Med Surg II Unit 1 Exam
A 77-year-old woman is brought to the emergency department by her family after she has had
diarrhea for 3 days. The family tells the nurse that she has not been eating or drinking well, but
that she has been taking her diuretics for congestive heart failure (CHF). Her laboratory results
include a potassium level of 3.0 mEq/L. What does the nurse include in the patient's medication
teaching? Select all that apply.
1 Diuretics increase fluid retention.
2 Laxatives can lead to fluid imbalance.
3 It is important to weigh daily at the same time.
4 Diuretics can lead to fluid and electrolyte imbalances.
5 Daily weights are a poor indicator of fluid loss or gain. - ANS-2 Laxatives can lead to fluid
imbalance.
3 It is important to weigh daily at the same time.
4 Diuretics can lead to fluid and electrolyte imbalances.
The nurse is planning care for a patient with hypocalcemia. Which nursing action is appropriate
to delegate to unlicensed assistive personnel (UAP)?
1 Evaluating the patient's laboratory results
2 Implementing seizure precautions for the patient
3 Transferring the patient from the bed to a stretcher using a lift sheet
4 Collaborating with the dietitian to provide calcium-rich foods for the patient - ANS-3
Transferring the patient from the bed to a stretcher using a lift sheet
When assessing the laboratory results of a patient who has hypomagnesemia, for which
additional electrolyte imbalance should the nurse monitor?
1 Hyperkalemia
2 Hypocalcemia
3 Hypernatremia
4 Hypophosphatemia - ANS-2 Hypocalcemia
A patient is admitted to the nursing unit with a diagnosis of hypokalemia. Which assessment
does the nurse complete first?
1 Auscultating bowel sounds
2 Obtaining a pulse oximetry reading
3 Checking deep tendon reflexes (DTRs)
4 Determining the level of consciousness (LOC) - ANS-2 Obtaining a pulse oximetry reading
The health care provider writes orders for a patient who is admitted with a serum potassium (K)
level of 6.9 mEq/L. What does the nurse implement first?
1 Place the patient on a cardiac monitor.
, 2 Administer sodium polystyrene sulfonate orally.
3 Ensure that a potassium-restricted diet is ordered.
4 Teach the patient about foods that are high in potassium. - ANS-1 Place the patient on a
cardiac monitor.
A patient with hyperkalemia is being treated with drugs to improve the condition. Which
potassium level indicates that therapy is effective?
1 7.6 mEq/L
2 5.6 mEq/L
3 4.6 mEq/L
4 2.6 mEq/L - ANS-3 4.6 mEq/L
When planning care for a patient with hypercalcemia, which intervention does the nurse
consider?
1 Monitor cardiac rhythm for changes.
2 Limit activities to protect against injury.
3 Assess oxygen saturation levels every 4 hours.
4 Avoid invasive procedures due to increased bleeding tendency. - ANS-1 Monitor cardiac
rhythm for changes.
Which electrolyte excess results in irritability and severe cellular dehydration?
1 Sodium
2 Calcium
3 Phosphorus
4 Magnesium - ANS-1 Sodium
The nurse is assessing a patient with hyponatremia. Which finding requires immediate action?
1 Heightened acuity
2 Muscular weakness
3 Urine output of 35 mL/hr
4 Diminished bowel sounds - ANS-2 Muscular weakness
Which hormone regulates fluid and electrolyte balance by preventing water and sodium loss?
1 Antidiuretic
2 Thyrotropin
3 Aldosterone
4 Natriuretic peptide (NP) - ANS-3 Aldosterone
The nurse is reviewing lab values for a patient recently admitted to the medical-surgical unit.
Which lab result is severely abnormal?
