NUR 205 | NUR 205 Med Surg Exam 3 Version 2 |
Questions with Correct Answers and Expert
Explanation for Each Question | Saint Paul’s School
of Nursing
1. A patient with acute kidney injury (AKI) has a serum potassium level of 6.8 mEq/L
and exhibit ECG changes. Which medication should the nurse expect to administer
first to protect the heart?
A. Sodium polystyrene sulfonate
B. Insulin with dextrose
C. Calcium gluconate
D. Sodium bicarbonate
Correct Answer: C
Expert Explanation: 1. Hyperkalemia is a critical electrolyte imbalance that can
lead to fatal cardiac arrhythmias. 2. Calcium gluconate is administered to stabilize
the myocardial cell membrane and prevent dysrhythmias. 3. This medication does
not lower the potassium level but provides immediate cardiac protection. 4. Other
treatments like insulin and glucose are then used to shift potassium into the cells. 5.
The nurse must prioritize patient safety by addressing the immediate threat to
cardiac function.
,2. Which assessment finding in a patient with a newly created arteriovenous (AV)
fistula is considered normal and indicates patency?
A. Absence of a palpable pulse distal to the site
B. Complaints of numbness and tingling in the hand
C. Presence of a thrill upon palpation
D. Pitting edema in the affected extremity
Correct Answer: C
Expert Explanation: 1. Assessing the patency of an AV fistula is a vital nursing
responsibility after surgical creation. 2. A thrill is a vibrating sensation felt over the
site, which indicates turbulent blood flow. 3. Nurses should also auscultate for a
bruit, which is the audible sound of the blood flow. 4. The absence of these findings
could suggest a clot or obstruction within the access. 5. Documentation of these
findings is essential for monitoring the maturity and usability of the fistula.
3. A patient is in the oliguric phase of acute kidney injury. Which clinical manifestation
should the nurse anticipate during this stage?
A. Urine output of 2,000 mL per day
B. Metabolic alkalosis
C. Urine output of less than 400 mL per day
,D. Fluid volume deficit
Correct Answer: C
Expert Explanation: 1. The oliguric phase of AKI is characterized by a significant
decrease in urine production. 2. This phase typically lasts one to two weeks and
involves severe fluid and electrolyte imbalances. 3. Because the kidneys cannot
excrete fluid, the patient is at high risk for fluid volume overload. 4. Laboratory
results often show rising blood urea nitrogen and creatinine levels during this
period. 5. Careful monitoring of intake and output is the priority nursing
intervention for these patients.
4. A patient with chronic kidney disease (CKD) is prescribed sevelamer (Renagel).
When should the nurse instruct the patient to take this medication?
A. Thirty minutes before breakfast
B. At bedtime with a full glass of water
C. With each meal and snack
D. Only when serum phosphorus levels are elevated
Correct Answer: C
Expert Explanation: 1. Sevelamer is a phosphate binder used to manage
hyperphosphatemia in patients with chronic kidney disease. 2. These medications
work by binding phosphorus from the food within the gastrointestinal tract. 3. If
, taken on an empty stomach, the medication will not be effective in removing dietary
phosphorus. 4. The nurse must educate the patient on the importance of timing to
prevent bone disease. 5. Constipation is a common side effect of phosphate binders
that requires nursing assessment and intervention.
5. During peritoneal dialysis, the nurse notes that the returned dialysate is cloudy.
What should be the nurse’s priority action?
A. Slow the infusion rate of the next exchange
B. Notify the healthcare provider immediately
C. Warm the dialysate to body temperature
D. Document the finding as a normal occurrence
Correct Answer: B
Expert Explanation: 1. Cloudy effluent or drainage during peritoneal dialysis is a
primary indicator of peritonitis. 2. Peritonitis is a serious complication that can lead
to scarring and failure of the peritoneal membrane. 3. The nurse should also assess
the patient for abdominal pain, rebound tenderness, and fever. 4. Cultures of the
drainage are usually obtained to identify the specific infecting organism. 5. Early
recognition and antibiotic treatment are crucial for maintaining the patient’s
dialysis access and health.
