NSG 3130 Exam 4 V3 | 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 assessing a client with a history of COPD who presents with a pH of 7.32, PaCO2
of 52 mmHg, and HCO3 of 26 mEq/L. Which acid-base imbalance is the client experiencing?
A. Respiratory alkalosis
B. Respiratory acidosis
C. Metabolic alkalosis
D. Metabolic acidosis
Answer: B
Rationale: Respiratory acidosis is characterized by a low pH and an elevated PaCO2, often
resulting from hypoventilation. In this case, the COPD patient is retaining CO2, which
causes the acid-base shift. The nurse should monitor for signs of respiratory distress and
encourage deep breathing or implement ordered oxygen therapy carefully.
2. A client is receiving a blood transfusion and begins to complain of back pain, chills, and
fever. What is the nurse’s priority action?
A. Slow the infusion rate and call the provider
,B. Stop the transfusion immediately and start normal saline with new tubing
C. Administer acetaminophen as ordered for the fever
D. Check the client’s vital signs and continue to monitor
Answer: B
Rationale: These symptoms suggest an acute hemolytic reaction, which is a medical
emergency. The transfusion must be stopped immediately to prevent further reaction and
potential kidney failure. Starting normal saline with new tubing helps maintain IV access
and supports blood pressure without infusing more of the donor blood.
3. Which electrolyte imbalance is most likely to cause a positive Chvostek’s sign and
Trousseau’s sign?
A. Hypokalemia
B. Hypernatremia
C. Hypocalcemia
D. Hypermagnesemia
Answer: C
Rationale: Hypocalcemia increases neuromuscular irritability, leading to spasms and
characteristic signs like Chvostek’s (facial twitch) and Trousseau’s (carpal spasm). The
nurse should prioritize safety and monitor the client’s cardiac rhythm. Calcium
, replacement therapy is typically indicated once the diagnosis is confirmed by laboratory
results.
4. A nurse is caring for a post-operative client who has developed an evisceration. What
should be the nurse’s immediate response?
A. Push the organs back into the abdominal cavity
B. Cover the protruding organs with sterile dressings soaked in sterile normal saline
C. Leave the wound open to air and call the surgeon
D. Apply a dry sterile pressure dressing to the site
Answer: B
Rationale: Evisceration is a surgical emergency where internal organs protrude through a
wound. Keeping the organs moist with sterile saline-soaked dressings prevents tissue
necrosis and infection. The nurse must also keep the client in a low-Fowler’s position with
knees flexed and notify the surgical team immediately.
5. While assessing a client with a peripheral IV, the nurse notes the site is cool to the touch,
swollen, and the infusion has slowed. What is the likely complication?
A. Phlebitis
B. Extravasation
C. Infiltration
D. Thrombosis
Fundamental Concepts & Skills for
Nursing Practice II | Actual Q&A with
Rationale (NSG3130 Exam 4) | Galen
College of Nursing
1. A nurse is assessing a client with a history of COPD who presents with a pH of 7.32, PaCO2
of 52 mmHg, and HCO3 of 26 mEq/L. Which acid-base imbalance is the client experiencing?
A. Respiratory alkalosis
B. Respiratory acidosis
C. Metabolic alkalosis
D. Metabolic acidosis
Answer: B
Rationale: Respiratory acidosis is characterized by a low pH and an elevated PaCO2, often
resulting from hypoventilation. In this case, the COPD patient is retaining CO2, which
causes the acid-base shift. The nurse should monitor for signs of respiratory distress and
encourage deep breathing or implement ordered oxygen therapy carefully.
2. A client is receiving a blood transfusion and begins to complain of back pain, chills, and
fever. What is the nurse’s priority action?
A. Slow the infusion rate and call the provider
,B. Stop the transfusion immediately and start normal saline with new tubing
C. Administer acetaminophen as ordered for the fever
D. Check the client’s vital signs and continue to monitor
Answer: B
Rationale: These symptoms suggest an acute hemolytic reaction, which is a medical
emergency. The transfusion must be stopped immediately to prevent further reaction and
potential kidney failure. Starting normal saline with new tubing helps maintain IV access
and supports blood pressure without infusing more of the donor blood.
3. Which electrolyte imbalance is most likely to cause a positive Chvostek’s sign and
Trousseau’s sign?
A. Hypokalemia
B. Hypernatremia
C. Hypocalcemia
D. Hypermagnesemia
Answer: C
Rationale: Hypocalcemia increases neuromuscular irritability, leading to spasms and
characteristic signs like Chvostek’s (facial twitch) and Trousseau’s (carpal spasm). The
nurse should prioritize safety and monitor the client’s cardiac rhythm. Calcium
, replacement therapy is typically indicated once the diagnosis is confirmed by laboratory
results.
4. A nurse is caring for a post-operative client who has developed an evisceration. What
should be the nurse’s immediate response?
A. Push the organs back into the abdominal cavity
B. Cover the protruding organs with sterile dressings soaked in sterile normal saline
C. Leave the wound open to air and call the surgeon
D. Apply a dry sterile pressure dressing to the site
Answer: B
Rationale: Evisceration is a surgical emergency where internal organs protrude through a
wound. Keeping the organs moist with sterile saline-soaked dressings prevents tissue
necrosis and infection. The nurse must also keep the client in a low-Fowler’s position with
knees flexed and notify the surgical team immediately.
5. While assessing a client with a peripheral IV, the nurse notes the site is cool to the touch,
swollen, and the infusion has slowed. What is the likely complication?
A. Phlebitis
B. Extravasation
C. Infiltration
D. Thrombosis
