NRSG 110 Exam 4 V3 | NRSG 110 Medical Surgical
Nursing II | Actual Q&A with Rationale (NRSG110
Exam 4) | Ivy Tech
1. A nurse is caring for a patient admitted with Diabetic Ketoacidosis (DKA). Which of the
following interventions should the nurse prioritize first?
A. Infusing 0.9% Normal Saline at a rapid rate
B. Administering an IV bolus of Regular Insulin
C. Administering IV Potassium Chloride
D. Checking the patient’s arterial blood gas (ABG)
Correct Answer: A
Explanation: The priority in treating DKA is fluid resuscitation to restore circulatory
volume and stabilize blood pressure. Rapid hydration with isotonic saline helps dilute
blood glucose levels and improves renal perfusion. Once fluids are initiated, insulin therapy
is started to address the metabolic acidosis and hyperglycemia.
2. A client is being evaluated for a head injury and shows signs of increased intracranial
pressure. Which clinical findings are consistent with Cushing’s Triad?
A. Tachycardia, hypotension, and Kussmaul respirations
B. Bradycardia, hypotension, and tachypnea
C. Tachycardia, hypertension, and bradypnea
,D. Bradycardia, systolic hypertension with widening pulse pressure, and irregular
respirations
E. Nausea, vomiting, and photophobia
Correct Answer: D
Explanation: Cushing’s Triad is a late sign of increased intracranial pressure (ICP)
indicating brainstem compression. It consists of a decreased heart rate, increased systolic
blood pressure with a widening gap between systolic and diastolic, and altered breathing
patterns. Failure to recognize these signs can lead to brain herniation and death.
3. A patient with Type 1 Diabetes Mellitus is found unconscious and diaphoretic. The finger-
stick glucose level is 42 mg/dL. Which action should the nurse take immediately?
A. Administer 15 grams of oral carbohydrates
B. Give 4 ounces of orange juice
C. Administer 25 mL of 50% Dextrose (D50) IV push
D. Inject 10 units of Regular insulin subcutaneously
Correct Answer: C
Explanation: In an unconscious patient with severe hypoglycemia, oral intake is
contraindicated due to the risk of aspiration. Intravenous Dextrose 50% is the standard
emergency treatment to rapidly raise blood glucose levels. If IV access is unavailable,
Glucagon IM would be the secondary choice.
, 4. Which assessment finding should the nurse anticipate in a patient diagnosed with
Myxedema Coma?
A. Tachycardia and heat intolerance
B. Diarrhea and hyperreflexia
C. Exophthalmos and weight loss
D. Hypothermia and generalized non-pitting edema
Correct Answer: D
Explanation: Myxedema coma is a life-threatening form of severe hypothyroidism
characterized by a slowing of all metabolic processes. Hallmark signs include extreme
hypothermia, hypotension, bradycardia, and cardiovascular collapse. Generalized edema,
particularly around the eyes and hands, is a common physical manifestation.
5. A patient is scheduled for a subtotal thyroidectomy. Which medication should the nurse
expect to administer preoperatively to reduce the vascularity of the thyroid gland?
A. Levothyroxine
B. Lugol’s solution (Potassium Iodide)
C. Propylthiouracil (PTU)
D. Atenolol
Correct Answer: B
Nursing II | Actual Q&A with Rationale (NRSG110
Exam 4) | Ivy Tech
1. A nurse is caring for a patient admitted with Diabetic Ketoacidosis (DKA). Which of the
following interventions should the nurse prioritize first?
A. Infusing 0.9% Normal Saline at a rapid rate
B. Administering an IV bolus of Regular Insulin
C. Administering IV Potassium Chloride
D. Checking the patient’s arterial blood gas (ABG)
Correct Answer: A
Explanation: The priority in treating DKA is fluid resuscitation to restore circulatory
volume and stabilize blood pressure. Rapid hydration with isotonic saline helps dilute
blood glucose levels and improves renal perfusion. Once fluids are initiated, insulin therapy
is started to address the metabolic acidosis and hyperglycemia.
2. A client is being evaluated for a head injury and shows signs of increased intracranial
pressure. Which clinical findings are consistent with Cushing’s Triad?
A. Tachycardia, hypotension, and Kussmaul respirations
B. Bradycardia, hypotension, and tachypnea
C. Tachycardia, hypertension, and bradypnea
,D. Bradycardia, systolic hypertension with widening pulse pressure, and irregular
respirations
E. Nausea, vomiting, and photophobia
Correct Answer: D
Explanation: Cushing’s Triad is a late sign of increased intracranial pressure (ICP)
indicating brainstem compression. It consists of a decreased heart rate, increased systolic
blood pressure with a widening gap between systolic and diastolic, and altered breathing
patterns. Failure to recognize these signs can lead to brain herniation and death.
3. A patient with Type 1 Diabetes Mellitus is found unconscious and diaphoretic. The finger-
stick glucose level is 42 mg/dL. Which action should the nurse take immediately?
A. Administer 15 grams of oral carbohydrates
B. Give 4 ounces of orange juice
C. Administer 25 mL of 50% Dextrose (D50) IV push
D. Inject 10 units of Regular insulin subcutaneously
Correct Answer: C
Explanation: In an unconscious patient with severe hypoglycemia, oral intake is
contraindicated due to the risk of aspiration. Intravenous Dextrose 50% is the standard
emergency treatment to rapidly raise blood glucose levels. If IV access is unavailable,
Glucagon IM would be the secondary choice.
, 4. Which assessment finding should the nurse anticipate in a patient diagnosed with
Myxedema Coma?
A. Tachycardia and heat intolerance
B. Diarrhea and hyperreflexia
C. Exophthalmos and weight loss
D. Hypothermia and generalized non-pitting edema
Correct Answer: D
Explanation: Myxedema coma is a life-threatening form of severe hypothyroidism
characterized by a slowing of all metabolic processes. Hallmark signs include extreme
hypothermia, hypotension, bradycardia, and cardiovascular collapse. Generalized edema,
particularly around the eyes and hands, is a common physical manifestation.
5. A patient is scheduled for a subtotal thyroidectomy. Which medication should the nurse
expect to administer preoperatively to reduce the vascularity of the thyroid gland?
A. Levothyroxine
B. Lugol’s solution (Potassium Iodide)
C. Propylthiouracil (PTU)
D. Atenolol
Correct Answer: B
