NUR104 | NUR104 Medsurg 2 Exam 4 Version 3
Questions with Correct Answers and Expert
Explanation for Each Question
1. A patient is admitted with suspected Addisonian crisis. Which clinical finding should
the nurse prioritize during the initial assessment?
A. Hyperglycemia and moon face
B. Increased appetite and weight gain
C. Severe hypotension and tachycardia
D. Exophthalmos and tremors
Correct Answer: C
Expert Explanation: Addisonian crisis is a life-threatening emergency caused by
acute adrenal insufficiency. The primary clinical manifestation is profound
hypotension resulting from fluid loss and electrolyte imbalances. Nurses must
monitor vital signs closely to detect early signs of hypovolemic shock. Immediate
administration of intravenous fluids and corticosteroids is required to stabilize the
patient. Prioritizing cardiovascular stability is essential to prevent organ failure and
death.
2. Which lab result would the nurse expect to find in a patient experiencing Syndrome
of Inappropriate Antidiuretic Hormone (SIADH)?
A. Urine specific gravity 1.002
,B. Serum osmolality 320 mOsm/kg
C. Serum sodium 125 mEq/L
D. Hematocrit 55%
Correct Answer: C
Expert Explanation: SIADH involves excessive release of ADH leading to significant
water retention and dilutional hyponatremia. A serum sodium level of 125 mEq/L
reflects this imbalance and poses a risk for neurological complications. The nurse
should implement fluid restrictions to manage the excess water volume.
Concentrated urine with a high specific gravity is another characteristic finding of
this disorder. Monitoring electrolyte levels is a critical component of nursing
management for SIADH patients.
3. A patient with Chronic Kidney Disease (CKD) has a potassium level of 6.8 mEq/L.
Which intervention should the nurse implement first?
A. Encourage a diet high in leafy greens
B. Notify the physician and prepare for EKG monitoring
C. Administer a dose of oral furosemide
D. Request a referral for a physical therapist
Correct Answer: B
,Expert Explanation: Hyperkalemia is a common and dangerous complication of
advanced chronic kidney disease. A potassium level of 6.8 mEq/L can cause fatal
cardiac arrhythmias and necessitates immediate intervention. Continuous EKG
monitoring is the priority to identify life-threatening heart rhythm changes. The
nurse may need to administer medications like calcium gluconate or insulin to shift
potassium. Close collaboration with the healthcare team ensures the patient
receives timely and safe care.
4. A patient is receiving hemodialysis through a left arm Arteriovenous (AV) fistula.
Which nursing action is essential for patient safety?
A. Draw routine lab samples directly from the fistula
B. Palpate the fistula every hour for a lack of pulse
C. Apply a tight dressing over the site daily
D. Avoid taking blood pressure readings on the left arm
Correct Answer: D
Expert Explanation: Protecting the patency of an AV fistula is vital for patients
requiring long-term hemodialysis. Nurses must never use the affected arm for blood
pressure or venipuncture to prevent clotting. Assessing for a thrill and bruit
indicates that the access is functioning correctly. Educating the patient on avoiding
, restrictive clothing on that limb is a key intervention. These precautions help
maintain a reliable route for life-saving dialysis treatments.
5. When caring for a patient with acute pancreatitis, which assessment finding is most
concerning?
A. Ecchymosis around the umbilicus (Cullen’s sign)
B. Serum amylase level three times normal
C. Nausea and epigastric pain radiating to the back
D. Increased bowel sounds in all quadrants
Correct Answer: A
Expert Explanation: Cullen’s sign indicates retroperitoneal bleeding and is a sign of
severe necrotizing pancreatitis. This finding suggests a high risk for hemorrhagic
shock and requires immediate medical attention. While elevated amylase and pain
are expected, they are not as immediately life-threatening as internal hemorrhage.
The nurse must monitor for signs of hemodynamic instability such as hypotension.
Swift clinical reasoning and assessment are crucial for managing complex
gastrointestinal disorders.
6. A patient with cirrhosis is prescribed lactulose. What is the primary therapeutic
outcome the nurse should monitor for?
