NSG 300 Exam 4 V3 | 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 6.2 mEq/L. Which of the following
manifestations should the nurse expect to observe? (Select All That Apply)
A. Cardiac dysrhythmias
B. Muscle weakness
C. Abdominal cramping
D. Tachycardia
E. Tall, peaked T waves on ECG
F. Hyporeflexia
Correct Answer: A, B, C, E
Explanation: Hyperkalemia, defined as a potassium level above 5.0 mEq/L, significantly
impacts neuromuscular and cardiac function. The presence of tall, peaked T waves is a
classic electrocardiogram change associated with elevated potassium levels. The nurse
must also monitor for muscle weakness and gastrointestinal hyperactivity such as
cramping, as these are common clinical findings.
,2. Which clinical manifestation should the nurse prioritize when assessing a patient for
hypocalcemia?
A. Positive Chvostek’s sign
B. Polyuria and polydipsia
C. Constipation and lethargy
D. Shortened QT interval
Correct Answer: A
Explanation: A positive Chvostek’s sign, which is a twitching of the facial muscles
following a tap on the facial nerve, indicates increased neuromuscular excitability due to
low calcium. Hypocalcemia often leads to tetany and tingling in the extremities, whereas
hypercalcemia typically causes lethargy and constipation. Prompt identification of these
signs is essential to prevent complications such as laryngospasm or seizures.
3. A patient’s arterial blood gas (ABG) results are: pH 7.30, PaCO2 52 mm Hg, and HCO3 24
mEq/L. How should the nurse interpret these findings?
A. Respiratory acidosis
B. Metabolic acidosis
C. Respiratory alkalosis
D. Metabolic alkalosis
Correct Answer: A
,Explanation: The pH of 7.30 indicates acidosis, while the elevated PaCO2 of 52 mm Hg
identifies the respiratory system as the cause of the imbalance. Because the bicarbonate
level (HCO3) is within the normal range of 22-26 mEq/L, the condition is uncompensated
respiratory acidosis. The nurse should assess the patient’s respiratory rate and depth, as
hypoventilation is the primary cause of this state.
4. During the preoperative phase, whose primary responsibility is it to obtain informed
consent from the patient?
A. The registered nurse
B. The anesthesiologist
C. The surgeon
D. The charge nurse
Correct Answer: C
Explanation: It is the legal and ethical responsibility of the surgeon to explain the
procedure, risks, benefits, and alternatives to the patient. The nurse’s role is typically
limited to witnessing the patient’s signature and ensuring the patient understands what
was discussed. If the patient expresses confusion about the surgery, the nurse must notify
the surgeon to return and provide further clarification.
5. A nurse is preparing to administer an enteral feeding through a nasogastric (NG) tube.
What is the most reliable bedside method for verifying tube placement?
A. Auscultating air injected into the stomach
, B. Confirming with a chest X-ray
C. Observing for coughing or choking
D. Measuring the pH of aspirated gastric contents
Correct Answer: D
Explanation: While a chest X-ray is the gold standard for initial placement, pH testing of
aspirate is the most reliable bedside method for subsequent checks. Gastric contents
usually have a pH of 5.5 or lower, whereas respiratory secretions have a higher pH.
Auscultation is no longer considered a reliable indicator of correct placement according to
evidence-based practice standards.
6. Which of the following patients is at the highest risk for developing respiratory alkalosis?
A. A patient with severe diarrhea
B. A patient with chronic obstructive pulmonary disease (COPD)
C. A patient experiencing a panic attack with hyperventilation
D. A patient who has overdosed on opioids
Correct Answer: C
Explanation: Respiratory alkalosis occurs when there is an excessive loss of CO2, often
caused by hyperventilation during anxiety or panic. The rapid breathing leads to a decrease
in carbonic acid levels in the blood, resulting in an alkaline pH. In contrast, COPD and
opioid overdoses lead to CO2 retention and acidosis, while diarrhea leads to metabolic
acidosis.
