NUR201 | NUR201 Medical Surgical Exam 3
Version 3 | Questions with Correct Answers and
Expert Explanation for Each Question | Saint Paul’s
School of Nursing
1. A patient with acute kidney injury (AKI) has a serum potassium level of 6.8 mEq/L.
Which prescribed intervention should the nurse implement first?
A. Administer sodium polystyrene sulfonate (Kayexalate) orally.
B. Administer IV regular insulin and 50% dextrose.
C. Place the patient on a continuous cardiac monitor.
D. Check the patient’s urine output for the last 8 hours.
Correct Answer: C
Expert Explanation: Hyperkalemia is a life-threatening electrolyte imbalance that
can cause lethal cardiac dysrhythmias. Placing the patient on a cardiac monitor is
the highest priority to detect changes like peaked T-waves or widened QRS
complexes. While insulin and Kayexalate are treatments for high potassium, patient
safety through monitoring must come first. Checking urine output provides data but
does not address the immediate cardiac risk. The nurse uses clinical reasoning to
prioritize physiological stability in emergency situations.
,2. Which assessment finding in a patient with chronic kidney disease (CKD) indicates a
need for immediate intervention?
A. Crackles auscultated at the lung bases
B. Blood pressure of 148/92 mmHg
C. Serum creatinine level of 2.5 mg/dL
D. Generalized pruritus and dry skin
Correct Answer: A
Expert Explanation: Crackles in the lungs indicate fluid volume excess and
pulmonary edema, which are common complications of renal failure. This finding
suggests that the kidneys are unable to maintain fluid balance, potentially leading to
respiratory distress. While elevated creatinine and high blood pressure are typical
in CKD, they are not as immediately life-threatening as respiratory compromise.
Pruritus is a common symptom of uremia but does not require emergency
intervention. The nurse must prioritize airway and breathing assessments to ensure
patient safety.
3. A nurse is caring for a patient undergoing hemodialysis via a right-arm
arteriovenous (AV) fistula. Which action should the nurse take to ensure the safety of
the access site?
A. Draw blood samples from the AV fistula for routine labs.
,B. Instruct the patient to sleep on the right arm to keep it warm.
C. Perform blood pressure measurements on the right arm only.
D. Palpate for a thrill and auscultate for a bruit every shift.
Correct Answer: D
Expert Explanation: Assessing for a thrill and bruit confirms that the AV fistula is
patent and functioning correctly. Blood pressure readings and blood draws should
never be performed on the arm with the fistula to prevent clotting or damage.
Sleeping on the affected arm can compress the site and cause thrombosis. If the
thrill or bruit is absent, the nurse must notify the provider immediately as the
access may be lost. Maintaining the integrity of the dialysis access is vital for the
patient’s ongoing treatment.
4. The nurse is teaching a patient with CKD about a low-potassium diet. Which food
choice indicates the patient understands the teaching?
A. A medium baked potato with skin
B. A fresh banana with breakfast
C. A half-cup of raw blueberries
D. A spinach salad with tomatoes
Correct Answer: C
, Expert Explanation: Blueberries are considered a low-potassium fruit choice
suitable for patients with impaired renal function. Potatoes, bananas, spinach, and
tomatoes are all high in potassium and should be avoided to prevent hyperkalemia.
Managing potassium intake is critical because the kidneys cannot effectively excrete
excess amounts in CKD. The nurse’s role in patient education is to help the patient
make safe dietary choices to prevent complications. Successful outcomes are
measured by the patient’s ability to select appropriate low-potassium foods.
5. A patient with AKI is in the diuretic phase. What is the nurse’s priority assessment?
A. Signs of fluid volume excess like edema
B. High serum creatinine and BUN levels
C. Blood pressure and heart rate for dehydration
D. Urine output for signs of oliguria
Correct Answer: C
Expert Explanation: During the diuretic phase of AKI, the kidneys begin to excrete
large volumes of urine but cannot concentrate it. This leads to a high risk of
dehydration, hypovolemia, and electrolyte imbalances such as hyponatremia and
hypokalemia. The nurse must monitor blood pressure and heart rate to detect early
signs of shock or severe fluid loss. Creatinine may still be high, but the physiological
Version 3 | Questions with Correct Answers and
Expert Explanation for Each Question | Saint Paul’s
School of Nursing
1. A patient with acute kidney injury (AKI) has a serum potassium level of 6.8 mEq/L.
Which prescribed intervention should the nurse implement first?
