NSG 300 Exam 4 V1 | NSG 300 Foundations of
Nursing | Actual Q&A with Rationale (NSG300
Exam 4) | Grand Canyon University
1. A nurse is caring for a patient with a potassium level of 2.8 mEq/L. Which clinical
manifestation should the nurse expect to observe?
A. Muscle weakness and leg cramps
B. Peaked T-waves on the ECG
C. Hyperactive bowel sounds
D. Increased muscle tone and tetany
Correct Answer: A
Explanation: Hypokalemia is defined as a serum potassium level below 3.5 mEq/L. This
condition often results in decreased muscle contractility, leading to muscle weakness,
fatigue, and cramping. The nurse should also monitor for cardiac dysrhythmias and
flattened T-waves as part of the assessment.
2. The nurse is evaluating a client’s arterial blood gas (ABG) results: pH 7.30, PaCO2 52 mmHg,
and HCO3 24 mEq/L. How should the nurse interpret these findings?
A. Respiratory Acidosis
B. Metabolic Acidosis
C. Metabolic Alkalosis
,D. Respiratory Alkalosis
Correct Answer: A
Explanation: A pH level below 7.35 indicates acidosis, while a PaCO2 above 45 mmHg
indicates a respiratory cause. Because the bicarbonate (HCO3) level is within the normal
range of 22-26 mEq/L, this represents uncompensated respiratory acidosis. The nurse
should assess the patient’s respiratory rate and depth to identify the cause of
hypoventilation.
3. A nurse is performing tracheal suctioning on a client. Which actions are essential to
maintain safety and efficacy? (Select all that apply.)
A. Hyperoxygenate the client before and after the procedure
B. Apply suction while inserting the catheter into the airway
C. Limit suctioning to no more than 10 to 15 seconds per pass
D. Use a clean, non-sterile technique for the procedure
E. Apply intermittent suction while rotating the catheter during withdrawal
F. Allow 30 seconds to 1 minute between passes for recovery
Correct Answer: A, C, E, F
Explanation: Hyperoxygenation prevents hypoxia during the suctioning procedure which
can cause cardiac stress. Suctioning should only be applied intermittently during
withdrawal to prevent mucosal damage and should never exceed 15 seconds. Sterile
,technique is required for tracheal suctioning to prevent the introduction of pathogens into
the lower respiratory tract.
4. The nurse notes that a client’s peripheral IV site is cool to the touch, swollen, and the
infusion rate has slowed. What is the nurse’s priority action?
A. Discontinue the IV and elevate the affected extremity
B. Flush the IV line with normal saline to check patency
C. Apply a warm compress and continue the infusion
D. Lower the IV bag below the level of the insertion site
Correct Answer: A
Explanation: These symptoms are classic indicators of IV infiltration, where non-vesicant
fluid enters the surrounding tissue. The immediate action is to stop the infusion and
remove the catheter to prevent further tissue damage. The nurse should then assess the
site for the extent of injury and initiate appropriate follow-up care like elevation.
5. A client is diagnosed with hypocalcemia. Which physical assessment finding supports this
diagnosis?
A. Negative Chvostek’s sign
B. Diminished deep tendon reflexes
C. Muscle flaccidity
D. Positive Trousseau’s sign
, Correct Answer: D
Explanation: Hypocalcemia increases neuromuscular excitability, which can be identified
through Trousseau’s sign. A positive Trousseau’s sign is characterized by carpal spasms
induced by inflating a blood pressure cuff above the systolic pressure. The nurse must
monitor the patient for more severe symptoms such as laryngospasm or seizures.
6. The nurse is preparing a client for surgery. Which of the following must be confirmed
before the client is transported to the operating room? (Select all that apply.)
A. Signed informed consent is on the chart
B. The client has been NPO for the required time
C. The surgical site has been marked by the surgeon
D. A post-operative room has been assigned
E. Prophylactic antibiotics have been administered if ordered
F. The client has voided or a catheter is in place
Correct Answer: A, B, C, E, F
Explanation: Pre-operative safety requires verification of legal consent and physiological
preparation such as NPO status to prevent aspiration. Site marking is a critical Universal
Protocol step to prevent wrong-site surgery. Assigning a post-operative room is part of
logistics but not a clinical safety requirement before transport to the OR.
