NUR104 Medsurg 2 Exam 2 Version 3 Questions
with Correct Answers and Expert Explanation for
Each Question
1. A patient with Chronic Kidney Disease (CKD) has a potassium level of 6.8 mEq/L.
Which medication should the nurse prioritize to stabilize the cardiac membrane?
A. Sodium Polystyrene Sulfonate (Kayexalate)
B. Furosemide (Lasix)
C. Regular Insulin with D50
D. Calcium Gluconate
Correct Answer: D
Expert Explanation: Hyperkalemia is a life-threatening complication of renal
failure that causes cardiac irritability. While insulin and Kayexalate help lower
potassium levels, they do not provide immediate cardiac protection. Calcium
Gluconate is the priority intervention because it antagonizes the effects of
hyperkalemia on the heart. The nurse must monitor the patient’s ECG continuously
during administration for changes. This intervention is temporary and must be
followed by measures to actually remove potassium from the body.
2. The nurse is caring for a client with an Arteriovenous (AV) fistula in the left arm.
Which action is appropriate for the nurse to take?
A. Measure blood pressure on the left arm.
,B. Palpate for a thrill and auscultate for a bruit.
C. Draw blood from the left arm for laboratory tests.
D. Apply a tight dressing to the site to prevent bleeding.
Correct Answer: B
Expert Explanation: An AV fistula is the preferred access for long-term
hemodialysis and requires specific maintenance. The nurse must assess the patency
of the fistula by feeling for a thrill and listening for a bruit. Blood pressure and
venipunctures are strictly prohibited in the affected arm to prevent clotting or
damage. Tight dressings or clothing should be avoided as they can occlude the blood
flow through the access. Regular assessment ensures that the patient can receive
their scheduled dialysis treatment without complications.
3. Which clinical finding is most characteristic of the oliguric phase of Acute Kidney
Injury (AKI)?
A. Urinary output less than 400 mL per day
B. Metabolic alkalosis
C. Fluid volume deficit
D. Urinary output of 3,000 mL per day
Correct Answer: A
,Expert Explanation: The oliguric phase is the first clinical phase of AKI following
the initial insult. It is characterized by a significant drop in urine output, typically
defined as less than 400 mL in 24 hours. During this phase, the nurse will observe
rising levels of BUN and Creatinine due to decreased filtration. Patients are at high
risk for metabolic acidosis and fluid volume excess during this time. Monitoring
intake and output becomes a critical nursing responsibility to prevent pulmonary
edema.
4. A patient receiving peritoneal dialysis reports that the dialysate drainage is cloudy.
What should the nurse suspect?
A. A normal finding for peritoneal dialysis
B. Fibrin clot formation
C. A bladder perforation
D. Peritonitis
Correct Answer: D
Expert Explanation: Peritonitis is the most common and serious complication
associated with peritoneal dialysis. Cloudy outflow is often the first sign of an
infection in the peritoneal cavity. The nurse should also assess the patient for
abdominal pain, rebound tenderness, and fever. Prompt notification of the
, healthcare provider is necessary to initiate antibiotic therapy. Early intervention is
essential to prevent systemic sepsis and the potential loss of the dialysis access.
5. Which diet is most appropriate for a patient in the late stages of Chronic Kidney
Disease who is not yet on dialysis?
A. High protein, low sodium, low potassium
B. Normal protein, low carbohydrate, low fat
C. High protein, high calorie, high sodium
D. Low protein, low sodium, low potassium
Correct Answer: D
Expert Explanation: Dietary management in CKD aims to minimize the buildup of
metabolic waste products. Before starting dialysis, protein is restricted to reduce
the workload on the kidneys and decrease nitrogenous waste. Sodium and
potassium are restricted to manage fluid balance and prevent electrolyte-induced
cardiac issues. Once dialysis begins, protein intake is usually increased because the
procedure removes amino acids from the blood. Patient education focuses on
reading labels and choosing nutrient-dense, kidney-friendly foods.
6. Immediately following hemodialysis, the nurse should assess the patient for which
of the following?
