses and the patient tires, they may
eventually shift into respiratory acidosis due to CO2 retention.
,4. When caring for a patient in the oliguric phase of acute kidney injury (AKI), which
electrolyte imbalance is the nurse most likely to observe?
A. Hypokalemia
B. Hyperkalemia
C. Hypernatremia
D. Hypomagnesemia
Correct Answer: B
Explanation: During the oliguric phase of AKI, the kidneys are unable to excrete potassium
effectively, leading to potentially dangerous serum levels. Hyperkalemia is a major concern
because it can cause lethal cardiac arrhythmias. The nurse must monitor the EKG for
peaked T-waves and other signs of cardiac instability.
5. A nurse is teaching a patient with Chronic Kidney Disease (CKD) about a renal-friendly diet.
Which foods should the patient be instructed to avoid?
A. Apples
B. White bread
C. Blueberries
D. Green beans
E. Cabbage
F. Spinach and bananas
, Correct Answer: F
Explanation: Patients with CKD need to limit potassium, phosphorus, and sodium intake to
prevent complications. Spinach and bananas are both high in potassium, which can
accumulate to toxic levels when renal function is impaired. Education should focus on
selecting low-potassium fruits and vegetables like apples and berries instead.
6. Which clinical finding is most characteristic of a patient experiencing autonomic dysreflexia
following a spinal cord injury at T6?
A. Severe headache and hypertension
B. Hypotension and tachycardia
C. Flaccid paralysis below the level of injury
D. Extreme coldness and shivering
Correct Answer: A
Explanation: Autonomic dysreflexia is a medical emergency occurring in patients with
spinal cord injuries at or above T6, triggered by noxious stimuli like a full bladder. It
manifests as sudden, severe hypertension, a pounding headache, and bradycardia. The
nurse should immediately sit the patient up and identify the triggering stimulus to lower
blood pressure.
7. A patient with cirrhosis of the liver has developed hepatic encephalopathy. Which
medication does the nurse anticipate administering to reduce serum ammonia levels?
A. Lactulose
Surgical Nursing II | Actual Q&A with Rationale
(NRSG110 Final Exam) | Ivy Tech
1. A patient with heart failure is prescribed digoxin (Lanoxin). Which clinical manifestation
should the nurse identify as an early sign of digoxin toxicity?
A. Anorexia and nausea
B. Increased appetite
C. Hypertension
D. Tachycardia
E. Constipation
Correct Answer: A
Explanation: Gastrointestinal distress including anorexia, nausea, and vomiting are often
the earliest signs of digoxin toxicity. The nurse must monitor for these symptoms along
with visual disturbances like yellow-green halos. It is also critical to monitor serum
potassium levels because hypokalemia potentiates the effects of digoxin.
2. The nurse is caring for a patient who is 24 hours post-op after a total hip replacement.
Which assessment finding requires immediate intervention?
A. Pain level of 4 on a 1-10 scale
B. Sudden shortness of breath and chest pain
,C. Small amount of serosanguinous drainage on the dressing
D. Limited range of motion in the affected hip
Correct Answer: B
Explanation: Sudden onset of respiratory distress and chest pain in a post-operative
patient suggests a pulmonary embolism, which is a life-threatening complication. The
nurse should immediately apply oxygen and notify the healthcare provider. While pain and
limited mobility are expected, they do not take priority over cardiovascular and respiratory
stability.
3. A patient is admitted with a diagnosis of Acute Respiratory Distress Syndrome (ARDS).
Which arterial blood gas (ABG) result would the nurse expect to see in the early stages?
A. pH 7.30, PaCO2 50, HCO3 26
B. pH 7.48, PaCO2 30, HCO3 22
C. pH 7.35, PaCO2 40, HCO3 24
D. pH 7.25, PaCO2 35, HCO3 18
Correct Answer: B
Explanation: In the early stages of ARDS, the patient typically hyperventilates to
compensate for hypoxia, leading to respiratory alkalosis. This is characterized by a high pH
and a low PaCO2 level. As the condition progresses and the patient tires, they may
eventually shift into respiratory acidosis due to CO2 retention.
,4. When caring for a patient in the oliguric phase of acute kidney injury (AKI), which
electrolyte imbalance is the nurse most likely to observe?
A. Hypokalemia
B. Hyperkalemia
C. Hypernatremia
D. Hypomagnesemia
Correct Answer: B
Explanation: During the oliguric phase of AKI, the kidneys are unable to excrete potassium
effectively, leading to potentially dangerous serum levels. Hyperkalemia is a major concern
because it can cause lethal cardiac arrhythmias. The nurse must monitor the EKG for
peaked T-waves and other signs of cardiac instability.
5. A nurse is teaching a patient with Chronic Kidney Disease (CKD) about a renal-friendly diet.
Which foods should the patient be instructed to avoid?
A. Apples
B. White bread
C. Blueberries
D. Green beans
E. Cabbage
F. Spinach and bananas
, Correct Answer: F
Explanation: Patients with CKD need to limit potassium, phosphorus, and sodium intake to
prevent complications. Spinach and bananas are both high in potassium, which can
accumulate to toxic levels when renal function is impaired. Education should focus on
selecting low-potassium fruits and vegetables like apples and berries instead.
6. Which clinical finding is most characteristic of a patient experiencing autonomic dysreflexia
following a spinal cord injury at T6?
A. Severe headache and hypertension
B. Hypotension and tachycardia
C. Flaccid paralysis below the level of injury
D. Extreme coldness and shivering
Correct Answer: A
Explanation: Autonomic dysreflexia is a medical emergency occurring in patients with
spinal cord injuries at or above T6, triggered by noxious stimuli like a full bladder. It
manifests as sudden, severe hypertension, a pounding headache, and bradycardia. The
nurse should immediately sit the patient up and identify the triggering stimulus to lower
blood pressure.
7. A patient with cirrhosis of the liver has developed hepatic encephalopathy. Which
medication does the nurse anticipate administering to reduce serum ammonia levels?
A. Lactulose
