NRSG 110 Final Exam V2 | NRSG 110 Medical
Surgical Nursing II | Actual Q&A with Rationale
(NRSG110 Final Exam) | Ivy Tech
1. A nurse is caring for a patient diagnosed with heart failure who is prescribed digoxin 0.25
mg daily. Which assessment finding should the nurse prioritize as a possible indicator of
digoxin toxicity?
A. Increased urine output
B. Visual disturbances, such as seeing yellow-green halos
C. Heart rate of 82 beats per minute
D. Increased appetite
Correct Answer: B
Explanation: Digoxin toxicity is a serious condition that requires immediate nursing
intervention. Classic signs of toxicity include gastrointestinal distress, bradycardia, and
visual changes like halos or blurred vision. The nurse must monitor serum digoxin levels
and electrolyte balances, particularly potassium, as hypokalemia increases the risk of
toxicity.
2. A client presents to the emergency department with fruity-smelling breath, extreme thirst,
and a blood glucose level of 450 mg/dL. Which condition is the client most likely
experiencing?
A. Hyperglycemic Hyperosmolar State (HHS)
,B. Hypoglycemic reaction
C. Diabetic Ketoacidosis (DKA)
D. Gestational Diabetes
E. Type 2 Diabetes Mellitus Insufficiency
Correct Answer: C
Explanation: Diabetic Ketoacidosis is characterized by profound hyperglycemia, ketosis,
and metabolic acidosis, often presenting with Kussmaul respirations and a fruity breath
odor due to acetone. This condition is more common in Type 1 Diabetes and constitutes a
medical emergency. Treatment involves aggressive fluid resuscitation, electrolyte
replacement, and intravenous insulin therapy.
3. The nurse is reviewing the arterial blood gas (ABG) results of a patient with chronic
obstructive pulmonary disease (COPD): pH 7.30, PaCO2 55 mmHg, and HCO3 26 mEq/L. How
should the nurse interpret these results?
A. Metabolic Acidosis
B. Respiratory Acidosis
C. Respiratory Alkalosis
D. Metabolic Alkalosis
Correct Answer: B
,Explanation: A pH below 7.35 indicates acidosis, and a PaCO2 above 45 mmHg indicates a
respiratory cause. The bicarbonate level is within or slightly above normal range,
indicating the body has not fully compensated for the respiratory failure. Patients with
COPD often retain CO2, leading to this chronic or acute-on-chronic acid-base imbalance.
4. A patient is two days postoperative following a total hip arthroplasty. Which nursing
intervention is most effective in preventing deep vein thrombosis (DVT)?
A. Applying sequential compression devices (SCDs) and encouraging early ambulation
B. Massaging the lower extremities twice daily
C. Restricting fluid intake to 1000 mL per day
D. Keeping the patient in a high-Fowler’s position
Correct Answer: A
Explanation: Mechanical prophylaxis using SCDs promotes venous return by mimicking
the action of the calf muscle pump. Early ambulation is considered the gold standard for
preventing venous stasis in postoperative patients. Nurses should also assess for signs of
DVT such as unilateral swelling, warmth, or redness in the calf area.
5. A client is admitted with severe dehydration and a serum potassium level of 6.2 mEq/L.
Which clinical manifestations should the nurse monitor for?
A. Cardiac dysrhythmias and muscle weakness
B. Polyuria and polydipsia
C. Increased deep tendon reflexes
, D. Hypertension and tachycardia
E. Hyperactive bowel sounds
F. Positive Trousseau sign
Correct Answer: A
Explanation: Hyperkalemia, defined as a potassium level above 5.0 mEq/L, significantly
affects cardiac electrical conduction and can lead to life-threatening arrhythmias. Muscle
weakness and paralysis can occur as the elevation in potassium affects the resting
membrane potential of neuromuscular tissues. The nurse should immediately obtain an
EKG and prepare to administer medications such as calcium gluconate or insulin with
dextrose.
6. A nurse is providing discharge teaching to a patient newly diagnosed with asthma. What is
the primary purpose of using a peak flow meter?
A. To deliver bronchodilator medication directly into the lungs
B. To measure the level of oxygen saturation in the blood
C. To prevent the development of secondary bacterial pneumonia
D. To monitor the patient’s airway obstruction and peak expiratory flow rate
Correct Answer: D
Explanation: A peak flow meter allows the patient to monitor their lung function at home
by measuring how fast they can blow air out. This helps in early detection of airway
Surgical Nursing II | Actual Q&A with Rationale
(NRSG110 Final Exam) | Ivy Tech
1. A nurse is caring for a patient diagnosed with heart failure who is prescribed digoxin 0.25
mg daily. Which assessment finding should the nurse prioritize as a possible indicator of
digoxin toxicity?
