NU 185 Exam 1: Med-Surg II - Galen College of Nursing
Updated and Latest Questions and Correct Answers with
Rationale
1. A patient with chronic kidney disease presents with a serum potassium level of 6.4 mEq/L. Which nursing
action is the absolute priority?
A. Administer sodium polystyrene sulfonate as ordered.
B. Assess the patient for muscle weakness in the lower extremities.
C. Encourage the patient to increase fluid intake.
D. Place the patient on a continuous cardiac monitor.
Correct Answer: D
Rationale: Hyperkalemia is a critical condition that directly affects the electrical activity of the heart.
Placing the patient on a cardiac monitor allows for the immediate detection of life-threatening
dysrhythmias such as peaked T-waves. While medications like sodium polystyrene sulfonate help lower
potassium, they do not provide immediate protection for the heart. Assessing for muscle weakness is
important but secondary to maintaining cardiac stability. The nurse must prioritize the assessment that
identifies potential cardiac arrest first.
2. A client is admitted with severe dehydration. Which of the following laboratory results should the nurse
expect to find?
A. Decreased Blood Urea Nitrogen (BUN) levels
B. Decreased serum sodium levels
C. Low urine specific gravity
D. Increased Hematocrit (Hct) level
,Correct Answer: D
Rationale: Dehydration leads to hemoconcentration, which typically results in an elevated hematocrit
level. This occurs because the ratio of red blood cells to plasma increases as fluid is lost from the vascular
space. Elevated BUN and high urine specific gravity are also common findings in a patient with fluid
volume deficit. Decreased serum sodium is not a standard finding unless the fluid loss is replaced with
water only. Monitoring these laboratory values helps the nurse evaluate the effectiveness of fluid
resuscitation therapy.
3. The nurse is caring for a patient with Syndrome of Inappropriate Antidiuretic Hormone (SIADH). Which
electrolyte imbalance is the patient at greatest risk for developing?
A. Hypernatremia
B. Hyponatremia
C. Hypocalcemia
D. Hyperkalemia
Correct Answer: B
Rationale: SIADH causes the body to retain excessive water, which dilutes the concentration of sodium
in the blood. This condition leads to dilutional hyponatremia, which can cause neurological symptoms
like confusion or seizures. The nurse must monitor serum sodium levels closely and implement fluid
restrictions as ordered. Treatment often focuses on removing excess water while maintaining or
replacing sodium carefully. Assessing the patient’s neurological status is a priority due to the risk of
cerebral edema.
4. Which arterial blood gas (ABG) result indicates that a patient is experiencing uncompensated Respiratory
Acidosis?
A. pH 7.48, PaCO2 30 mmHg, HCO3 22 mEq/L
,B. pH 7.42, PaCO2 48 mmHg, HCO3 28 mEq/L
C. pH 7.32, PaCO2 38 mmHg, HCO3 18 mEq/L
D. pH 7.30, PaCO2 52 mmHg, HCO3 24 mEq/L
Correct Answer: D
Rationale: Respiratory acidosis is characterized by a low pH and an elevated PaCO2 level. In an
uncompensated state, the bicarbonate (HCO3) level remains within the normal range of 22 to 26 mEq/L.
This indicates that the kidneys have not yet had time to retain bicarbonate to buffer the acid. Common
causes for this condition include hypoventilation, COPD, or opioid overdose. The nurse should focus on
improving the patient’s ventilation and oxygenation status immediately.
5. A nurse is assessing a patient with hypocalcemia. Which clinical finding should the nurse document as a
positive Trousseau’s sign?
A. Twitching of the facial muscles when the facial nerve is tapped.
B. Muscle tremors occurring during voluntary movement.
C. Sharp pain in the calf when the foot is dorsiflexed.
D. Carpal spasm after a blood pressure cuff is inflated above systolic pressure.
Correct Answer: D
Rationale: Trousseau’s sign is a classic indicator of hypocalcemia or neuromuscular irritability. It is
elicited by inflating a blood pressure cuff on the upper arm to a level above the systolic pressure for
several minutes. A positive sign is indicated by carpal spasms and adduction of the thumb. This occurs
because low calcium levels increase the excitability of peripheral nerves. The nurse must also monitor the
patient for laryngospasm and seizures as safety precautions.
, 6. A client with heart failure is receiving Furosemide. Which assessment finding is most important for the
nurse to report to the healthcare provider?
A. Serum potassium level of 2.9 mEq/L.
B. Urine output of 50 mL over the last hour.
C. Blood pressure of 110/70 mmHg.
D. Occasional leg cramps when walking.
Correct Answer: A
Rationale: Furosemide is a loop diuretic that causes the excretion of both water and potassium. A
potassium level of 2.9 mEq/L is significantly low and increases the risk for cardiac arrhythmias. The
nurse must report this finding to ensure the patient receives potassium supplementation. Hypokalemia
also increases the risk of digoxin toxicity if the patient is taking that medication. Prompt intervention is
necessary to maintain electrolyte balance and cardiac safety.
7. A patient with a history of chronic alcoholism presents with tremors, tachycardia, and a serum
magnesium level of 1.1 mg/dL. Which intervention is most appropriate?
A. Restrict dietary intake of leafy green vegetables.
B. Administer magnesium sulfate as ordered.
C. Maintain the patient on strict bedrest.
D. Assess for deep tendon reflexes every 8 hours.
Correct Answer: B
Rationale: A serum magnesium level of 1.1 mg/dL indicates hypomagnesemia, which is common in
patients with alcoholism due to poor intake and malabsorption. Low magnesium can lead to
neuromuscular irritability, tremors, and even cardiac issues like Torsades de Pointes. Administering
Updated and Latest Questions and Correct Answers with
Rationale
1. A patient with chronic kidney disease presents with a serum potassium level of 6.4 mEq/L. Which nursing
action is the absolute priority?