Questions with Correct Answers and Expert
Explanation for Each Question | Saint Paul’s School
of Nursing
1. A patient with acute kidney injury (AKI) has a serum potassium level of 6.8 mEq/L
and exhibit ECG changes. Which medication should the nurse expect to administer
first to protect the heart?
A. Sodium polystyrene sulfonate
B. Insulin with dextrose
C. Calcium gluconate
D. Sodium bicarbonate
Correct Answer: C
Expert Explanation: 1. Hyperkalemia is a critical electrolyte imbalance that can
lead to fatal cardiac arrhythmias. 2. Calcium gluconate is administered to stabilize
the myocardial cell membrane and prevent dysrhythmias. 3. This medication does
not lower the potassium level but provides immediate cardiac protection. 4. Other
treatments like insulin and glucose are then used to shift potassium into the cells. 5.
The nurse must prioritize patient safety by addressing the immediate threat to
cardiac function.
,2. Which assessment finding in a patient with a newly created arteriovenous (AV)
fistula is considered normal and indicates patency?
A. Absence of a palpable pulse distal to the site
B. Complaints of numbness and tingling in the hand
C. Presence of a thrill upon palpation
D. Pitting edema in the affected extremity
Correct Answer: C
Expert Explanation: 1. Assessing the patency of an AV fistula is a vital nursing
responsibility after surgical creation. 2. A thrill is a vibrating sensation felt over the
site, which indicates turbulent blood flow. 3. Nurses should also auscultate for a
bruit, which is the audible sound of the blood flow. 4. The absence of these findings
could suggest a clot or obstruction within the access. 5. Documentation of these
findings is essential for monitoring the maturity and usability of the fistula.
3. A patient is in the oliguric phase of acute kidney injury. Which clinical manifestation
should the nurse anticipate during this stage?
A. Urine output of 2,000 mL per day
B. Metabolic alkalosis
C. Urine output of less than 400 mL per day
,D. Fluid volume deficit
Correct Answer: C
Expert Explanation: 1. The oliguric phase of AKI is characterized by a significant
decrease in urine production. 2. This phase typically lasts one to two weeks and
involves severe fluid and electrolyte imbalances. 3. Because the kidneys cannot
excrete fluid, the patient is at high risk for fluid volume overload. 4. Laboratory
results often show rising blood urea nitrogen and creatinine levels during this
period. 5. Careful monitoring of intake and output is the priority nursing
intervention for these patients.
4. A patient with chronic kidney disease (CKD) is prescribed sevelamer (Renagel).
When should the nurse instruct the patient to take this medication?
A. Thirty minutes before breakfast
B. At bedtime with a full glass of water
C. With each meal and snack
D. Only when serum phosphorus levels are elevated
Correct Answer: C
Expert Explanation: 1. Sevelamer is a phosphate binder used to manage
hyperphosphatemia in patients with chronic kidney disease. 2. These medications
work by binding phosphorus from the food within the gastrointestinal tract. 3. If
, taken on an empty stomach, the medication will not be effective in removing dietary
phosphorus. 4. The nurse must educate the patient on the importance of timing to
prevent bone disease. 5. Constipation is a common side effect of phosphate binders
that requires nursing assessment and intervention.
5. During peritoneal dialysis, the nurse notes that the returned dialysate is cloudy.
What should be the nurse’s priority action?
A. Slow the infusion rate of the next exchange
B. Notify the healthcare provider immediately
C. Warm the dialysate to body temperature
D. Document the finding as a normal occurrence
Correct Answer: B
Expert Explanation: 1. Cloudy effluent or drainage during peritoneal dialysis is a
primary indicator of peritonitis. 2. Peritonitis is a serious complication that can lead
to scarring and failure of the peritoneal membrane. 3. The nurse should also assess
the patient for abdominal pain, rebound tenderness, and fever. 4. Cultures of the
drainage are usually obtained to identify the specific infecting organism. 5. Early
recognition and antibiotic treatment are crucial for maintaining the patient’s
dialysis access and health.
