NU189 | NU 189 Medical-Surgical Nursing II Exam
2 v1 | Questions with Correct Answers and Expert
Explanation for Each Question | Galen
1. A patient with heart failure is prescribed Digoxin. Which laboratory result would the
nurse be most concerned about?
A. Sodium 138 mEq/L
B. Magnesium 2.0 mg/dL
C. Calcium 9.5 mg/dL
D. Potassium 3.1 mEq/L
Correct Answer: D
Expert Explanation: Hypokalemia significantly increases the risk of Digoxin
toxicity because potassium and digoxin compete for binding sites on the sodium-
potassium ATPase pump. When potassium levels are low, more digoxin can bind to
these sites, leading to toxic effects. The nurse must monitor electrolyte levels closely
and notify the provider of low potassium before administering the dose.
2. The nurse is caring for a client in the oliguric phase of acute kidney injury (AKI).
Which finding is expected?
A. Elevated BUN and Creatinine
B. Hypernatremia
,C. Metabolic alkalosis
D. Urine output of 2 liters per day
Correct Answer: A
Expert Explanation: In the oliguric phase of AKI, the kidneys are unable to filter
waste products effectively, leading to a rise in blood urea nitrogen (BUN) and serum
creatinine. This phase is characterized by a significant decrease in urine output,
typically less than 400 mL per day. Other common findings include metabolic
acidosis and hyperkalemia due to the lack of excretion.
3. A client is admitted with a suspected Myocardial Infarction (MI). Which cardiac
biomarker is most specific for myocardial damage?
A. Creatine Kinase (CK-MB)
B. Troponin I
C. Myoglobin
D. C-reactive protein
Correct Answer: B
Expert Explanation: Troponin I is a highly specific and sensitive marker for
myocardial injury and remains elevated for several days after an event. While CK-
MB is also used, it is less specific than Troponin because it can be elevated in
,skeletal muscle damage. Myoglobin rises early but is not specific to heart muscle,
making Troponin the gold standard for MI diagnosis.
4. A nurse is monitoring a patient receiving a blood transfusion. The patient develops
chills, low back pain, and hypotension. What is the priority nursing action?
A. Slow the infusion rate
B. Stop the transfusion immediately
C. Administer diphenhydramine
D. Check the patient’s temperature
Correct Answer: B
Expert Explanation: The symptoms described indicate an acute hemolytic
transfusion reaction, which is a life-threatening emergency. The nurse must stop the
infusion immediately to prevent further exposure to incompatible blood. After
stopping the transfusion, the nurse should maintain the IV line with normal saline
and notify the physician and blood bank.
5. Which assessment finding should the nurse expect in a client with SIADH (Syndrome
of Inappropriate Antidiuretic Hormone)?
A. Excessive thirst and polyuria
B. Dilutional hyponatremia
, C. High serum osmolality
D. Weight loss and dehydration
Correct Answer: B
Expert Explanation: SIADH involves the excessive release of ADH, causing the
kidneys to reabsorb too much water, which dilutes the blood. This results in
dilutional hyponatremia and low serum osmolality despite increased fluid volume.
Patients typically present with fluid retention and concentrated urine, not polyuria
or weight loss.
6. A client with Type 1 Diabetes presents to the ER with Kussmaul respirations and
fruity breath. What condition does the nurse suspect?
A. Hypoglycemia
B. Diabetic Ketoacidosis (DKA)
C. Hyperglycemic Hyperosmolar State (HHS)
D. Respiratory Alkalosis
Correct Answer: B
Expert Explanation: Kussmaul respirations and fruity (acetone) breath are classic
signs of DKA, which occurs when the body breaks down fat for energy, producing
2 v1 | Questions with Correct Answers and Expert
Explanation for Each Question | Galen
1. A patient with heart failure is prescribed Digoxin. Which laboratory result would the
nurse be most concerned about?
A. Sodium 138 mEq/L
B. Magnesium 2.0 mg/dL
C. Calcium 9.5 mg/dL
D. Potassium 3.1 mEq/L
Correct Answer: D
Expert Explanation: Hypokalemia significantly increases the risk of Digoxin
toxicity because potassium and digoxin compete for binding sites on the sodium-
potassium ATPase pump. When potassium levels are low, more digoxin can bind to
these sites, leading to toxic effects. The nurse must monitor electrolyte levels closely
and notify the provider of low potassium before administering the dose.
2. The nurse is caring for a client in the oliguric phase of acute kidney injury (AKI).
Which finding is expected?
A. Elevated BUN and Creatinine
B. Hypernatremia
,C. Metabolic alkalosis
D. Urine output of 2 liters per day
Correct Answer: A
Expert Explanation: In the oliguric phase of AKI, the kidneys are unable to filter
waste products effectively, leading to a rise in blood urea nitrogen (BUN) and serum
creatinine. This phase is characterized by a significant decrease in urine output,
typically less than 400 mL per day. Other common findings include metabolic
acidosis and hyperkalemia due to the lack of excretion.
3. A client is admitted with a suspected Myocardial Infarction (MI). Which cardiac
biomarker is most specific for myocardial damage?
A. Creatine Kinase (CK-MB)
B. Troponin I
C. Myoglobin
D. C-reactive protein
Correct Answer: B
Expert Explanation: Troponin I is a highly specific and sensitive marker for
myocardial injury and remains elevated for several days after an event. While CK-
MB is also used, it is less specific than Troponin because it can be elevated in
,skeletal muscle damage. Myoglobin rises early but is not specific to heart muscle,
making Troponin the gold standard for MI diagnosis.
4. A nurse is monitoring a patient receiving a blood transfusion. The patient develops
chills, low back pain, and hypotension. What is the priority nursing action?
A. Slow the infusion rate
B. Stop the transfusion immediately
C. Administer diphenhydramine
D. Check the patient’s temperature
Correct Answer: B
Expert Explanation: The symptoms described indicate an acute hemolytic
transfusion reaction, which is a life-threatening emergency. The nurse must stop the
infusion immediately to prevent further exposure to incompatible blood. After
stopping the transfusion, the nurse should maintain the IV line with normal saline
and notify the physician and blood bank.
5. Which assessment finding should the nurse expect in a client with SIADH (Syndrome
of Inappropriate Antidiuretic Hormone)?
A. Excessive thirst and polyuria
B. Dilutional hyponatremia
, C. High serum osmolality
D. Weight loss and dehydration
Correct Answer: B
Expert Explanation: SIADH involves the excessive release of ADH, causing the
kidneys to reabsorb too much water, which dilutes the blood. This results in
dilutional hyponatremia and low serum osmolality despite increased fluid volume.
Patients typically present with fluid retention and concentrated urine, not polyuria
or weight loss.
6. A client with Type 1 Diabetes presents to the ER with Kussmaul respirations and
fruity breath. What condition does the nurse suspect?
A. Hypoglycemia
B. Diabetic Ketoacidosis (DKA)
C. Hyperglycemic Hyperosmolar State (HHS)
D. Respiratory Alkalosis
Correct Answer: B
Expert Explanation: Kussmaul respirations and fruity (acetone) breath are classic
signs of DKA, which occurs when the body breaks down fat for energy, producing
