Med Surg Final Exam Questions from ATI
with Complete Solution
The nurse is assessing the client who reports nausea, vomiting, and weakness. Which
of the following findings nurse are manifestations of fluid volume deficit? Select all that
apply.
A Potassium level
B Urine specific gravity
C Heart rate
D Temperature
E Oxygen saturation - ANSWER- B Urine specific gravity
C Heart rate
D Temperature
The nurse should identify that concentrated urine, tachycardia, and elevated
temperature are manifestations of fluid volume deficit.
A nurse is planning care for a client who has fluid volume excess. Which of the following
interventions should the nurse include in the plan? Select all that apply.
A Check the client's weight 2 times per week
B Place the client in a semi-Fowler's position
C Monitor the client's breath sounds
D Change the client's position every 4 hrs
E Assess the client for peripheral edema - ANSWER- B Place the client in a semi-
Fowler's position
C Monitor the client's breath sounds
E Assess the client for peripheral edema
The nurse should place the client in semi-Fowler's or Fowler's position, and reposition
every 2 hrs to reduce the risk for tissue breakdown. Monitor the client's breath sounds,
because the client is at risk for pulmonary edema. Monitor the client for peripheral
edema.
A nurse is assessing two clients. Sort the findings into manifestations associated with
either fluid volume deficit or fluid volume excess.
bounding pulse
,sunken eyeballs
crackles heard in lung fields
poor skin turgor
fever
distended neck veins - ANSWER- fluid volume deficit: sunken eyeballs, poor skin turgor,
fever
fluid volume excess: bounding pulse, crackles heard in lung fields, distended neck veins
A nurse is teaching a class about electrolyte imbalances. The nurse should include that
which of the following conditions places a client at risk for hyperkalemia?
A Diabetic ketoacidosis
B Heart failure
C Cushing's syndrome
D Thyroidectomy - ANSWER- A Diabetic ketoacidosis
The nurse should instruct that diabetic ketoacidosis places a client at risk for
hyperkalemia. During acidosis, hydrogen enters cells and potassium is pushed out of
cells, causing blood potassium levels to rise.
A nurse is teaching a class about electrolyte imbalances.
Match the electrolyte imbalance with the associated manifestations.
hyponatremia, hypocalcemia, hyperkalemia, hypokalemia
hypoactive bowel sounds
ECG with tall, peaked t-waves
positive trousseau's sign
bounding pulse - ANSWER- hyponatremia: bounding pulse
hypocalcemia: positive trousseau's sign
hyperkalemia: ECG with tall, peaked t-waves
hypokalemia: hypoactive bowel sounds
The nurse is assessing the client for Chvostek's sign. Which of the following actions
should the nurse take?
A Apply a blood pressure cuff to the client's arm.
B Place a stethoscope bell over the client's carotid artery.
C Ask the client to lower their chin to their chest.
, D Tap lightly on the client's cheek. - ANSWER- D Tap lightly on the client's cheek.
The nurse should tap the client's cheek over the facial nerve just below and anterior to
the ear to elicit Chvostek's sign. A positive response is indicated when the client exhibits
facial twitching on this side of the face.
The nurse is assessing the client who reports nausea, vomiting, and weakness. Which
of the following findings are manifestations of hypocalcemia? Select all that apply.
A Tingling in fingers
B Poor skin turgor
C Abdominal pain
D Elevated temperature
E Muscle twitching - ANSWER- A Tingling in fingers
C Abdominal pain
E Muscle twitching
The nurse should identify that numbness and tingling in fingers and toes, abdominal
cramps and diarrhea, and muscle twitching are manifestations of hypocalcemia.
A nurse is teaching a group of nurses about conditions that can cause metabolic
acidosis. Which of the following conditions should the nurse include?
A Diabetic ketoacidosis
B Myasthenia gravis
C Asthma
D Laxative overuse - ANSWER- A Diabetic ketoacidosis
A nurse is reviewing ABGs on a client who has vomited for 24 hr. Which of the following
acid-base imbalances should the nurse expect?
A Respiratory acidosis
B Respiratory alkalosis
C Metabolic acidosis
D Metabolic alkalosis - ANSWER- D Metabolic alkalosis
The nurse should expect the client who has vomited for 24 hrs to have metabolic
alkalosis. Excessive vomiting causes a loss of gastric acids and an accumulation of
bicarbonate in the blood, resulting in metabolic alkalosis.
with Complete Solution
The nurse is assessing the client who reports nausea, vomiting, and weakness. Which
of the following findings nurse are manifestations of fluid volume deficit? Select all that
apply.