A. Increased urine output
B. Visual disturbances, such as seeing yellow-green halos
C. Heart rate of 82 beats per minute
D. Increased appetite
Correct Answer: B
Explanation: Digoxin toxicity is a serious condition that requires immediate nursing
intervention. Classic signs of toxicity include gastrointestinal distress, bradycardia, and
visual changes like halos or blurred vision. The nurse must monitor serum digoxin levels
and electrolyte balances, particularly potassium, as hypokalemia increases the risk of
toxicity.
2. A client presents to the emergency department with fruity-smelling breath, extreme thirst,
and a blood glucose level of 450 mg/dL. Which condition is the client most likely
experiencing?
A. Hyperglycemic Hyperosmolar State (HHS)
,B. Hypoglycemic reaction
C. Diabetic Ketoacidosis (DKA)
D. Gestational Diabetes
E. Type 2 Diabetes Mellitus Insufficiency
Correct Answer: C
Explanation: Diabetic Ketoacidosis is characterized by profound hyperglycemia, ketosis,
and metabolic acidosis, often presenting with Kussmaul respirations and a fruity breath
odor due to acetone. This condition is more common in Type 1 Diabetes and constitutes a
medical emergency. Treatment involves aggressive fluid resuscitation, electrolyte
replacement, and intravenous insulin therapy.
3. The nurse is reviewing the arterial blood gas (ABG) results of a patient with chronic
obstructive pulmonary disease (COPD): pH 7.30, PaCO2 55 mmHg, and HCO3 26 mEq/L. How
should the nurse interpret these results?
A. Metabolic Acidosis
B. Respiratory Acidosis
C. Respiratory Alkalosis
D. Metabolic Alkalosis
Correct Answer: B
,Explanation: A pH below 7.35 indicates acidosis, and a PaCO2 above 45 mmHg indicates a
respiratory cause. The bicarbonate level is within or slightly above normal range,
indicating the body has not fully compensated for the respiratory failure. Patients with
COPD often retain CO2, leading to this chronic or acute-on-chronic acid-base imbalance.
4. A patient is two days postoperative following a total hip arthroplasty. Which nursing
intervention is most effective in preventing deep vein thrombosis (DVT)?
A. Applying sequential compression devices (SCDs) and encouraging early ambulation
B. Massaging the lower extremities twice daily
C. Restricting fluid intake to 1000 mL per day
D. Keeping the patient in a high-Fowler’s position
Correct Answer: A
Explanation: Mechanical prophylaxis using SCDs promotes venous return by mimicking
the action of the calf muscle pump. Early ambulation is considered the gold standard for
preventing venous stasis in postoperative patients. Nurses should also assess for signs of
DVT such as unilateral swelling, warmth, or redness in the calf area.
5. A client is admitted with severe dehydration and a serum potassium level of 6.2 mEq/L.
Which clinical manifestations should the nurse monitor for?
A. Cardiac dysrhythmias and muscle weakness
B. Polyuria and polydipsia
C. Increased deep tendon reflexes
, D. Hypertension and tachycardia
E. Hyperactive bowel sounds
F. Positive Trousseau sign
Correct Answer: A
Explanation: Hyperkalemia, defined as a potassium level above 5.0 mEq/L, significantly
affects cardiac electrical conduction and can lead to life-threatening arrhythmias. Muscle
weakness and paralysis can occur as the elevation in potassium affects the resting
membrane potential of neuromuscular tissues. The nurse should immediately obtain an
EKG and prepare to administer medications such as calcium gluconate or insulin with
dextrose.
6. A nurse is providing discharge teaching to a patient newly diagnosed with asthma. What is
the primary purpose of using a peak flow meter?
A. To deliver bronchodilator medication directly into the lungs
B. To measure the level of oxygen saturation in the blood
C. To prevent the development of secondary bacterial pneumonia
D. To monitor the patient’s airway obstruction and peak expiratory flow rate
Correct Answer: D
Explanation: A peak flow meter allows the patient to monitor their lung function at home
by measuring how fast they can blow air out. This helps in early detection of airway