A. Administer sodium polystyrene sulfonate as ordered.
B. Assess the patient for muscle weakness in the lower extremities.
C. Encourage the patient to increase fluid intake.
D. Place the patient on a continuous cardiac monitor.
Correct Answer: D
Rationale: Hyperkalemia is a critical condition that directly affects the electrical activity of the heart.
Placing the patient on a cardiac monitor allows for the immediate detection of life-threatening
dysrhythmias such as peaked T-waves. While medications like sodium polystyrene sulfonate help lower
potassium, they do not provide immediate protection for the heart. Assessing for muscle weakness is
important but secondary to maintaining cardiac stability. The nurse must prioritize the assessment that
identifies potential cardiac arrest first.
2. A client is admitted with severe dehydration. Which of the following laboratory results should the nurse
expect to find?
A. Decreased Blood Urea Nitrogen (BUN) levels
B. Decreased serum sodium levels
C. Low urine specific gravity
D. Increased Hematocrit (Hct) level
,Correct Answer: D
Rationale: Dehydration leads to hemoconcentration, which typically results in an elevated hematocrit
level. This occurs because the ratio of red blood cells to plasma increases as fluid is lost from the vascular
space. Elevated BUN and high urine specific gravity are also common findings in a patient with fluid
volume deficit. Decreased serum sodium is not a standard finding unless the fluid loss is replaced with
water only. Monitoring these laboratory values helps the nurse evaluate the effectiveness of fluid
resuscitation therapy.
3. The nurse is caring for a patient with Syndrome of Inappropriate Antidiuretic Hormone (SIADH). Which
electrolyte imbalance is the patient at greatest risk for developing?
A. Hypernatremia
B. Hyponatremia
C. Hypocalcemia
D. Hyperkalemia
Correct Answer: B
Rationale: SIADH causes the body to retain excessive water, which dilutes the concentration of sodium
in the blood. This condition leads to dilutional hyponatremia, which can cause neurological symptoms
like confusion or seizures. The nurse must monitor serum sodium levels closely and implement fluid
restrictions as ordered. Treatment often focuses on removing excess water while maintaining or
replacing sodium carefully. Assessing the patient’s neurological status is a priority due to the risk of
cerebral edema.
4. Which arterial blood gas (ABG) result indicates that a patient is experiencing uncompensated Respiratory
Acidosis?
A. pH 7.48, PaCO2 30 mmHg, HCO3 22 mEq/L
,B. pH 7.42, PaCO2 48 mmHg, HCO3 28 mEq/L
C. pH 7.32, PaCO2 38 mmHg, HCO3 18 mEq/L
D. pH 7.30, PaCO2 52 mmHg, HCO3 24 mEq/L
Correct Answer: D
Rationale: Respiratory acidosis is characterized by a low pH and an elevated PaCO2 level. In an
uncompensated state, the bicarbonate (HCO3) level remains within the normal range of 22 to 26 mEq/L.
This indicates that the kidneys have not yet had time to retain bicarbonate to buffer the acid. Common
causes for this condition include hypoventilation, COPD, or opioid overdose. The nurse should focus on
improving the patient’s ventilation and oxygenation status immediately.
5. A nurse is assessing a patient with hypocalcemia. Which clinical finding should the nurse document as a
positive Trousseau’s sign?
A. Twitching of the facial muscles when the facial nerve is tapped.
B. Muscle tremors occurring during voluntary movement.
C. Sharp pain in the calf when the foot is dorsiflexed.
D. Carpal spasm after a blood pressure cuff is inflated above systolic pressure.
Correct Answer: D
Rationale: Trousseau’s sign is a classic indicator of hypocalcemia or neuromuscular irritability. It is
elicited by inflating a blood pressure cuff on the upper arm to a level above the systolic pressure for
several minutes. A positive sign is indicated by carpal spasms and adduction of the thumb. This occurs
because low calcium levels increase the excitability of peripheral nerves. The nurse must also monitor the
patient for laryngospasm and seizures as safety precautions.
, 6. A client with heart failure is receiving Furosemide. Which assessment finding is most important for the
nurse to report to the healthcare provider?
A. Serum potassium level of 2.9 mEq/L.
B. Urine output of 50 mL over the last hour.
C. Blood pressure of 110/70 mmHg.
D. Occasional leg cramps when walking.
Correct Answer: A
Rationale: Furosemide is a loop diuretic that causes the excretion of both water and potassium. A
potassium level of 2.9 mEq/L is significantly low and increases the risk for cardiac arrhythmias. The
nurse must report this finding to ensure the patient receives potassium supplementation. Hypokalemia
also increases the risk of digoxin toxicity if the patient is taking that medication. Prompt intervention is
necessary to maintain electrolyte balance and cardiac safety.
7. A patient with a history of chronic alcoholism presents with tremors, tachycardia, and a serum
magnesium level of 1.1 mg/dL. Which intervention is most appropriate?
A. Restrict dietary intake of leafy green vegetables.
B. Administer magnesium sulfate as ordered.
C. Maintain the patient on strict bedrest.
D. Assess for deep tendon reflexes every 8 hours.
Correct Answer: B
Rationale: A serum magnesium level of 1.1 mg/dL indicates hypomagnesemia, which is common in
patients with alcoholism due to poor intake and malabsorption. Low magnesium can lead to
neuromuscular irritability, tremors, and even cardiac issues like Torsades de Pointes. Administering