A. Improved mental status and decreased ammonia
Questions with Correct Answers and Expert
Explanation for Each Question
1. A patient is admitted with suspected Addisonian crisis. Which clinical finding should
the nurse prioritize during the initial assessment?
A. Hyperglycemia and moon face
B. Increased appetite and weight gain
C. Severe hypotension and tachycardia
D. Exophthalmos and tremors
Correct Answer: C
Expert Explanation: Addisonian crisis is a life-threatening emergency caused by
acute adrenal insufficiency. The primary clinical manifestation is profound
hypotension resulting from fluid loss and electrolyte imbalances. Nurses must
monitor vital signs closely to detect early signs of hypovolemic shock. Immediate
administration of intravenous fluids and corticosteroids is required to stabilize the
patient. Prioritizing cardiovascular stability is essential to prevent organ failure and
death.
2. Which lab result would the nurse expect to find in a patient experiencing Syndrome
of Inappropriate Antidiuretic Hormone (SIADH)?
A. Urine specific gravity 1.002
,B. Serum osmolality 320 mOsm/kg
C. Serum sodium 125 mEq/L
D. Hematocrit 55%
Correct Answer: C
Expert Explanation: SIADH involves excessive release of ADH leading to significant
water retention and dilutional hyponatremia. A serum sodium level of 125 mEq/L
reflects this imbalance and poses a risk for neurological complications. The nurse
should implement fluid restrictions to manage the excess water volume.
Concentrated urine with a high specific gravity is another characteristic finding of
this disorder. Monitoring electrolyte levels is a critical component of nursing
management for SIADH patients.
3. A patient with Chronic Kidney Disease (CKD) has a potassium level of 6.8 mEq/L.
Which intervention should the nurse implement first?
A. Encourage a diet high in leafy greens
B. Notify the physician and prepare for EKG monitoring
C. Administer a dose of oral furosemide
D. Request a referral for a physical therapist
Correct Answer: B
,Expert Explanation: Hyperkalemia is a common and dangerous complication of
advanced chronic kidney disease. A potassium level of 6.8 mEq/L can cause fatal
cardiac arrhythmias and necessitates immediate intervention. Continuous EKG
monitoring is the priority to identify life-threatening heart rhythm changes. The
nurse may need to administer medications like calcium gluconate or insulin to shift
potassium. Close collaboration with the healthcare team ensures the patient
receives timely and safe care.
4. A patient is receiving hemodialysis through a left arm Arteriovenous (AV) fistula.
Which nursing action is essential for patient safety?
A. Draw routine lab samples directly from the fistula
B. Palpate the fistula every hour for a lack of pulse
C. Apply a tight dressing over the site daily
D. Avoid taking blood pressure readings on the left arm
Correct Answer: D
Expert Explanation: Protecting the patency of an AV fistula is vital for patients
requiring long-term hemodialysis. Nurses must never use the affected arm for blood
pressure or venipuncture to prevent clotting. Assessing for a thrill and bruit
indicates that the access is functioning correctly. Educating the patient on avoiding
, restrictive clothing on that limb is a key intervention. These precautions help
maintain a reliable route for life-saving dialysis treatments.
5. When caring for a patient with acute pancreatitis, which assessment finding is most
concerning?
A. Ecchymosis around the umbilicus (Cullen’s sign)
B. Serum amylase level three times normal
C. Nausea and epigastric pain radiating to the back
D. Increased bowel sounds in all quadrants
Correct Answer: A
Expert Explanation: Cullen’s sign indicates retroperitoneal bleeding and is a sign of
severe necrotizing pancreatitis. This finding suggests a high risk for hemorrhagic
shock and requires immediate medical attention. While elevated amylase and pain
are expected, they are not as immediately life-threatening as internal hemorrhage.
The nurse must monitor for signs of hemodynamic instability such as hypotension.
Swift clinical reasoning and assessment are crucial for managing complex
gastrointestinal disorders.
6. A patient with cirrhosis is prescribed lactulose. What is the primary therapeutic
outcome the nurse should monitor for?
A. Improved mental status and decreased ammonia