1 Sodium, 137 mEq/L
2 Chloride, 107 mEq/L
3 Potassium, 3.5 mEq/L
4 Magnesium, 6.2 mEq/L - ANS-4 Magnesium, 6.2 mEq/L
A 77-year-old woman is brought to the emergency department by her family after she has had
diarrhea for 3 days. The family tells the nurse that she has not been eating or drinking well, but
that she has been taking her diuretics for congestive heart failure (CHF). Her laboratory results
include a potassium level of 3.0 mEq/L. What does the nurse include in the patient's medication
teaching? Select all that apply.
1 Diuretics increase fluid retention.
2 Laxatives can lead to fluid imbalance.
3 It is important to weigh daily at the same time.
4 Diuretics can lead to fluid and electrolyte imbalances.
5 Daily weights are a poor indicator of fluid loss or gain. - ANS-2 Laxatives can lead to fluid
imbalance.
3 It is important to weigh daily at the same time.
4 Diuretics can lead to fluid and electrolyte imbalances.
The nurse is planning care for a patient with hypocalcemia. Which nursing action is appropriate
to delegate to unlicensed assistive personnel (UAP)?
1 Evaluating the patient's laboratory results
2 Implementing seizure precautions for the patient
3 Transferring the patient from the bed to a stretcher using a lift sheet
4 Collaborating with the dietitian to provide calcium-rich foods for the patient - ANS-3
Transferring the patient from the bed to a stretcher using a lift sheet
When assessing the laboratory results of a patient who has hypomagnesemia, for which
additional electrolyte imbalance should the nurse monitor?
1 Hyperkalemia
2 Hypocalcemia
3 Hypernatremia
4 Hypophosphatemia - ANS-2 Hypocalcemia
A patient is admitted to the nursing unit with a diagnosis of hypokalemia. Which assessment
does the nurse complete first?
1 Auscultating bowel sounds
2 Obtaining a pulse oximetry reading
3 Checking deep tendon reflexes (DTRs)
4 Determining the level of consciousness (LOC) - ANS-2 Obtaining a pulse oximetry reading
The health care provider writes orders for a patient who is admitted with a serum potassium (K)
level of 6.9 mEq/L. What does the nurse implement first?
1 Place the patient on a cardiac monitor.
, 2 Administer sodium polystyrene sulfonate orally.
3 Ensure that a potassium-restricted diet is ordered.
4 Teach the patient about foods that are high in potassium. - ANS-1 Place the patient on a
cardiac monitor.
A patient with hyperkalemia is being treated with drugs to improve the condition. Which
potassium level indicates that therapy is effective?
1 7.6 mEq/L
2 5.6 mEq/L
3 4.6 mEq/L
4 2.6 mEq/L - ANS-3 4.6 mEq/L
When planning care for a patient with hypercalcemia, which intervention does the nurse
consider?
1 Monitor cardiac rhythm for changes.
2 Limit activities to protect against injury.
3 Assess oxygen saturation levels every 4 hours.
4 Avoid invasive procedures due to increased bleeding tendency. - ANS-1 Monitor cardiac
rhythm for changes.
Which electrolyte excess results in irritability and severe cellular dehydration?
1 Sodium
2 Calcium
3 Phosphorus
4 Magnesium - ANS-1 Sodium
The nurse is assessing a patient with hyponatremia. Which finding requires immediate action?
1 Heightened acuity
2 Muscular weakness
3 Urine output of 35 mL/hr
4 Diminished bowel sounds - ANS-2 Muscular weakness
Which hormone regulates fluid and electrolyte balance by preventing water and sodium loss?
1 Antidiuretic
2 Thyrotropin
3 Aldosterone
4 Natriuretic peptide (NP) - ANS-3 Aldosterone
The nurse is reviewing lab values for a patient recently admitted to the medical-surgical unit.
Which lab result is severely abnormal?
1 Sodium, 137 mEq/L
2 Chloride, 107 mEq/L
3 Potassium, 3.5 mEq/L
4 Magnesium, 6.2 mEq/L - ANS-4 Magnesium, 6.2 mEq/L
