NSG 300 Exam 3 V1 | NSG 300 Foundations of
Nursing | Actual Q&A with Rationale (NSG300
Exam 3) | Grand Canyon University
1. A nurse is assessing a patient with a fluid volume deficit. Which clinical manifestation
should the nurse expect to find? (Select all that apply)
A. Orthostatic hypotension
B. Distended neck veins
C. Tachycardia
D. Dry mucous membranes
E. Peripheral edema
F. Decreased skin turgor
Correct Answer: A, C, D, F
Explanation: Fluid volume deficit, or hypovolemia, occurs when there is a loss of water
and electrolytes from the extracellular fluid. The clinical manifestations include orthostatic
hypotension due to reduced blood volume, tachycardia as a compensatory mechanism to
maintain cardiac output, and dry mucous membranes. Distended neck veins and peripheral
edema are signs of fluid volume excess, not deficit.
,2. A patient’s arterial blood gas (ABG) results are as follows: pH 7.30, PaCO2 52 mmHg, and
HCO3 24 mEq/L. How should the nurse interpret these findings?
A. Metabolic acidosis
B. Respiratory alkalosis
C. Metabolic alkalosis
D. Respiratory acidosis
Correct Answer: D
Explanation: The pH of 7.30 indicates acidosis as it is below the normal range of 7.35-7.45.
The PaCO2 of 52 mmHg is elevated, which signifies respiratory retention of carbon dioxide.
Because the bicarbonate level (HCO3) is normal, this confirms an uncompensated
respiratory acidosis.
3. During the preoperative phase, whose primary responsibility is it to obtain the patient’s
informed consent for a surgical procedure?
A. The registered nurse
B. The anesthesiologist
C. The surgeon
D. The unit manager
Correct Answer: C
,Explanation: The surgeon is legally responsible for providing the necessary information to
the patient regarding the procedure and obtaining the informed consent. The nurse’s role is
to witness the patient’s signature and verify that the patient understands the information.
If the patient has questions about the surgery, the nurse must call the surgeon to provide
further explanation.
4. Which electrolyte imbalance is most commonly associated with a positive Trousseau’s
sign?
A. Hyperkalemia
B. Hyponatremia
C. Hypocalcemia
D. Hypermagnesemia
Correct Answer: C
Explanation: Hypocalcemia increases neuromuscular excitability, which can lead to tetany.
Trousseau’s sign is an indicator of latent tetany and is elicited by inflating a blood pressure
cuff on the upper arm to a level above systolic pressure for three minutes. A positive
response is characterized by carpal spasm involving flexion of the wrist and thumb.
5. A nurse is caring for a patient who is 2 days postoperative. The nurse notes that the
surgical wound has separated and internal organs are protruding. What should be the nurse’s
immediate action?
A. Apply a dry sterile dressing
, B. Cover the wound with sterile towels soaked in warm normal saline
C. Push the organs back into the abdominal cavity
D. Position the patient in a high-Fowler’s position
Correct Answer: B
Explanation: Wound evisceration is a medical emergency where abdominal organs
protrude through a dehisced incision. The nurse should immediately cover the exposed
organs with sterile dressings or towels moistened with sterile normal saline to prevent the
tissue from drying out. The patient should be kept in low-Fowler’s position with knees
flexed, and the surgeon must be notified immediately.
6. Which of the following are potential complications of general anesthesia? (Select all that
apply)
A. Aspiration
B. Malignant hyperthermia
C. Hypoventilation
D. Increased gag reflex
E. Cardiovascular collapse
Correct Answer: A, B, C, E
Explanation: General anesthesia impacts all systems and carries significant risks including
respiratory depression (hypoventilation) and aspiration due to the loss of protective
Nursing | Actual Q&A with Rationale (NSG300
Exam 3) | Grand Canyon University
1. A nurse is assessing a patient with a fluid volume deficit. Which clinical manifestation
should the nurse expect to find? (Select all that apply)
A. Orthostatic hypotension
B. Distended neck veins
C. Tachycardia
D. Dry mucous membranes
E. Peripheral edema
F. Decreased skin turgor
Correct Answer: A, C, D, F
Explanation: Fluid volume deficit, or hypovolemia, occurs when there is a loss of water
and electrolytes from the extracellular fluid. The clinical manifestations include orthostatic
hypotension due to reduced blood volume, tachycardia as a compensatory mechanism to
maintain cardiac output, and dry mucous membranes. Distended neck veins and peripheral
edema are signs of fluid volume excess, not deficit.
,2. A patient’s arterial blood gas (ABG) results are as follows: pH 7.30, PaCO2 52 mmHg, and
HCO3 24 mEq/L. How should the nurse interpret these findings?
A. Metabolic acidosis
B. Respiratory alkalosis
C. Metabolic alkalosis
D. Respiratory acidosis
Correct Answer: D
Explanation: The pH of 7.30 indicates acidosis as it is below the normal range of 7.35-7.45.
The PaCO2 of 52 mmHg is elevated, which signifies respiratory retention of carbon dioxide.
Because the bicarbonate level (HCO3) is normal, this confirms an uncompensated
respiratory acidosis.
3. During the preoperative phase, whose primary responsibility is it to obtain the patient’s
informed consent for a surgical procedure?
A. The registered nurse
B. The anesthesiologist
C. The surgeon
D. The unit manager
Correct Answer: C
,Explanation: The surgeon is legally responsible for providing the necessary information to
the patient regarding the procedure and obtaining the informed consent. The nurse’s role is
to witness the patient’s signature and verify that the patient understands the information.
If the patient has questions about the surgery, the nurse must call the surgeon to provide
further explanation.
4. Which electrolyte imbalance is most commonly associated with a positive Trousseau’s
sign?
A. Hyperkalemia
B. Hyponatremia
C. Hypocalcemia
D. Hypermagnesemia
Correct Answer: C
Explanation: Hypocalcemia increases neuromuscular excitability, which can lead to tetany.
Trousseau’s sign is an indicator of latent tetany and is elicited by inflating a blood pressure
cuff on the upper arm to a level above systolic pressure for three minutes. A positive
response is characterized by carpal spasm involving flexion of the wrist and thumb.
5. A nurse is caring for a patient who is 2 days postoperative. The nurse notes that the
surgical wound has separated and internal organs are protruding. What should be the nurse’s
immediate action?
A. Apply a dry sterile dressing
, B. Cover the wound with sterile towels soaked in warm normal saline
C. Push the organs back into the abdominal cavity
D. Position the patient in a high-Fowler’s position
Correct Answer: B
Explanation: Wound evisceration is a medical emergency where abdominal organs
protrude through a dehisced incision. The nurse should immediately cover the exposed
organs with sterile dressings or towels moistened with sterile normal saline to prevent the
tissue from drying out. The patient should be kept in low-Fowler’s position with knees
flexed, and the surgeon must be notified immediately.
6. Which of the following are potential complications of general anesthesia? (Select all that
apply)
A. Aspiration
B. Malignant hyperthermia
C. Hypoventilation
D. Increased gag reflex
E. Cardiovascular collapse
Correct Answer: A, B, C, E
Explanation: General anesthesia impacts all systems and carries significant risks including
respiratory depression (hypoventilation) and aspiration due to the loss of protective
