NRSG 110 Final Exam V3 | NRSG 110 Medical
Surgical Nursing II | Actual Q&A with Rationale
(NRSG110 Final Exam) | Ivy Tech
1. A nurse is caring for a client who is 24 hours postoperative following a total hip
arthroplasty. Which of the following actions should the nurse prioritize to prevent deep vein
thrombosis (DVT)?
A. Applying cold compresses to the calves.
B. Massaging the lower extremities twice daily.
C. Instructing the client to maintain bed rest for 48 hours.
D. Encouraging the use of sequential compression devices (SCDs) while in bed.
Correct Answer: D
Explanation: The use of sequential compression devices (SCDs) or anti-embolism
stockings promotes venous return and prevents blood stasis in the lower extremities.
Massaging the legs is contraindicated because it can dislodge an existing clot. Early
ambulation and mechanical prophylaxis are standard of care in the postoperative period
for orthopedic surgeries.
2. A client is admitted to the emergency department with a suspected myocardial infarction.
Which of the following cardiac markers is most specific for myocardial injury?
A. Creatine kinase (CK-MB)
B. Myoglobin
,C. Troponin I
D. Lactate dehydrogenase (LDH)
Correct Answer: C
Explanation: Troponin I is highly specific to cardiac muscle and remains elevated for up to
two weeks following an acute myocardial infarction. While CK-MB is also used, it is less
specific than Troponin I and returns to baseline much faster. Myoglobin rises early but is
not specific to the heart muscle alone.
3. A nurse is reviewing the arterial blood gas (ABG) results for a client with chronic
obstructive pulmonary disease (COPD): pH 7.32, PaCO2 58 mmHg, HCO3 30 mEq/L. How
should the nurse interpret these results?
A. Partially compensated respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Fully compensated respiratory acidosis
Correct Answer: A
Explanation: The low pH indicates acidosis, and the high PaCO2 indicates a respiratory
origin. The elevated HCO3 shows that the kidneys are attempting to compensate by
retaining base, but since the pH is not yet within the normal range, it is considered partially
compensated. This pattern is common in clients with chronic CO2 retention due to
obstructive lung disease.
,4. A client with Type 1 Diabetes Mellitus presents with Kussmaul respirations, a fruity breath
odor, and a blood glucose of 450 mg/dL. Which of the following is the priority nursing
intervention?
A. Administering subcutaneous glargine insulin.
B. Initiating intravenous fluid resuscitation with normal saline.
C. Providing a carbohydrate-rich snack.
D. Administering oral potassium supplements.
Correct Answer: B
Explanation: The client is exhibiting classic signs of Diabetic Ketoacidosis (DKA), which
requires immediate fluid volume replacement to address dehydration and hypotension.
Once fluid resuscitation has begun, intravenous regular insulin is administered to lower
blood glucose and stop ketone production. Potassium levels must be monitored closely, but
fluid volume is the immediate priority to stabilize the patient’s hemodynamic status.
5. A nurse is preparing to administer digoxin to a client with heart failure. Which of the
following assessment findings requires the nurse to withhold the medication and notify the
provider?
A. Blood pressure of 140/90 mmHg
B. Respiratory rate of 18 breaths per minute
C. Heart rate of 52 beats per minute
D. Potassium level of 4.2 mEq/L
, Correct Answer: C
Explanation: Digoxin is a positive inotrope and negative chronotrope, meaning it increases
contractility but slows the heart rate. A heart rate below 60 beats per minute in an adult is
a contraindication for administration because it may indicate digoxin toxicity or excessive
vagal tone. The nurse must assess the apical pulse for a full minute before administration to
ensure safety.
6. A client in the telemetry unit develops ventricular fibrillation (V-fib). Which of the
following actions should the nurse perform immediately?
A. Prepare for synchronized cardioversion.
B. Administer an IV bolus of amiodarone.
C. Notify the rapid response team and wait for orders.
D. Assess the client’s carotid pulse for 10 seconds.
E. Initiate CPR and prepare for defibrillation.
Correct Answer: E
Explanation: Ventricular fibrillation is a pulseless, lethal rhythm that requires immediate
high-quality CPR and unsynchronized defibrillation. Synchronized cardioversion is not
used for V-fib because there is no R-wave to time the shock. Early defibrillation is the most
critical factor in improving survival rates for patients in V-fib.
