NUR 209/NUR209 Exam 2 V1 | Medical-
Surgical Nursing II Q&A with Rationale |
Fortis College
1. A nurse is assessing a client with acute kidney injury (AKI) who is in the oliguric phase.
Which of the following clinical findings should the nurse expect?
A. Urine output of 1500 mL/day
B. Metabolic alkalosis
C. Hyperkalemia
D. Hypophosphatemia
Correct Answer: C
Expert Explanation: In the oliguric phase of AKI, the kidneys are unable to effectively
excrete potassium, leading to hyperkalemia. This phase is also characterized by fluid
volume excess and metabolic acidosis due to the accumulation of hydrogen ions. The nurse
must monitor the ECG closely for signs of potassium toxicity, such as peaked T waves.
2. A client with chronic kidney disease (CKD) is prescribed epoetin alfa. What is the primary
purpose of this medication?
A. To lower serum potassium levels
B. To bind phosphate in the gastrointestinal tract
C. To stimulate red blood cell production
,D. To prevent calcium loss from the bones
Correct Answer: C
Expert Explanation: Epoetin alfa is a synthetic version of erythropoietin, a hormone
produced by healthy kidneys to stimulate the bone marrow to produce red blood cells.
Patients with CKD often develop anemia because their damaged kidneys cannot produce
enough of this hormone. The effectiveness of this treatment is monitored through
hemoglobin and hematocrit levels.
3. Which of the following instructions should the nurse include for a client with CKD who is
being started on a low-protein diet?
A. ‘Limit protein to reduce the buildup of nitrogenous wastes like urea.’
B. ‘You should increase your intake of potassium-rich foods.’
C. ‘Protein restriction is only necessary if you are on dialysis.’
D. ‘You can consume unlimited amounts of dairy products.’
Correct Answer: A
Expert Explanation: A low-protein diet is often recommended for pre-dialysis CKD
patients to slow the progression of kidney damage and reduce the accumulation of urea
and creatinine. When protein is metabolized, it produces nitrogenous waste that the failing
kidneys struggle to clear. Once a patient starts dialysis, protein intake may actually need to
be increased to compensate for losses during the procedure.
,4. A nurse is caring for a client who just returned from a kidney biopsy. Which nursing
intervention is the priority?
A. Ambulate the client immediately to prevent DVT.
B. Administer a dose of aspirin for pain management.
C. Assess the biopsy site and monitor for signs of hemorrhage.
D. Place the client in a high-Fowler’s position.
Correct Answer: C
Expert Explanation: The kidneys are highly vascular organs, making hemorrhage the most
significant risk following a biopsy. The nurse should monitor vital signs for hypotension
and tachycardia, which could indicate internal bleeding. Additionally, the client should be
kept on the affected side for 30 to 60 minutes to provide pressure to the site.
5. The nurse is evaluating a client’s understanding of peritoneal dialysis (PD). Which
statement by the client indicates a need for further teaching?
A. ‘I should use aseptic technique when connecting the bags.’
B. ‘The drainage fluid should be clear or light yellow.’
C. ‘If the fluid doesn’t drain well, I should vigorously massage my abdomen.’
D. ‘I will perform the exchanges four times a day.’
Correct Answer: C
, Expert Explanation: If PD drainage is slow, the client should be taught to turn from side to
side or check for kinks in the tubing rather than massaging the abdomen vigorously. Cloudy
drainage is a major red flag as it often indicates peritonitis, the most common complication
of PD. Aseptic technique is crucial to prevent infections at the catheter exit site or within
the peritoneum.
6. A client with cirrhosis presents with increased abdominal girth and a fluid wave. Which
medication does the nurse anticipate administering to manage this condition?
A. Lactulose
B. Neomycin
C. Spironolactone
D. Propranolol
Correct Answer: C
Expert Explanation: Spironolactone is a potassium-sparing diuretic often used as the first-
line treatment for ascites in cirrhosis because it antagonizes aldosterone. Aldosterone
levels are typically elevated in liver failure, causing sodium and water retention. By
blocking aldosterone, spironolactone helps reduce fluid accumulation in the peritoneal
cavity.
7. When assessing a client with hepatic encephalopathy, the nurse notes flapping tremors of
the hands. How should the nurse document this finding?
