NUR 170 Exam 3 Study Guide - Medical-Surgical Nursing 2026 Galen
College
1. A patient’s ABG results are pH 7.30, PaCO2 52, and HCO3 24. How should the
nurse interpret these findings?
A. Respiratory Acidosis
B. Respiratory Alkalosis
C. Metabolic Acidosis
D. Metabolic Alkalosis
Answer: A
Rationale: A pH below 7.35 indicates acidosis. A PaCO2 above 45 indicates a respiratory
cause, and since the HCO3 is normal, it is uncompensated respiratory acidosis.
2. Which clinical manifestation is most characteristic of right-sided heart failure?
A. Crackles in the lungs
B. Orthopnea
C. Dyspnea on exertion
D. Peripheral edema
Answer: D
Rationale: Right-sided heart failure causes blood to back up into the systemic circulation,
leading to peripheral edema, JVD, and hepatomegaly.
,3. A nurse is caring for a patient with a potassium level of 6.2 mEq/L. Which
intervention is the priority?
A. Administering a potassium supplement
B. Encouraging the intake of bananas
C. Monitoring the EKG for tall, peaked T-waves
D. Checking the patient’s blood pressure
Answer: C
Rationale: Hyperkalemia (potassium > 5.0) can cause life-threatening cardiac
dysrhythmias. Monitoring the EKG for changes like peaked T-waves is the priority.
4. What is the primary goal of pursed-lip breathing in a patient with COPD?
A. To increase the respiratory rate
B. To strengthen the diaphragm
C. To promote carbon dioxide elimination
D. To decrease the use of accessory muscles
Answer: C
Rationale: Pursed-lip breathing creates back-pressure in the airways, keeping them open
longer and allowing more CO2 to be exhaled.
5. Which electrolyte imbalance is associated with a positive Trousseau’s sign?
A. Hyperkalemia
B. Hypocalcemia
C. Hyponatremia
D. Hypermagnesemia
Answer: B
Rationale: Hypocalcemia causes increased neuromuscular excitability, leading to
Trousseau’s sign (carpal spasm with BP cuff inflation) and Chvostek’s sign.
, 6. When administering Albuterol to a patient with asthma, the nurse should
monitor for which side effect?
A. Tachycardia
B. Drowsiness
C. Bradycardia
D. Hypoglycemia
Answer: A
Rationale: Albuterol is a beta-2 agonist that can stimulate beta-1 receptors in the heart,
causing tachycardia and tremors.
7. A patient with a deep vein thrombosis (DVT) is on Heparin. What is the
priority nursing assessment?
A. Measuring calf circumference
B. Encouraging vigorous exercise
C. Assessing for peripheral pulses
D. Monitoring for signs of bleeding
Answer: D
Rationale: Heparin is an anticoagulant; the most significant risk is hemorrhage. The nurse
must monitor for bleeding in gums, stool, or urine.
8. Which positioning is most appropriate for a patient experiencing shortness of
breath?
A. High-Fowler’s
B. Supine
C. Trendelenburg
D. Sims position
Answer: A
Rationale: High-Fowler’s position (sitting at 90 degrees) allows for maximum lung
expansion and eases the work of breathing.
College
1. A patient’s ABG results are pH 7.30, PaCO2 52, and HCO3 24. How should the
nurse interpret these findings?
A. Respiratory Acidosis
B. Respiratory Alkalosis
C. Metabolic Acidosis
D. Metabolic Alkalosis
Answer: A
Rationale: A pH below 7.35 indicates acidosis. A PaCO2 above 45 indicates a respiratory
cause, and since the HCO3 is normal, it is uncompensated respiratory acidosis.
2. Which clinical manifestation is most characteristic of right-sided heart failure?
A. Crackles in the lungs
B. Orthopnea
C. Dyspnea on exertion
D. Peripheral edema
Answer: D
Rationale: Right-sided heart failure causes blood to back up into the systemic circulation,
leading to peripheral edema, JVD, and hepatomegaly.
,3. A nurse is caring for a patient with a potassium level of 6.2 mEq/L. Which
intervention is the priority?
A. Administering a potassium supplement
B. Encouraging the intake of bananas
C. Monitoring the EKG for tall, peaked T-waves
D. Checking the patient’s blood pressure
Answer: C
Rationale: Hyperkalemia (potassium > 5.0) can cause life-threatening cardiac
dysrhythmias. Monitoring the EKG for changes like peaked T-waves is the priority.
4. What is the primary goal of pursed-lip breathing in a patient with COPD?
A. To increase the respiratory rate
B. To strengthen the diaphragm
C. To promote carbon dioxide elimination
D. To decrease the use of accessory muscles
Answer: C
Rationale: Pursed-lip breathing creates back-pressure in the airways, keeping them open
longer and allowing more CO2 to be exhaled.
5. Which electrolyte imbalance is associated with a positive Trousseau’s sign?
A. Hyperkalemia
B. Hypocalcemia
C. Hyponatremia
D. Hypermagnesemia
Answer: B
Rationale: Hypocalcemia causes increased neuromuscular excitability, leading to
Trousseau’s sign (carpal spasm with BP cuff inflation) and Chvostek’s sign.
, 6. When administering Albuterol to a patient with asthma, the nurse should
monitor for which side effect?
A. Tachycardia
B. Drowsiness
C. Bradycardia
D. Hypoglycemia
Answer: A
Rationale: Albuterol is a beta-2 agonist that can stimulate beta-1 receptors in the heart,
causing tachycardia and tremors.
7. A patient with a deep vein thrombosis (DVT) is on Heparin. What is the
priority nursing assessment?
A. Measuring calf circumference
B. Encouraging vigorous exercise
C. Assessing for peripheral pulses
D. Monitoring for signs of bleeding
Answer: D
Rationale: Heparin is an anticoagulant; the most significant risk is hemorrhage. The nurse
must monitor for bleeding in gums, stool, or urine.
8. Which positioning is most appropriate for a patient experiencing shortness of
breath?
A. High-Fowler’s
B. Supine
C. Trendelenburg
D. Sims position
Answer: A
Rationale: High-Fowler’s position (sitting at 90 degrees) allows for maximum lung
expansion and eases the work of breathing.
