MED SURGE 4th EDITION 2026 PASS ON FIRST
ATTEMPT/LATEST VERSION
1. The nurse is caring for a client with deficient fluid volume caused by a massive burn injury.
Which of the following assessment data will be of greatest concern to the nurse?
a. The blood pressure is 90/40 mm Hg.
b. Urine output is 30 mL over the last hour.
c. Oral fluid intake is 100 mL for the last 8 hours.
d. There is prolonged skin ten*ng over the sternum.
:A
The blood pressure indicates that the client may be developing hypovolemic shock as a
result
of fluid loss. This will require immediate interven*on to prevent the complica*ons
associated
with systemic hypoperfusion. The poor oral intake, decreased urine output, and skin ten*ng
all indicate the need for increasing the client's fluid intake but not as urgently as the
hypotension.
DIF: Cogni*ve Level: Applica*on TOP: Nursing Process: Assessment
MSC:
Physiological Integrity
2. The nurse is caring for a client recently admi9ed with small cell carcinoma of the lung and
the
syndrome of inappropriate an*diure*c hormone (SIADH). Which of the following
assessments should the nurse carefully monitor?
a. Increased total urinary output
b. Eleva*on of serum hematocrit
c. Decreased serum sodium level
d. Rapid and unexpected weight loss
:C
SIADH causes water reten*on and hyponatremia—a decrease in serum sodium level. Weight
loss, increased urine output, and elevated serum hematocrit may be associated with
excessive
loss of water, but not with SIADH and water reten*on.
DIF: Cogni*ve Level: Comprehension TOP: Nursing Process: Assessment
MSC:
,Physiological Integrity
3. The nurse is evalua*ng the fluid balance for a client admi9ed for hypovolemia associated
with
mul*ple draining wounds. Which of the following assessments is the most accurate to
evaluate volume status in this client?
a. Skin turgor
b. Daily weight
c. Presence of edema
d. Hourly urine output
:B
NURSINGTB.COM
Medical-Surgical Nursing in Canada 4th Edi*on Lewi Test Bank
Daily weight is the most easily obtained and accurate means of assessing volume status. Skin
turgor varies considerably with age. Considerable excess fluid volume may be present before
fluid moves into the inters**al space and causes edema. Hourly urine outputs do not take
account of fluid intake or of fluid loss through insensible loss, swea*ng, or loss from the
gastrointes*nal tract or wounds.
DIF: Cogni*ve Level: Applica*on TOP: Nursing Process: Evalua*on
MSC:
Physiological Integrity
4. The nurse is caring for an alert and oriented older-adult client with a history of
dehydra*on.
Which of the following informa*on should the home health nurse teach the client as to
when
to increase fluid intake?
a. In the late evening hours
b. If the oral mucosa feels dry
c. When the client feels thirsty
d. As soon as changes in level of consciousness (LOC) occur
:B
An alert, elderly client will be able to self-assess for signs of oral dryness such as thick oral
secre*ons or dry-appearing mucosa. The thirst mechanism decreases with age and is not an
accurate indicator of volume deple*on. Many older clients prefer to restrict fluids slightly in
the evening to improve sleep quality. The client will not be likely to no*ce and act
appropriately when changes in LOC occur.
DIF: Cogni*ve Level: Applica*on TOP: Nursing Process: Implementa*on
MSC:
,Health Promo*on and Maintenance
5. The nurse is caring for a client who is taking a potassium-was*ng diure*c for treatment of
hypertension. Which of the following assessment data would the nurse include in the
teaching
plan?
a. Personality changes
b. Frequent loose stools
c. Facial muscle spasms
d. Lower extremity weakness
:D
Lower extremity weakness progressing to flaccidity is a manifesta*on of hypokalemia. Facial
muscle spasms might occur with hypocalcemia. Loose stools are associated with
hyperkalemia. Personality changes are not associated with electrolyte disturbances,
although
changes in mental status are common manifesta*ons with sodium excess or deficit.
DIF: Cogni*ve Level: Applica*on TOP: Nursing Process: Implementa*on
MSC:
Physiological Integrity
6. The nurse is teaching a client about spironolactone as a diure*c. Which statement by the
client
indicates that the teaching about this medica*on has been effec*ve?
a. "I will try to drink at least eight glasses of water every day."
b. "I will use a salt subs*tute to decrease my sodium intake."
c. "I will increase my intake of potassium-containing foods."
d. "I will drink apple juice instead of orange juice for breakfast."