A. Chvostek’s sign
Surgical Nursing II Q&A with Rationale |
Fortis College
1. A nurse is assessing a client with acute kidney injury (AKI) who is in the oliguric phase.
Which of the following clinical findings should the nurse expect?
A. Urine output of 1500 mL/day
B. Metabolic alkalosis
C. Hyperkalemia
D. Hypophosphatemia
Correct Answer: C
Expert Explanation: In the oliguric phase of AKI, the kidneys are unable to effectively
excrete potassium, leading to hyperkalemia. This phase is also characterized by fluid
volume excess and metabolic acidosis due to the accumulation of hydrogen ions. The nurse
must monitor the ECG closely for signs of potassium toxicity, such as peaked T waves.
2. A client with chronic kidney disease (CKD) is prescribed epoetin alfa. What is the primary
purpose of this medication?
A. To lower serum potassium levels
B. To bind phosphate in the gastrointestinal tract
C. To stimulate red blood cell production
,D. To prevent calcium loss from the bones
Correct Answer: C
Expert Explanation: Epoetin alfa is a synthetic version of erythropoietin, a hormone
produced by healthy kidneys to stimulate the bone marrow to produce red blood cells.
Patients with CKD often develop anemia because their damaged kidneys cannot produce
enough of this hormone. The effectiveness of this treatment is monitored through
hemoglobin and hematocrit levels.
3. Which of the following instructions should the nurse include for a client with CKD who is
being started on a low-protein diet?
A. ‘Limit protein to reduce the buildup of nitrogenous wastes like urea.’
B. ‘You should increase your intake of potassium-rich foods.’
C. ‘Protein restriction is only necessary if you are on dialysis.’
D. ‘You can consume unlimited amounts of dairy products.’
Correct Answer: A
Expert Explanation: A low-protein diet is often recommended for pre-dialysis CKD
patients to slow the progression of kidney damage and reduce the accumulation of urea
and creatinine. When protein is metabolized, it produces nitrogenous waste that the failing
kidneys struggle to clear. Once a patient starts dialysis, protein intake may actually need to
be increased to compensate for losses during the procedure.
,4. A nurse is caring for a client who just returned from a kidney biopsy. Which nursing
intervention is the priority?
A. Ambulate the client immediately to prevent DVT.
B. Administer a dose of aspirin for pain management.
C. Assess the biopsy site and monitor for signs of hemorrhage.
D. Place the client in a high-Fowler’s position.
Correct Answer: C
Expert Explanation: The kidneys are highly vascular organs, making hemorrhage the most
significant risk following a biopsy. The nurse should monitor vital signs for hypotension
and tachycardia, which could indicate internal bleeding. Additionally, the client should be
kept on the affected side for 30 to 60 minutes to provide pressure to the site.
5. The nurse is evaluating a client’s understanding of peritoneal dialysis (PD). Which
statement by the client indicates a need for further teaching?
A. ‘I should use aseptic technique when connecting the bags.’
B. ‘The drainage fluid should be clear or light yellow.’
C. ‘If the fluid doesn’t drain well, I should vigorously massage my abdomen.’
D. ‘I will perform the exchanges four times a day.’
Correct Answer: C
, Expert Explanation: If PD drainage is slow, the client should be taught to turn from side to
side or check for kinks in the tubing rather than massaging the abdomen vigorously. Cloudy
drainage is a major red flag as it often indicates peritonitis, the most common complication
of PD. Aseptic technique is crucial to prevent infections at the catheter exit site or within
the peritoneum.
6. A client with cirrhosis presents with increased abdominal girth and a fluid wave. Which
medication does the nurse anticipate administering to manage this condition?
A. Lactulose
B. Neomycin
C. Spironolactone
D. Propranolol
Correct Answer: C
Expert Explanation: Spironolactone is a potassium-sparing diuretic often used as the first-
line treatment for ascites in cirrhosis because it antagonizes aldosterone. Aldosterone
levels are typically elevated in liver failure, causing sodium and water retention. By
blocking aldosterone, spironolactone helps reduce fluid accumulation in the peritoneal
cavity.
7. When assessing a client with hepatic encephalopathy, the nurse notes flapping tremors of
the hands. How should the nurse document this finding?
A. Chvostek’s sign
