NSG 3130 Exam 2 V2 | NSG 3130 Fundamental
Concepts & Skills for Nursing Practice II | Actual
Q&A with Rationale (NSG3130 Exam 2) | Galen
College of Nursing
1. A nurse is preparing a client for an elective surgery. The client expresses concern that they
do not fully understand the risks of the procedure. What is the most appropriate action by
the nurse?
A. Explain the potential risks and benefits to the client immediately.
B. Notify the surgeon that the client needs further clarification before signing.
C. Ask the client’s family to explain the risks to the client.
D. Proceed with the consent process as the surgeon has already spoken to them.
Correct Answer: B
Explanation: The surgeon is legally responsible for providing the explanation of risks and
benefits to the client to obtain informed consent. The nurse’s role is to witness the
signature and verify that the client has been informed. If the client lacks understanding, the
nurse must advocate for the client by having the surgeon return to provide additional
information.
2. Which of the following is considered an early sign of malignant hyperthermia during
general anesthesia?
A. Severe hyperthermia (temperature of 105°F).
,B. Hypotension and bradycardia.
C. Masseter muscle rigidity and sinus tachycardia.
D. Generalized skin pallor and decreased capnography.
Correct Answer: C
Explanation: Masseter muscle rigidity and an unexplained rise in heart rate are among the
earliest clinical indicators of malignant hyperthermia. While high fever is a hallmark of the
condition, it is actually a late sign that indicates a critical metabolic crisis. Prompt
recognition of early signs and administration of dantrolene are vital for patient survival.
3. A postoperative client has a large abdominal incision. The nurse notes that the wound
edges are no longer approximated and the bowel is protruding. What is the nurse’s priority
action?
A. Push the bowel back into the abdominal cavity gently.
B. Apply a dry sterile dressing and call the physician.
C. Place the client in a high-Fowler’s position to reduce pressure.
D. Cover the protruding organs with sterile towels moistened with sterile normal saline.
Correct Answer: D
Explanation: Wound evisceration is a medical emergency that requires immediate
intervention to keep the exposed organs moist. The nurse should use sterile, saline-soaked
dressings to prevent the tissue from drying out or becoming necrotic. Additionally, the
,nurse should place the client in a low-Fowler’s position with knees flexed and notify the
surgical team immediately.
4. A nurse is assessing a client with a serum potassium level of 6.2 mEq/L. Which cardiac
rhythm change should the nurse expect to see on the EKG?
A. Presence of U waves.
B. Tall, peaked T waves.
C. ST segment depression.
D. Shortened QRS complex.
Correct Answer: B
Explanation: Hyperkalemia, defined as a potassium level above 5.0 mEq/L, causes specific
changes in cardiac conduction such as tall, peaked T waves. As the potassium level
continues to rise, the QRS complex may widen and the P wave may disappear, eventually
leading to cardiac arrest. This electrolyte imbalance requires urgent treatment with
medications like calcium gluconate or insulin with dextrose.
5. A client is diagnosed with fluid volume excess. Which assessment finding is most consistent
with this diagnosis?
A. Flat neck veins when lying supine.
B. Crackles upon auscultation of the lungs.
C. Tachycardia and thread pulse.
, D. Increased urine specific gravity.
Correct Answer: B
Explanation: Fluid volume excess often leads to pulmonary congestion, which manifests as
crackles (rales) in the lung bases. Other common symptoms include peripheral edema,
jugular venous distension, and rapid weight gain. The nurse must monitor respiratory
status closely as this can lead to acute pulmonary edema.
6. Which electrolyte imbalance is a client with positive Chvostek’s and Trousseau’s signs likely
experiencing?
A. Hypokalemia.
B. Hypernatremia.
C. Hypermagnesemia.
D. Hypocalcemia.
Correct Answer: D
Explanation: Hypocalcemia increases neuromuscular excitability, leading to tetany and
characteristic signs like Chvostek’s (facial twitching) and Trousseau’s (carpal spasm).
These assessments are crucial for identifying low calcium levels which can occur after
thyroid or parathyroid surgery. The nurse should maintain seizure precautions and
prepare for calcium replacement therapy.