:D
NURSINGTB.COM
Medical-Surgical Nursing in Canada 4th Edi*on Lewi Test Bank
Since spironolactone is a potassium-sparing diure*c, clients should be taught to choose low
potassium foods such as apple juice rather than foods that have higher levels of potassium,
such as citrus fruits. Because the client is using spironolactone as a diure*c, the nurse would
not encourage the client to increase fluid intake. Teach clients to avoid salt subs*tutes,
which
are high in potassium.
DIF: Cogni*ve Level: Applica*on TOP: Nursing Process: Implementa*on
MSC:
Physiological Integrity
7. The nurse is caring for a client admi9ed with hyponatremia. Which of the following
, ac*ons
should the nurse an*cipate implemen*ng?
a. Restrict client's oral free water intake.
b. Avoid use of electrolyte-containing drinks.
c. Infuse a solu*on of 5% dextrose in 0.45% saline.
d. Administer vasopressin (an*diure*c hormone, [ADH]).
:A
To help improve serum sodium levels, water intake is restricted. Electrolyte-containing
beverages will improve the client's sodium level. Administra*on of vasopressin or hypotonic
IV solu*ons will decrease the serum sodium level further.
DIF: Cogni*ve Level: Applica*on TOP: Nursing Process: Planning
MSC:
Physiological Integrity
8. The nurse is caring for a client with severe hypokalemia and is preparing to administer
intravenous potassium chloride (KCl) 40 mmol as prescribed by the health care provider.
Which of the following ac*ons should the nurse take?
a. Administer the KCl as a rapid IV bolus.
b. Infuse the KCl at a rate of 20 mEq/hour.
c. Give the KCl only through a central venous line.
d. Add no more than 40 mEq/L to a litre of IV fluid.
:B
Intravenous KCl is administered at a maximal rate of 20 mEq/hour. Rapid IV infusion of KCl
can cause cardiac arrest. Although the preferred concentra*on for KCl is no more than 40
mmol, concentra*ons up to 60 mmol may be used for some clients. KCl can cause
inflamma*on of peripheral veins, but it can be administered by this route.
DIF: Cogni*ve Level: Applica*on TOP: Nursing Process: Implementa*on
MSC:
Physiological Integrity
9. The nurse is caring for a client with hyperkalemia and is interpre*ng the
electrocardiogram
(ECG) report. Which of the following ECG changes would the nurse expect to assess in this
client?
a. Ventricular dysrhythmias
b. Bradycardia
c. Fla9en T wave
d. Prolonged P-R interval
:D
NURSINGTB.COM
ATTEMPT/LATEST VERSION
1. The nurse is caring for a client with deficient fluid volume caused by a massive burn injury.
Which of the following assessment data will be of greatest concern to the nurse?
a. The blood pressure is 90/40 mm Hg.
b. Urine output is 30 mL over the last hour.
c. Oral fluid intake is 100 mL for the last 8 hours.
d. There is prolonged skin ten*ng over the sternum.
:A
The blood pressure indicates that the client may be developing hypovolemic shock as a
result
of fluid loss. This will require immediate interven*on to prevent the complica*ons
associated
with systemic hypoperfusion. The poor oral intake, decreased urine output, and skin ten*ng
all indicate the need for increasing the client's fluid intake but not as urgently as the
hypotension.
DIF: Cogni*ve Level: Applica*on TOP: Nursing Process: Assessment
MSC:
Physiological Integrity
2. The nurse is caring for a client recently admi9ed with small cell carcinoma of the lung and
the
syndrome of inappropriate an*diure*c hormone (SIADH). Which of the following
assessments should the nurse carefully monitor?
a. Increased total urinary output
b. Eleva*on of serum hematocrit
c. Decreased serum sodium level
d. Rapid and unexpected weight loss
:C
SIADH causes water reten*on and hyponatremia—a decrease in serum sodium level. Weight
loss, increased urine output, and elevated serum hematocrit may be associated with
excessive
loss of water, but not with SIADH and water reten*on.
DIF: Cogni*ve Level: Comprehension TOP: Nursing Process: Assessment
MSC:
,Physiological Integrity
3. The nurse is evalua*ng the fluid balance for a client admi9ed for hypovolemia associated
with
mul*ple draining wounds. Which of the following assessments is the most accurate to
evaluate volume status in this client?
a. Skin turgor
b. Daily weight
c. Presence of edema
d. Hourly urine output
:B
NURSINGTB.COM
Medical-Surgical Nursing in Canada 4th Edi*on Lewi Test Bank
Daily weight is the most easily obtained and accurate means of assessing volume status. Skin
turgor varies considerably with age. Considerable excess fluid volume may be present before
fluid moves into the inters**al space and causes edema. Hourly urine outputs do not take
account of fluid intake or of fluid loss through insensible loss, swea*ng, or loss from the
gastrointes*nal tract or wounds.