A. Increased weight
with Correct Answers and Expert Explanation for
Each Question
1. A patient with Chronic Kidney Disease (CKD) has a potassium level of 6.8 mEq/L.
Which medication should the nurse prioritize to stabilize the cardiac membrane?
A. Sodium Polystyrene Sulfonate (Kayexalate)
B. Furosemide (Lasix)
C. Regular Insulin with D50
D. Calcium Gluconate
Correct Answer: D
Expert Explanation: Hyperkalemia is a life-threatening complication of renal
failure that causes cardiac irritability. While insulin and Kayexalate help lower
potassium levels, they do not provide immediate cardiac protection. Calcium
Gluconate is the priority intervention because it antagonizes the effects of
hyperkalemia on the heart. The nurse must monitor the patient’s ECG continuously
during administration for changes. This intervention is temporary and must be
followed by measures to actually remove potassium from the body.
2. The nurse is caring for a client with an Arteriovenous (AV) fistula in the left arm.
Which action is appropriate for the nurse to take?
A. Measure blood pressure on the left arm.
,B. Palpate for a thrill and auscultate for a bruit.
C. Draw blood from the left arm for laboratory tests.
D. Apply a tight dressing to the site to prevent bleeding.
Correct Answer: B
Expert Explanation: An AV fistula is the preferred access for long-term
hemodialysis and requires specific maintenance. The nurse must assess the patency
of the fistula by feeling for a thrill and listening for a bruit. Blood pressure and
venipunctures are strictly prohibited in the affected arm to prevent clotting or
damage. Tight dressings or clothing should be avoided as they can occlude the blood
flow through the access. Regular assessment ensures that the patient can receive
their scheduled dialysis treatment without complications.
3. Which clinical finding is most characteristic of the oliguric phase of Acute Kidney
Injury (AKI)?
A. Urinary output less than 400 mL per day
B. Metabolic alkalosis
C. Fluid volume deficit
D. Urinary output of 3,000 mL per day
Correct Answer: A
,Expert Explanation: The oliguric phase is the first clinical phase of AKI following
the initial insult. It is characterized by a significant drop in urine output, typically
defined as less than 400 mL in 24 hours. During this phase, the nurse will observe
rising levels of BUN and Creatinine due to decreased filtration. Patients are at high
risk for metabolic acidosis and fluid volume excess during this time. Monitoring
intake and output becomes a critical nursing responsibility to prevent pulmonary
edema.
4. A patient receiving peritoneal dialysis reports that the dialysate drainage is cloudy.
What should the nurse suspect?
A. A normal finding for peritoneal dialysis
B. Fibrin clot formation
C. A bladder perforation
D. Peritonitis
Correct Answer: D
Expert Explanation: Peritonitis is the most common and serious complication
associated with peritoneal dialysis. Cloudy outflow is often the first sign of an
infection in the peritoneal cavity. The nurse should also assess the patient for
abdominal pain, rebound tenderness, and fever. Prompt notification of the
, healthcare provider is necessary to initiate antibiotic therapy. Early intervention is
essential to prevent systemic sepsis and the potential loss of the dialysis access.
5. Which diet is most appropriate for a patient in the late stages of Chronic Kidney
Disease who is not yet on dialysis?
A. High protein, low sodium, low potassium
B. Normal protein, low carbohydrate, low fat
C. High protein, high calorie, high sodium
D. Low protein, low sodium, low potassium
Correct Answer: D
Expert Explanation: Dietary management in CKD aims to minimize the buildup of
metabolic waste products. Before starting dialysis, protein is restricted to reduce
the workload on the kidneys and decrease nitrogenous waste. Sodium and
potassium are restricted to manage fluid balance and prevent electrolyte-induced
cardiac issues. Once dialysis begins, protein intake is usually increased because the
procedure removes amino acids from the blood. Patient education focuses on
reading labels and choosing nutrient-dense, kidney-friendly foods.
6. Immediately following hemodialysis, the nurse should assess the patient for which
of the following?
A. Increased weight