Concepts & Skills for Nursing Practice II | Actual
Q&A with Rationale (NSG3130 Exam 2) | Galen
College of Nursing
1. A nurse is preparing a client for an elective surgery. The client expresses concern that they
do not fully understand the risks of the procedure. What is the most appropriate action by
the nurse?
A. Explain the potential risks and benefits to the client immediately.
B. Notify the surgeon that the client needs further clarification before signing.
C. Ask the client’s family to explain the risks to the client.
D. Proceed with the consent process as the surgeon has already spoken to them.
Correct Answer: B
Explanation: The surgeon is legally responsible for providing the explanation of risks and
benefits to the client to obtain informed consent. The nurse’s role is to witness the
signature and verify that the client has been informed. If the client lacks understanding, the
nurse must advocate for the client by having the surgeon return to provide additional
information.
2. Which of the following is considered an early sign of malignant hyperthermia during
general anesthesia?
A. Severe hyperthermia (temperature of 105°F).
,B. Hypotension and bradycardia.
C. Masseter muscle rigidity and sinus tachycardia.
D. Generalized skin pallor and decreased capnography.
Correct Answer: C
Explanation: Masseter muscle rigidity and an unexplained rise in heart rate are among the
earliest clinical indicators of malignant hyperthermia. While high fever is a hallmark of the
condition, it is actually a late sign that indicates a critical metabolic crisis. Prompt
recognition of early signs and administration of dantrolene are vital for patient survival.
3. A postoperative client has a large abdominal incision. The nurse notes that the wound
edges are no longer approximated and the bowel is protruding. What is the nurse’s priority
action?
A. Push the bowel back into the abdominal cavity gently.
B. Apply a dry sterile dressing and call the physician.
C. Place the client in a high-Fowler’s position to reduce pressure.
D. Cover the protruding organs with sterile towels moistened with sterile normal saline.
Correct Answer: D
Explanation: Wound evisceration is a medical emergency that requires immediate
intervention to keep the exposed organs moist. The nurse should use sterile, saline-soaked
dressings to prevent the tissue from drying out or becoming necrotic. Additionally, the
,nurse should place the client in a low-Fowler’s position with knees flexed and notify the
surgical team immediately.
4. A nurse is assessing a client with a serum potassium level of 6.2 mEq/L. Which cardiac
rhythm change should the nurse expect to see on the EKG?
A. Presence of U waves.
B. Tall, peaked T waves.
C. ST segment depression.
D. Shortened QRS complex.
Correct Answer: B
Explanation: Hyperkalemia, defined as a potassium level above 5.0 mEq/L, causes specific
changes in cardiac conduction such as tall, peaked T waves. As the potassium level
continues to rise, the QRS complex may widen and the P wave may disappear, eventually
leading to cardiac arrest. This electrolyte imbalance requires urgent treatment with
medications like calcium gluconate or insulin with dextrose.
5. A client is diagnosed with fluid volume excess. Which assessment finding is most consistent
with this diagnosis?
A. Flat neck veins when lying supine.
B. Crackles upon auscultation of the lungs.
C. Tachycardia and thread pulse.
, D. Increased urine specific gravity.
Correct Answer: B
Explanation: Fluid volume excess often leads to pulmonary congestion, which manifests as
crackles (rales) in the lung bases. Other common symptoms include peripheral edema,
jugular venous distension, and rapid weight gain. The nurse must monitor respiratory
status closely as this can lead to acute pulmonary edema.
6. Which electrolyte imbalance is a client with positive Chvostek’s and Trousseau’s signs likely
experiencing?
A. Hypokalemia.
B. Hypernatremia.
C. Hypermagnesemia.
D. Hypocalcemia.
Correct Answer: D
Explanation: Hypocalcemia increases neuromuscular excitability, leading to tetany and
characteristic signs like Chvostek’s (facial twitching) and Trousseau’s (carpal spasm).
These assessments are crucial for identifying low calcium levels which can occur after
thyroid or parathyroid surgery. The nurse should maintain seizure precautions and
prepare for calcium replacement therapy.