Surgical Nursing II | Actual Q&A with Rationale
(NRSG110 Final Exam) | Ivy Tech
1. A nurse is caring for a client who is 24 hours postoperative following a total hip
arthroplasty. Which of the following actions should the nurse prioritize to prevent deep vein
thrombosis (DVT)?
A. Applying cold compresses to the calves.
B. Massaging the lower extremities twice daily.
C. Instructing the client to maintain bed rest for 48 hours.
D. Encouraging the use of sequential compression devices (SCDs) while in bed.
Correct Answer: D
Explanation: The use of sequential compression devices (SCDs) or anti-embolism
stockings promotes venous return and prevents blood stasis in the lower extremities.
Massaging the legs is contraindicated because it can dislodge an existing clot. Early
ambulation and mechanical prophylaxis are standard of care in the postoperative period
for orthopedic surgeries.
2. A client is admitted to the emergency department with a suspected myocardial infarction.
Which of the following cardiac markers is most specific for myocardial injury?
A. Creatine kinase (CK-MB)
B. Myoglobin
,C. Troponin I
D. Lactate dehydrogenase (LDH)
Correct Answer: C
Explanation: Troponin I is highly specific to cardiac muscle and remains elevated for up to
two weeks following an acute myocardial infarction. While CK-MB is also used, it is less
specific than Troponin I and returns to baseline much faster. Myoglobin rises early but is
not specific to the heart muscle alone.
3. A nurse is reviewing the arterial blood gas (ABG) results for a client with chronic
obstructive pulmonary disease (COPD): pH 7.32, PaCO2 58 mmHg, HCO3 30 mEq/L. How
should the nurse interpret these results?
A. Partially compensated respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Fully compensated respiratory acidosis
Correct Answer: A
Explanation: The low pH indicates acidosis, and the high PaCO2 indicates a respiratory
origin. The elevated HCO3 shows that the kidneys are attempting to compensate by
retaining base, but since the pH is not yet within the normal range, it is considered partially
compensated. This pattern is common in clients with chronic CO2 retention due to
obstructive lung disease.
,4. A client with Type 1 Diabetes Mellitus presents with Kussmaul respirations, a fruity breath
odor, and a blood glucose of 450 mg/dL. Which of the following is the priority nursing
intervention?
A. Administering subcutaneous glargine insulin.
B. Initiating intravenous fluid resuscitation with normal saline.
C. Providing a carbohydrate-rich snack.
D. Administering oral potassium supplements.
Correct Answer: B
Explanation: The client is exhibiting classic signs of Diabetic Ketoacidosis (DKA), which
requires immediate fluid volume replacement to address dehydration and hypotension.
Once fluid resuscitation has begun, intravenous regular insulin is administered to lower
blood glucose and stop ketone production. Potassium levels must be monitored closely, but
fluid volume is the immediate priority to stabilize the patient’s hemodynamic status.
5. A nurse is preparing to administer digoxin to a client with heart failure. Which of the
following assessment findings requires the nurse to withhold the medication and notify the
provider?
A. Blood pressure of 140/90 mmHg
B. Respiratory rate of 18 breaths per minute
C. Heart rate of 52 beats per minute
D. Potassium level of 4.2 mEq/L
, Correct Answer: C
Explanation: Digoxin is a positive inotrope and negative chronotrope, meaning it increases
contractility but slows the heart rate. A heart rate below 60 beats per minute in an adult is
a contraindication for administration because it may indicate digoxin toxicity or excessive
vagal tone. The nurse must assess the apical pulse for a full minute before administration to
ensure safety.
6. A client in the telemetry unit develops ventricular fibrillation (V-fib). Which of the
following actions should the nurse perform immediately?
A. Prepare for synchronized cardioversion.
B. Administer an IV bolus of amiodarone.
C. Notify the rapid response team and wait for orders.
D. Assess the client’s carotid pulse for 10 seconds.
E. Initiate CPR and prepare for defibrillation.
Correct Answer: E
Explanation: Ventricular fibrillation is a pulseless, lethal rhythm that requires immediate
high-quality CPR and unsynchronized defibrillation. Synchronized cardioversion is not
used for V-fib because there is no R-wave to time the shock. Early defibrillation is the most
critical factor in improving survival rates for patients in V-fib.