DIF: Cogni*ve Level: Applica*on TOP: Nursing Process: Evalua*on
MSC:
Physiological Integrity
4. The nurse is caring for an alert and oriented older-adult client with a history of
dehydra*on.
Which of the following informa*on should the home health nurse teach the client as to
when
to increase fluid intake?
a. In the late evening hours
b. If the oral mucosa feels dry
c. When the client feels thirsty
d. As soon as changes in level of consciousness (LOC) occur
:B
An alert, elderly client will be able to self-assess for signs of oral dryness such as thick oral
secre*ons or dry-appearing mucosa. The thirst mechanism decreases with age and is not an
accurate indicator of volume deple*on. Many older clients prefer to restrict fluids slightly in
the evening to improve sleep quality. The client will not be likely to no*ce and act
appropriately when changes in LOC occur.
DIF: Cogni*ve Level: Applica*on TOP: Nursing Process: Implementa*on
MSC:
,Health Promo*on and Maintenance
5. The nurse is caring for a client who is taking a potassium-was*ng diure*c for treatment of
hypertension. Which of the following assessment data would the nurse include in the
teaching
plan?
a. Personality changes
b. Frequent loose stools
c. Facial muscle spasms
d. Lower extremity weakness
:D
Lower extremity weakness progressing to flaccidity is a manifesta*on of hypokalemia. Facial
muscle spasms might occur with hypocalcemia. Loose stools are associated with
hyperkalemia. Personality changes are not associated with electrolyte disturbances,
although
changes in mental status are common manifesta*ons with sodium excess or deficit.
DIF: Cogni*ve Level: Applica*on TOP: Nursing Process: Implementa*on
MSC:
Physiological Integrity
6. The nurse is teaching a client about spironolactone as a diure*c. Which statement by the
client
indicates that the teaching about this medica*on has been effec*ve?
a. "I will try to drink at least eight glasses of water every day."
b. "I will use a salt subs*tute to decrease my sodium intake."
c. "I will increase my intake of potassium-containing foods."
d. "I will drink apple juice instead of orange juice for breakfast."
:D
NURSINGTB.COM
Medical-Surgical Nursing in Canada 4th Edi*on Lewi Test Bank
Since spironolactone is a potassium-sparing diure*c, clients should be taught to choose low
potassium foods such as apple juice rather than foods that have higher levels of potassium,
such as citrus fruits. Because the client is using spironolactone as a diure*c, the nurse would
not encourage the client to increase fluid intake. Teach clients to avoid salt subs*tutes,
which
are high in potassium.
DIF: Cogni*ve Level: Applica*on TOP: Nursing Process: Implementa*on
MSC:
Physiological Integrity
7. The nurse is caring for a client admi9ed with hyponatremia. Which of the following
, ac*ons
should the nurse an*cipate implemen*ng?
a. Restrict client's oral free water intake.
b. Avoid use of electrolyte-containing drinks.
c. Infuse a solu*on of 5% dextrose in 0.45% saline.
d. Administer vasopressin (an*diure*c hormone, [ADH]).
:A
To help improve serum sodium levels, water intake is restricted. Electrolyte-containing
beverages will improve the client's sodium level. Administra*on of vasopressin or hypotonic
IV solu*ons will decrease the serum sodium level further.
DIF: Cogni*ve Level: Applica*on TOP: Nursing Process: Planning
MSC:
Physiological Integrity
8. The nurse is caring for a client with severe hypokalemia and is preparing to administer
intravenous potassium chloride (KCl) 40 mmol as prescribed by the health care provider.
Which of the following ac*ons should the nurse take?
a. Administer the KCl as a rapid IV bolus.
b. Infuse the KCl at a rate of 20 mEq/hour.
c. Give the KCl only through a central venous line.
d. Add no more than 40 mEq/L to a litre of IV fluid.
:B
Intravenous KCl is administered at a maximal rate of 20 mEq/hour. Rapid IV infusion of KCl
can cause cardiac arrest. Although the preferred concentra*on for KCl is no more than 40
mmol, concentra*ons up to 60 mmol may be used for some clients. KCl can cause
inflamma*on of peripheral veins, but it can be administered by this route.
DIF: Cogni*ve Level: Applica*on TOP: Nursing Process: Implementa*on
MSC:
Physiological Integrity
9. The nurse is caring for a client with hyperkalemia and is interpre*ng the
electrocardiogram
(ECG) report. Which of the following ECG changes would the nurse expect to assess in this
client?
a. Ventricular dysrhythmias
b. Bradycardia
c. Fla9en T wave
d. Prolonged P-R interval
:D
NURSINGTB.COM
