NSG 3130 Exam 4 V1 | NSG 3130
Fundamental Concepts & Skills for
Nursing Practice II | Actual Q&A with
Rationale (NSG3130 Exam 4) | Galen
College of Nursing
1. A nurse is caring for a client who is post-operative following an abdominal surgery. Which
of the following findings should the nurse identify as an early indicator of hypoxia?
A. Cyanosis of the lips and nail beds
B. Restlessness and irritability
C. Bradypnea
D. Hypotension
Answer: B
Rationale: Restlessness and irritability are early signs of hypoxia as the brain is highly
sensitive to decreased oxygen levels. Cyanosis is a late sign of hypoxia indicating significant
hemoglobin desaturation. The nurse must monitor for mental status changes to intervene
before severe respiratory distress occurs.
2. Which of the following laboratory values should the nurse report to the provider for a
client who has been taking a loop diuretic?
A. Sodium 138 mEq/L
,B. Potassium 3.1 mEq/L
C. Calcium 9.5 mg/dL
D. Chloride 100 mEq/L
Answer: B
Rationale: Loop diuretics such as furosemide often cause the excretion of potassium,
leading to hypokalemia. A potassium level of 3.1 mEq/L is below the normal range of 3.5 to
5.0 mEq/L. Low potassium can lead to cardiac dysrhythmias and muscle weakness,
requiring immediate clinical attention.
3. A nurse is reviewing a client’s arterial blood gas (ABG) results: pH 7.30, PaCO2 55 mm Hg,
and HCO3 26 mEq/L. The nurse should interpret these findings as which of the following?
A. Respiratory alkalosis
B. Respiratory acidosis
C. Metabolic acidosis
D. Metabolic alkalosis
Answer: B
Rationale: The pH of 7.30 indicates acidosis (below 7.35), and the elevated PaCO2 of 55
mm Hg (above 45) indicates a respiratory cause. The HCO3 is within the normal range,
suggesting no compensation has occurred yet. This pattern is characteristic of respiratory
acidosis, often caused by hypoventilation.
, 4. When performing tracheostomy suctioning for a client, which action should the nurse
take?
A. Apply suction while inserting the catheter.
B. Suction the client every hour routinely.
C. Use a clean technique during the procedure.
D. Limit suctioning to no more than 10 to 15 seconds.
Answer: D
Rationale: Suctioning should be limited to 10 to 15 seconds to prevent hypoxia and
mucosal damage. Suction should only be applied intermittently while withdrawing the
catheter, not during insertion. Sterile technique is mandatory for tracheostomy suctioning
to prevent healthcare-associated infections.
5. A client is diagnosed with hypocalcemia. Which of the following clinical manifestations
should the nurse expect to observe?
A. Positive Chvostek’s sign
B. Constipation
C. Hyporeflexia
D. Lethargy
Answer: A
Fundamental Concepts & Skills for
Nursing Practice II | Actual Q&A with
Rationale (NSG3130 Exam 4) | Galen
College of Nursing
1. A nurse is caring for a client who is post-operative following an abdominal surgery. Which
of the following findings should the nurse identify as an early indicator of hypoxia?
A. Cyanosis of the lips and nail beds
B. Restlessness and irritability
C. Bradypnea
D. Hypotension
Answer: B
Rationale: Restlessness and irritability are early signs of hypoxia as the brain is highly
sensitive to decreased oxygen levels. Cyanosis is a late sign of hypoxia indicating significant
hemoglobin desaturation. The nurse must monitor for mental status changes to intervene
before severe respiratory distress occurs.
2. Which of the following laboratory values should the nurse report to the provider for a
client who has been taking a loop diuretic?
A. Sodium 138 mEq/L
,B. Potassium 3.1 mEq/L
C. Calcium 9.5 mg/dL
D. Chloride 100 mEq/L
Answer: B
Rationale: Loop diuretics such as furosemide often cause the excretion of potassium,
leading to hypokalemia. A potassium level of 3.1 mEq/L is below the normal range of 3.5 to
5.0 mEq/L. Low potassium can lead to cardiac dysrhythmias and muscle weakness,
requiring immediate clinical attention.
3. A nurse is reviewing a client’s arterial blood gas (ABG) results: pH 7.30, PaCO2 55 mm Hg,
and HCO3 26 mEq/L. The nurse should interpret these findings as which of the following?
A. Respiratory alkalosis
B. Respiratory acidosis
C. Metabolic acidosis
D. Metabolic alkalosis
Answer: B
Rationale: The pH of 7.30 indicates acidosis (below 7.35), and the elevated PaCO2 of 55
mm Hg (above 45) indicates a respiratory cause. The HCO3 is within the normal range,
suggesting no compensation has occurred yet. This pattern is characteristic of respiratory
acidosis, often caused by hypoventilation.
, 4. When performing tracheostomy suctioning for a client, which action should the nurse
take?
A. Apply suction while inserting the catheter.
B. Suction the client every hour routinely.
C. Use a clean technique during the procedure.
D. Limit suctioning to no more than 10 to 15 seconds.
Answer: D
Rationale: Suctioning should be limited to 10 to 15 seconds to prevent hypoxia and
mucosal damage. Suction should only be applied intermittently while withdrawing the
catheter, not during insertion. Sterile technique is mandatory for tracheostomy suctioning
to prevent healthcare-associated infections.
5. A client is diagnosed with hypocalcemia. Which of the following clinical manifestations
should the nurse expect to observe?
A. Positive Chvostek’s sign
B. Constipation
C. Hyporeflexia
D. Lethargy
Answer: A