Nursing | Actual Q&A with Rationale (NSG300
Exam 4) | Grand Canyon University
1. A nurse is caring for a patient with a potassium level of 2.8 mEq/L. Which clinical
manifestation should the nurse expect to observe?
A. Muscle weakness and leg cramps
B. Peaked T-waves on the ECG
C. Hyperactive bowel sounds
D. Increased muscle tone and tetany
Correct Answer: A
Explanation: Hypokalemia is defined as a serum potassium level below 3.5 mEq/L. This
condition often results in decreased muscle contractility, leading to muscle weakness,
fatigue, and cramping. The nurse should also monitor for cardiac dysrhythmias and
flattened T-waves as part of the assessment.
2. The nurse is evaluating a client’s arterial blood gas (ABG) results: pH 7.30, PaCO2 52 mmHg,
and HCO3 24 mEq/L. How should the nurse interpret these findings?
A. Respiratory Acidosis
B. Metabolic Acidosis
C. Metabolic Alkalosis
,D. Respiratory Alkalosis
Correct Answer: A
Explanation: A pH level below 7.35 indicates acidosis, while a PaCO2 above 45 mmHg
indicates a respiratory cause. Because the bicarbonate (HCO3) level is within the normal
range of 22-26 mEq/L, this represents uncompensated respiratory acidosis. The nurse
should assess the patient’s respiratory rate and depth to identify the cause of
hypoventilation.
3. A nurse is performing tracheal suctioning on a client. Which actions are essential to
maintain safety and efficacy? (Select all that apply.)
A. Hyperoxygenate the client before and after the procedure
B. Apply suction while inserting the catheter into the airway
C. Limit suctioning to no more than 10 to 15 seconds per pass
D. Use a clean, non-sterile technique for the procedure
E. Apply intermittent suction while rotating the catheter during withdrawal
F. Allow 30 seconds to 1 minute between passes for recovery
Correct Answer: A, C, E, F
Explanation: Hyperoxygenation prevents hypoxia during the suctioning procedure which
can cause cardiac stress. Suctioning should only be applied intermittently during
withdrawal to prevent mucosal damage and should never exceed 15 seconds. Sterile
,technique is required for tracheal suctioning to prevent the introduction of pathogens into
the lower respiratory tract.
4. The nurse notes that a client’s peripheral IV site is cool to the touch, swollen, and the
infusion rate has slowed. What is the nurse’s priority action?
A. Discontinue the IV and elevate the affected extremity
B. Flush the IV line with normal saline to check patency
C. Apply a warm compress and continue the infusion
D. Lower the IV bag below the level of the insertion site
Correct Answer: A
Explanation: These symptoms are classic indicators of IV infiltration, where non-vesicant
fluid enters the surrounding tissue. The immediate action is to stop the infusion and
remove the catheter to prevent further tissue damage. The nurse should then assess the
site for the extent of injury and initiate appropriate follow-up care like elevation.
5. A client is diagnosed with hypocalcemia. Which physical assessment finding supports this
diagnosis?
A. Negative Chvostek’s sign
B. Diminished deep tendon reflexes
C. Muscle flaccidity
D. Positive Trousseau’s sign
, Correct Answer: D
Explanation: Hypocalcemia increases neuromuscular excitability, which can be identified
through Trousseau’s sign. A positive Trousseau’s sign is characterized by carpal spasms
induced by inflating a blood pressure cuff above the systolic pressure. The nurse must
monitor the patient for more severe symptoms such as laryngospasm or seizures.
6. The nurse is preparing a client for surgery. Which of the following must be confirmed
before the client is transported to the operating room? (Select all that apply.)
A. Signed informed consent is on the chart
B. The client has been NPO for the required time
C. The surgical site has been marked by the surgeon
D. A post-operative room has been assigned
E. Prophylactic antibiotics have been administered if ordered
F. The client has voided or a catheter is in place
Correct Answer: A, B, C, E, F
Explanation: Pre-operative safety requires verification of legal consent and physiological
preparation such as NPO status to prevent aspiration. Site marking is a critical Universal
Protocol step to prevent wrong-site surgery. Assigning a post-operative room is part of
logistics but not a clinical safety requirement before transport to the OR.
