Med-Surg 1 Final Exam
Where is the best place to begin to select a vein for an initial intravenous (IV) site in a
left-handed patient?
Right forearm
Antecubital vein of the left arm
Left forearm
Antecubital vein of the right arm - ANS Right Forearm
RATIONALE: Unless other reasons are identified, IV sites should be started in the most
distal portion of the nondominant arm or hand.
A nurse assesses an area where an intravenous (IV) line had been recently removed.
The area has redness, swelling, and warmth. What should the nurse suspect as the
cause?
Blood loss and hemorrhage
Embolus from the former catheter
Inflammation and possible phlebitis
Infiltration and air embolus - ANS Inflammation and possible phlebitis
RATIONALE: IV sites may show signs of inflammation or infection or both after an IV
line has been removed.
The K+ laboratory report shows a level of 5.2 mEq/L. What is the most important
assessment for the nurse to make?
Excessive thirst
Frightening hallucinations
Irregular heartbeat
Swelling of ankles - ANS Irregular heartbeat
RATIONALE: Arrhythmias can be triggered by hyperkalemia.
,A small child is hospitalized with severe metabolic acidosis after ingesting a whole bottle
of baby aspirin approximately 8 hours earlier. In addition to providing reassurance to the
patient, which nursing action is the most appropriate?
Inducing vomiting
Frequently assessing the mental and neurologic status
Taking daily weights and vital signs - ANS Frequently assessing the mental and
neurologic status
RATIONALE: The baby aspirin was ingested too long ago to have vomiting or stomach
aspiration be of any use. The child requires frequent assessment of neurologic function
because the child may need mechanical ventilation.
When the water absorption in the renal tubules becomes greater than normal, what
assessment finding should a nurse anticipate?
Less concentrated urine
More concentrated urine
Less alkaline urine
More alkaline urine - ANS More concentrated urine
RATIONALE: When more water is kept back in the body, the water left to form urine is
less; therefore, the urine is more concentrated.
A patient has renal damage because of diabetes. What is the highest risk for this
patient?
Hypokalemia
Hypercalcemia
Hyperkalemia
Hypocalcemia - ANS Hyperkalemia
RATIONALE: When the renal system cannot rid the body of enough K+, this electrolyte
builds up and a condition called hyperkalemia develops.
A nurse understands that fluid balance is mainly monitored in the body by which two
systems?
Respiratory and circulatory
Renal and gastrointestinal
, Circulatory and renal
Hepatic and lymphatic - ANS Circulatory and renal
RATIONALE: The monitoring of basic fluid balance in the body is performed by the renal
and circulatory systems.
What is usually associated with hyperchloremia?
Respiratory acidosis
Respiratory alkalosis
Metabolic acidosis
Metabolic alkalosis - ANS Metabolic acidosis
RATIONALE: Chlorides bind with positively charged ions such as K+ in the patient with
metabolic acidosis.
Each compartment of the body has a water-fluid distribution movement of its own. What
is the process allowing these fluids to move and distribute themselves among
compartments?
Active transport
Osmosis
Filtration
Diffusion - ANS Osmosis
RATIONALE: The intracellular and extracellular compartments contain water and
dissolved substances. The water filters back and forth as needed to maintain
homeostasis via osmolarity.
Which order should be clarified by a nurse when transcribing orders?
Potassium chloride, 80 mEq in 1000 mL D5W in 24 hours
Potassium chloride, 40 mEq IV in 10 mL D5W IV push
Potassium chloride, 80 mEq in 1000 mL D5W in 12 hours
Potassium chloride, 50 mEq in 500 mL D5W in 4 hours - ANS Potassium chloride, 40
mEq IV in 10 mL D5W IV push
RATIONALE: Potassium chloride is never given by intravenous push in such a small
amount of diluent. Potassium chloride is always dissolved in D5W and should be
infused at no more than 10 mEq/hr.
Where is the best place to begin to select a vein for an initial intravenous (IV) site in a
left-handed patient?
Right forearm
Antecubital vein of the left arm
Left forearm
Antecubital vein of the right arm - ANS Right Forearm
RATIONALE: Unless other reasons are identified, IV sites should be started in the most
distal portion of the nondominant arm or hand.
A nurse assesses an area where an intravenous (IV) line had been recently removed.
The area has redness, swelling, and warmth. What should the nurse suspect as the
cause?
Blood loss and hemorrhage
Embolus from the former catheter
Inflammation and possible phlebitis
Infiltration and air embolus - ANS Inflammation and possible phlebitis
RATIONALE: IV sites may show signs of inflammation or infection or both after an IV
line has been removed.
The K+ laboratory report shows a level of 5.2 mEq/L. What is the most important
assessment for the nurse to make?
Excessive thirst
Frightening hallucinations
Irregular heartbeat
Swelling of ankles - ANS Irregular heartbeat
RATIONALE: Arrhythmias can be triggered by hyperkalemia.
,A small child is hospitalized with severe metabolic acidosis after ingesting a whole bottle
of baby aspirin approximately 8 hours earlier. In addition to providing reassurance to the
patient, which nursing action is the most appropriate?
Inducing vomiting
Frequently assessing the mental and neurologic status
Taking daily weights and vital signs - ANS Frequently assessing the mental and
neurologic status
RATIONALE: The baby aspirin was ingested too long ago to have vomiting or stomach
aspiration be of any use. The child requires frequent assessment of neurologic function
because the child may need mechanical ventilation.
When the water absorption in the renal tubules becomes greater than normal, what
assessment finding should a nurse anticipate?
Less concentrated urine
More concentrated urine
Less alkaline urine
More alkaline urine - ANS More concentrated urine
RATIONALE: When more water is kept back in the body, the water left to form urine is
less; therefore, the urine is more concentrated.
A patient has renal damage because of diabetes. What is the highest risk for this
patient?
Hypokalemia
Hypercalcemia
Hyperkalemia
Hypocalcemia - ANS Hyperkalemia
RATIONALE: When the renal system cannot rid the body of enough K+, this electrolyte
builds up and a condition called hyperkalemia develops.
A nurse understands that fluid balance is mainly monitored in the body by which two
systems?
Respiratory and circulatory
Renal and gastrointestinal
, Circulatory and renal
Hepatic and lymphatic - ANS Circulatory and renal
RATIONALE: The monitoring of basic fluid balance in the body is performed by the renal
and circulatory systems.
What is usually associated with hyperchloremia?
Respiratory acidosis
Respiratory alkalosis
Metabolic acidosis
Metabolic alkalosis - ANS Metabolic acidosis
RATIONALE: Chlorides bind with positively charged ions such as K+ in the patient with
metabolic acidosis.
Each compartment of the body has a water-fluid distribution movement of its own. What
is the process allowing these fluids to move and distribute themselves among
compartments?
Active transport
Osmosis
Filtration
Diffusion - ANS Osmosis
RATIONALE: The intracellular and extracellular compartments contain water and
dissolved substances. The water filters back and forth as needed to maintain
homeostasis via osmolarity.
Which order should be clarified by a nurse when transcribing orders?
Potassium chloride, 80 mEq in 1000 mL D5W in 24 hours
Potassium chloride, 40 mEq IV in 10 mL D5W IV push
Potassium chloride, 80 mEq in 1000 mL D5W in 12 hours
Potassium chloride, 50 mEq in 500 mL D5W in 4 hours - ANS Potassium chloride, 40
mEq IV in 10 mL D5W IV push
RATIONALE: Potassium chloride is never given by intravenous push in such a small
amount of diluent. Potassium chloride is always dissolved in D5W and should be
infused at no more than 10 mEq/hr.