A Potassium level
B Urine specific gravity
C Heart rate
D Temperature
E Oxygen saturation - ANSWER- B Urine specific gravity
C Heart rate
D Temperature
The nurse should identify that concentrated urine, tachycardia, and elevated
temperature are manifestations of fluid volume deficit.
A nurse is planning care for a client who has fluid volume excess. Which of the following
interventions should the nurse include in the plan? Select all that apply.
A Check the client's weight 2 times per week
B Place the client in a semi-Fowler's position
C Monitor the client's breath sounds
D Change the client's position every 4 hrs
E Assess the client for peripheral edema - ANSWER- B Place the client in a semi-
Fowler's position
C Monitor the client's breath sounds
E Assess the client for peripheral edema
The nurse should place the client in semi-Fowler's or Fowler's position, and reposition
every 2 hrs to reduce the risk for tissue breakdown. Monitor the client's breath sounds,
because the client is at risk for pulmonary edema. Monitor the client for peripheral
edema.
A nurse is assessing two clients. Sort the findings into manifestations associated with
either fluid volume deficit or fluid volume excess.
bounding pulse
,sunken eyeballs
crackles heard in lung fields
poor skin turgor
fever
distended neck veins - ANSWER- fluid volume deficit: sunken eyeballs, poor skin turgor,
fever
fluid volume excess: bounding pulse, crackles heard in lung fields, distended neck veins
A nurse is teaching a class about electrolyte imbalances. The nurse should include that
which of the following conditions places a client at risk for hyperkalemia?
A Diabetic ketoacidosis
B Heart failure
C Cushing's syndrome
D Thyroidectomy - ANSWER- A Diabetic ketoacidosis
The nurse should instruct that diabetic ketoacidosis places a client at risk for
hyperkalemia. During acidosis, hydrogen enters cells and potassium is pushed out of
cells, causing blood potassium levels to rise.
A nurse is teaching a class about electrolyte imbalances.
Match the electrolyte imbalance with the associated manifestations.
hyponatremia, hypocalcemia, hyperkalemia, hypokalemia
hypoactive bowel sounds
ECG with tall, peaked t-waves
positive trousseau's sign
bounding pulse - ANSWER- hyponatremia: bounding pulse
hypocalcemia: positive trousseau's sign
hyperkalemia: ECG with tall, peaked t-waves
hypokalemia: hypoactive bowel sounds
The nurse is assessing the client for Chvostek's sign. Which of the following actions
should the nurse take?
A Apply a blood pressure cuff to the client's arm.
B Place a stethoscope bell over the client's carotid artery.
C Ask the client to lower their chin to their chest.
, D Tap lightly on the client's cheek. - ANSWER- D Tap lightly on the client's cheek.
The nurse should tap the client's cheek over the facial nerve just below and anterior to
the ear to elicit Chvostek's sign. A positive response is indicated when the client exhibits
facial twitching on this side of the face.
The nurse is assessing the client who reports nausea, vomiting, and weakness. Which
of the following findings are manifestations of hypocalcemia? Select all that apply.
A Tingling in fingers
B Poor skin turgor
C Abdominal pain
D Elevated temperature
E Muscle twitching - ANSWER- A Tingling in fingers
C Abdominal pain
E Muscle twitching
The nurse should identify that numbness and tingling in fingers and toes, abdominal
cramps and diarrhea, and muscle twitching are manifestations of hypocalcemia.
A nurse is teaching a group of nurses about conditions that can cause metabolic
acidosis. Which of the following conditions should the nurse include?
A Diabetic ketoacidosis
B Myasthenia gravis
C Asthma
D Laxative overuse - ANSWER- A Diabetic ketoacidosis
A nurse is reviewing ABGs on a client who has vomited for 24 hr. Which of the following
acid-base imbalances should the nurse expect?
A Respiratory acidosis
B Respiratory alkalosis
C Metabolic acidosis
D Metabolic alkalosis - ANSWER- D Metabolic alkalosis
The nurse should expect the client who has vomited for 24 hrs to have metabolic
alkalosis. Excessive vomiting causes a loss of gastric acids and an accumulation of
bicarbonate in the blood, resulting in metabolic alkalosis.
