ED-SURG
ACTUAL EXAM
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ANSWERS (100%
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,A client with acute pancreatitis reports
severe epigastric pain radiating to the
back and nausea without relief from
vomiting. What is the nurse’s priority
action?
A. Administer oral fluids
B. Place the client in supine position
C. Initiate IV fluid resuscitation
D. Encourage ambulation
Correct Answer: C. Initiate IV fluid
resuscitation
The priority in acute pancreatitis is
preventing hypovolemia and shock due to
third-spacing of fluids. Aggressive IV fluid
resuscitation maintains perfusion and
prevents complications such as renal failure
and cardiovascular collapse. Oral intake is
contraindicated (NPO status), and
positioning or ambulation does not address
the immediate life-threatening fluid
imbalance.
,A nurse is assessing a client with cirrhosis
and ascites. Which finding requires
immediate intervention?
A. Abdominal girth increase of 2 cm
B. Mild peripheral edema
C. Dyspnea and decreased oxygen saturation
D. Fatigue
Correct Answer: C. Dyspnea and
decreased oxygen saturation
Respiratory compromise is the priority
because ascites can impair diaphragmatic
movement, leading to hypoxia. While fluid
accumulation and edema are expected,
impaired breathing threatens oxygenation
and requires urgent intervention such as
positioning or possible paracentesis.
A client with SIADH has a sodium level of
120 mEq/L. Which interventions should
the nurse implement? (Select all that
apply)
, A. Fluid restriction
B. Administer hypertonic saline
C. Encourage oral fluids
D. Administer loop diuretics
E. Monitor neurological status
Correct Answers: A, B, D, E
SIADH leads to dilutional hyponatremia, so
restricting fluids prevents further dilution.
Hypertonic saline corrects severe
hyponatremia, while loop diuretics help
excrete excess water. Neurological
monitoring is essential due to risk of
seizures. Encouraging fluids would worsen
the condition.
A client with diabetes insipidus is at
greatest risk for which complication?
A. Fluid overload
B. Severe dehydration
C. Hyponatremia
D. Bradycardia