A. Administer sodium polystyrene sulfonate (Kayexalate) orally.
B. Administer IV regular insulin and 50% dextrose.
C. Place the patient on a continuous cardiac monitor.
D. Check the patient’s urine output for the last 8 hours.
Correct Answer: C
Expert Explanation: Hyperkalemia is a life-threatening electrolyte imbalance that
can cause lethal cardiac dysrhythmias. Placing the patient on a cardiac monitor is
the highest priority to detect changes like peaked T-waves or widened QRS
complexes. While insulin and Kayexalate are treatments for high potassium, patient
safety through monitoring must come first. Checking urine output provides data but
does not address the immediate cardiac risk. The nurse uses clinical reasoning to
prioritize physiological stability in emergency situations.
,2. Which assessment finding in a patient with chronic kidney disease (CKD) indicates a
need for immediate intervention?
A. Crackles auscultated at the lung bases
B. Blood pressure of 148/92 mmHg
C. Serum creatinine level of 2.5 mg/dL
D. Generalized pruritus and dry skin
Correct Answer: A
Expert Explanation: Crackles in the lungs indicate fluid volume excess and
pulmonary edema, which are common complications of renal failure. This finding
suggests that the kidneys are unable to maintain fluid balance, potentially leading to
respiratory distress. While elevated creatinine and high blood pressure are typical
in CKD, they are not as immediately life-threatening as respiratory compromise.
Pruritus is a common symptom of uremia but does not require emergency
intervention. The nurse must prioritize airway and breathing assessments to ensure
patient safety.
3. A nurse is caring for a patient undergoing hemodialysis via a right-arm
arteriovenous (AV) fistula. Which action should the nurse take to ensure the safety of
the access site?
A. Draw blood samples from the AV fistula for routine labs.
,B. Instruct the patient to sleep on the right arm to keep it warm.
C. Perform blood pressure measurements on the right arm only.
D. Palpate for a thrill and auscultate for a bruit every shift.
Correct Answer: D
Expert Explanation: Assessing for a thrill and bruit confirms that the AV fistula is
patent and functioning correctly. Blood pressure readings and blood draws should
never be performed on the arm with the fistula to prevent clotting or damage.
Sleeping on the affected arm can compress the site and cause thrombosis. If the
thrill or bruit is absent, the nurse must notify the provider immediately as the
access may be lost. Maintaining the integrity of the dialysis access is vital for the
patient’s ongoing treatment.
4. The nurse is teaching a patient with CKD about a low-potassium diet. Which food
choice indicates the patient understands the teaching?
A. A medium baked potato with skin
B. A fresh banana with breakfast
C. A half-cup of raw blueberries
D. A spinach salad with tomatoes
Correct Answer: C
, Expert Explanation: Blueberries are considered a low-potassium fruit choice
suitable for patients with impaired renal function. Potatoes, bananas, spinach, and
tomatoes are all high in potassium and should be avoided to prevent hyperkalemia.
Managing potassium intake is critical because the kidneys cannot effectively excrete
excess amounts in CKD. The nurse’s role in patient education is to help the patient
make safe dietary choices to prevent complications. Successful outcomes are
measured by the patient’s ability to select appropriate low-potassium foods.
5. A patient with AKI is in the diuretic phase. What is the nurse’s priority assessment?
A. Signs of fluid volume excess like edema
B. High serum creatinine and BUN levels
C. Blood pressure and heart rate for dehydration
D. Urine output for signs of oliguria
Correct Answer: C
Expert Explanation: During the diuretic phase of AKI, the kidneys begin to excrete
large volumes of urine but cannot concentrate it. This leads to a high risk of
dehydration, hypovolemia, and electrolyte imbalances such as hyponatremia and
hypokalemia. The nurse must monitor blood pressure and heart rate to detect early
signs of shock or severe fluid loss. Creatinine may still be high, but the physiological