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 6.2 mEq/L. Which of the following
manifestations should the nurse expect to observe? (Select All That Apply)
A. Cardiac dysrhythmias
B. Muscle weakness
C. Abdominal cramping
D. Tachycardia
E. Tall, peaked T waves on ECG
F. Hyporeflexia
Correct Answer: A, B, C, E
Explanation: Hyperkalemia, defined as a potassium level above 5.0 mEq/L, significantly
impacts neuromuscular and cardiac function. The presence of tall, peaked T waves is a
classic electrocardiogram change associated with elevated potassium levels. The nurse
must also monitor for muscle weakness and gastrointestinal hyperactivity such as
cramping, as these are common clinical findings.
,2. Which clinical manifestation should the nurse prioritize when assessing a patient for
hypocalcemia?
A. Positive Chvostek’s sign
B. Polyuria and polydipsia
C. Constipation and lethargy
D. Shortened QT interval
Correct Answer: A
Explanation: A positive Chvostek’s sign, which is a twitching of the facial muscles
following a tap on the facial nerve, indicates increased neuromuscular excitability due to
low calcium. Hypocalcemia often leads to tetany and tingling in the extremities, whereas
hypercalcemia typically causes lethargy and constipation. Prompt identification of these
signs is essential to prevent complications such as laryngospasm or seizures.
3. A patient’s arterial blood gas (ABG) results are: pH 7.30, PaCO2 52 mm Hg, and HCO3 24
mEq/L. How should the nurse interpret these findings?
A. Respiratory acidosis
B. Metabolic acidosis
C. Respiratory alkalosis
D. Metabolic alkalosis
Correct Answer: A
,Explanation: The pH of 7.30 indicates acidosis, while the elevated PaCO2 of 52 mm Hg
identifies the respiratory system as the cause of the imbalance. Because the bicarbonate
level (HCO3) is within the normal range of 22-26 mEq/L, the condition is uncompensated
respiratory acidosis. The nurse should assess the patient’s respiratory rate and depth, as
hypoventilation is the primary cause of this state.
4. During the preoperative phase, whose primary responsibility is it to obtain informed
consent from the patient?
A. The registered nurse
B. The anesthesiologist
C. The surgeon
D. The charge nurse
Correct Answer: C
Explanation: It is the legal and ethical responsibility of the surgeon to explain the
procedure, risks, benefits, and alternatives to the patient. The nurse’s role is typically
limited to witnessing the patient’s signature and ensuring the patient understands what
was discussed. If the patient expresses confusion about the surgery, the nurse must notify
the surgeon to return and provide further clarification.
5. A nurse is preparing to administer an enteral feeding through a nasogastric (NG) tube.
What is the most reliable bedside method for verifying tube placement?
A. Auscultating air injected into the stomach
, B. Confirming with a chest X-ray
C. Observing for coughing or choking
D. Measuring the pH of aspirated gastric contents
Correct Answer: D
Explanation: While a chest X-ray is the gold standard for initial placement, pH testing of
aspirate is the most reliable bedside method for subsequent checks. Gastric contents
usually have a pH of 5.5 or lower, whereas respiratory secretions have a higher pH.
Auscultation is no longer considered a reliable indicator of correct placement according to
evidence-based practice standards.
6. Which of the following patients is at the highest risk for developing respiratory alkalosis?
A. A patient with severe diarrhea
B. A patient with chronic obstructive pulmonary disease (COPD)
C. A patient experiencing a panic attack with hyperventilation
D. A patient who has overdosed on opioids
Correct Answer: C
Explanation: Respiratory alkalosis occurs when there is an excessive loss of CO2, often
caused by hyperventilation during anxiety or panic. The rapid breathing leads to a decrease
in carbonic acid levels in the blood, resulting in an alkaline pH. In contrast, COPD and
opioid overdoses lead to CO2 retention and acidosis, while diarrhea leads to metabolic
acidosis.
