NUR 209/NUR209 Exam 4 V2 | Medical-
Surgical Nursing II Q&A with Rationale |
Fortis College
1. A nurse is assessing a client who has sustained deep partial-thickness burns over 35% of
their body 24 hours ago. Which of the following laboratory findings should the nurse expect?
A. Decreased hemoglobin
B. Decreased BUN
C. Increased serum potassium
D. Increased serum sodium
Correct Answer: C
Expert Explanation: In the emergent phase of a burn injury, potassium is released from
the damaged cells into the extracellular fluid, leading to hyperkalemia. Hemoconcentration
usually occurs during this period, which would cause an increased hemoglobin level rather
than a decrease. Sodium typically shifts into the interstitial space, often resulting in
hyponatremia during the initial 24 to 48 hours.
2. A client with a spinal cord injury at T4 reports a sudden, severe headache and is found to
have a blood pressure of 190/110 mmHg. Which action should the nurse take first?
A. Elevate the head of the bed to 90 degrees
B. Check for bladder distention
,C. Notify the healthcare provider
D. Administer an antihypertensive medication
Correct Answer: A
Expert Explanation: The client is exhibiting signs of autonomic dysreflexia, which is a life-
threatening emergency in spinal cord injury patients. The immediate priority is to sit the
patient upright to utilize orthostatic pressure to help lower the blood pressure. After
elevating the head of the bed, the nurse should then assess for the cause, such as a full
bladder or impacted bowel.
3. A nurse is caring for a client in the diuretic phase of acute kidney injury (AKI). What is the
priority nursing assessment for this client?
A. Monitor for signs of fluid volume overload
B. Monitor for dehydration and electrolyte imbalances
C. Assess for hyperkalemia and peaked T waves
D. Monitor for rising creatinine and BUN levels
Correct Answer: B
Expert Explanation: During the diuretic phase of AKI, the kidneys begin to recover, but
they cannot concentrate urine yet, leading to the excretion of large volumes of fluid. This
phase puts the client at a high risk for hypovolemia, hypotension, and significant electrolyte
losses like hypokalemia. The nurse must prioritize monitoring fluid status and electrolyte
levels to prevent vascular collapse.
, 4. Using the Parkland Formula, calculate the total fluid resuscitation required in the first 24
hours for a client weighing 70 kg with a 40% Total Body Surface Area (TBSA) burn.
A. 11,200 mL
B. 5,600 mL
C. 8,400 mL
D. 2,800 mL
Correct Answer: A
Expert Explanation: The Parkland Formula is 4 mL x weight (kg) x % TBSA. In this case, 4
mL x 70 kg x 40 = 11,200 mL. This total volume is intended to be administered over the
first 24 hours following the burn injury.
5. A nurse is monitoring a client undergoing hemodialysis. The client reports a headache,
nausea, and becomes increasingly agitated. Which complication should the nurse suspect?
A. Disequilibrium syndrome
B. Air embolism
C. Hypovolemic shock
D. Septicemia
Correct Answer: A
Expert Explanation: Disequilibrium syndrome occurs due to the rapid removal of urea
and other solutes from the blood during dialysis, creating an osmotic gradient that causes
Surgical Nursing II Q&A with Rationale |
Fortis College
1. A nurse is assessing a client who has sustained deep partial-thickness burns over 35% of
their body 24 hours ago. Which of the following laboratory findings should the nurse expect?
A. Decreased hemoglobin
B. Decreased BUN
C. Increased serum potassium
D. Increased serum sodium
Correct Answer: C
Expert Explanation: In the emergent phase of a burn injury, potassium is released from
the damaged cells into the extracellular fluid, leading to hyperkalemia. Hemoconcentration
usually occurs during this period, which would cause an increased hemoglobin level rather
than a decrease. Sodium typically shifts into the interstitial space, often resulting in
hyponatremia during the initial 24 to 48 hours.
2. A client with a spinal cord injury at T4 reports a sudden, severe headache and is found to
have a blood pressure of 190/110 mmHg. Which action should the nurse take first?
A. Elevate the head of the bed to 90 degrees
B. Check for bladder distention
,C. Notify the healthcare provider
D. Administer an antihypertensive medication
Correct Answer: A
Expert Explanation: The client is exhibiting signs of autonomic dysreflexia, which is a life-
threatening emergency in spinal cord injury patients. The immediate priority is to sit the
patient upright to utilize orthostatic pressure to help lower the blood pressure. After
elevating the head of the bed, the nurse should then assess for the cause, such as a full
bladder or impacted bowel.
3. A nurse is caring for a client in the diuretic phase of acute kidney injury (AKI). What is the
priority nursing assessment for this client?
A. Monitor for signs of fluid volume overload
B. Monitor for dehydration and electrolyte imbalances
C. Assess for hyperkalemia and peaked T waves
D. Monitor for rising creatinine and BUN levels
Correct Answer: B
Expert Explanation: During the diuretic phase of AKI, the kidneys begin to recover, but
they cannot concentrate urine yet, leading to the excretion of large volumes of fluid. This
phase puts the client at a high risk for hypovolemia, hypotension, and significant electrolyte
losses like hypokalemia. The nurse must prioritize monitoring fluid status and electrolyte
levels to prevent vascular collapse.
, 4. Using the Parkland Formula, calculate the total fluid resuscitation required in the first 24
hours for a client weighing 70 kg with a 40% Total Body Surface Area (TBSA) burn.
A. 11,200 mL
B. 5,600 mL
C. 8,400 mL
D. 2,800 mL
Correct Answer: A
Expert Explanation: The Parkland Formula is 4 mL x weight (kg) x % TBSA. In this case, 4
mL x 70 kg x 40 = 11,200 mL. This total volume is intended to be administered over the
first 24 hours following the burn injury.
5. A nurse is monitoring a client undergoing hemodialysis. The client reports a headache,
nausea, and becomes increasingly agitated. Which complication should the nurse suspect?
A. Disequilibrium syndrome
B. Air embolism
C. Hypovolemic shock
D. Septicemia
Correct Answer: A
Expert Explanation: Disequilibrium syndrome occurs due to the rapid removal of urea
and other solutes from the blood during dialysis, creating an osmotic gradient that causes
