JERSEY COLLEGE MEDSURG
1 RN FINAL EXAM | Complete
Solutions | Medical-Surgical
Nursing | A+ Graded | Pass
Guaranteed
[DOMAIN 1: FLUID & ELECTROLYTES, ACID-BASE BALANCE - 20 Questions]
uestion 1
Q
A client with heart failure has a serum sodium level of 128 mEq/L. Which clinical manifestation
should the nurse expect to assess first?
) Severe seizures and coma
A
B) Muscle weakness and fatigue
C) Confusion and headache **[CORRECT]**
D) Oliguria and thirst
* *Rationale:** Hyponatremia (serum sodium <135 mEq/L) causes water movement into cells,
leading to cerebral edema. Early symptoms include headache, confusion, and nausea. Severe
symptoms (seizures, coma) occur at levels <115 mEq/L. Muscle weakness is more
characteristic of potassium imbalances, while oliguria and thirst indicate hypernatremia.
---
# Question 2
#
The nurse is caring for a client receiving 3% saline for severe symptomatic hyponatremia. What
is the priority nursing intervention?
) Monitor neurological status every 15 minutes **[CORRECT]**
A
B) Assess for signs of fluid overload every hour
C) Check deep tendon reflexes every 4 hours
D) Measure abdominal girth daily
* *Rationale:** Rapid correction of hyponatremia can cause osmotic demyelination syndrome
(central pontine myelinolysis). The nurse must monitor neurological status closely to detect
, hanges in mental status, which indicates overly rapid sodium correction. While fluid overload is
c
a concern with hypertonic saline, neurological monitoring takes priority in severe symptomatic
hyponatremia.
---
## Question 3
#
A client with diabetes insipidus has a serum sodium of 152 mEq/L. Which nursing intervention is
most appropriate?
) Restrict fluid intake to 1,000 mL/day
A
B) Encourage oral fluid intake as tolerated **[CORRECT]**
C) Administer diuretics as ordered
D) Apply cooling blankets for hyperthermia
* *Rationale:** Hypernatremia in diabetes insipidus results from free water loss due to insufficient
ADH. Treatment focuses on replacing water deficit. Oral fluids are preferred if the client can
drink; otherwise, IV D5W is administered. Fluid restriction worsens hypernatremia. Diuretics
would exacerbate fluid loss.
---
## Question 4
#
A client receiving furosemide (Lasix) develops muscle weakness and cardiac arrhythmias. The
ECG shows flattened T waves and U waves. What is the priority nursing action?
) Administer potassium chloride IV push immediately
A
B) Obtain a serum potassium level and prepare for replacement **[CORRECT]**
C) Increase dietary sodium intake
D) Place the client on telemetry without intervention
* *Rationale:** These are classic signs of hypokalemia (serum potassium <3.5 mEq/L) caused by
loop diuretics. Flattened T waves and U waves are pathognomonic. The nurse must verify the
potassium level before replacement. Potassium is NEVER given IV push due to risk of cardiac
arrest; it must be infused slowly with cardiac monitoring.
---
## Question 5
#
The nurse is preparing to administer potassium chloride IV to a client with hypokalemia. Which
action demonstrates safe practice?
) Administer via IV push over 2 minutes
A
B) Add to IV solution and infuse over 1 hour without cardiac monitoring
, ) Dilute in IV fluid and administer via infusion pump with continuous cardiac monitoring
C
**[CORRECT]**
D) Mix with D5W solution for better absorption
* *Rationale:** IV potassium must be diluted (usually 10-20 mEq/L) and infused slowly (max 10
mEq/hour via peripheral line, 20 mEq/hour via central line) with continuous cardiac monitoring.
D5W stimulates insulin release, which drives potassium into cells, worsening hypokalemia. NS
is the preferred diluent.
---
## Question 6
#
A client with renal failure presents with peaked T waves on ECG, muscle weakness, and
paresthesia. Which medication should the nurse prepare to administer first?
) Sodium polystyrene sulfonate (Kayexalate)
A
B) Regular insulin with 50% glucose
C) Calcium gluconate **[CORRECT]**
D) Albuterol nebulizer
* *Rationale:** These are signs of hyperkalemia (serum potassium >5.0 mEq/L). Peaked T
waves indicate cardiotoxicity. Calcium gluconate is administered first to stabilize cardiac
membranes (cardioprotective effect), though it does not lower potassium levels. Other
treatments (insulin/glucose, Kayexalate, albuterol) shift or remove potassium but take longer to
protect the heart.
---
## Question 7
#
Following a massive blood transfusion, a client develops carpopedal spasm and a positive
Chvostek's sign. Which electrolyte imbalance is suspected?
) Hyperkalemia
A
B) Hypocalcemia **[CORRECT]**
C) Hyponatremia
D) Hypermagnesemia
* *Rationale:** Massive transfusions contain citrate (anticoagulant) that binds calcium.
Hypocalcemia (<8.5 mg/dL) causes neuromuscular irritability evidenced by Chvostek's sign
(facial twitching when tapping facial nerve) and Trousseau's sign (carpal spasm with BP cuff
inflation). Tetany and seizures may follow.
---
, ## Question 8
#
A client with hyperparathyroidism presents with constipation, polyuria, and confusion. Which
laboratory value supports this diagnosis?
) Serum calcium 7.2 mg/dL
A
B) Serum calcium 12.8 mg/dL **[CORRECT]**
C) Serum phosphorus 4.5 mg/dL
D) Serum magnesium 1.2 mEq/L
* *Rationale:** Hyperparathyroidism causes hypercalcemia (>10.5 mg/dL). Symptoms include
"bones, stones, abdominal groans, and psychic moans"—bone pain, kidney stones, constipation
(decreased GI motility), and mental status changes. Polyuria results from impaired renal
concentrating ability.
---
## Question 9
#
A client with alcoholism presents with tremors, tetany, and cardiac arrhythmias. Which
electrolyte imbalance should the nurse suspect?
) Hypernatremia
A
B) Hypomagnesemia **[CORRECT]**
C) Hyperkalemia
D) Hypochloremia
* *Rationale:** Alcoholism is a major risk factor for hypomagnesemia (<1.5 mEq/L) due to poor
nutrition, malabsorption, and increased renal excretion. Magnesium deficiency causes
neuromuscular irritability (tremors, tetany) and cardiac arrhythmias. It often coexists with
hypokalemia and hypocalcemia, which are refractory to treatment until magnesium is corrected.
---
## Question 10
#
A client with prolonged NG suction and vomiting has arterial blood gas results: pH 7.52, PaCO2
48 mmHg, HCO3- 35 mEq/L. Which acid-base disorder is present?
) Respiratory acidosis
A
B) Metabolic alkalosis **[CORRECT]**
C) Respiratory alkalosis
D) Metabolic acidosis
* *Rationale:** The elevated pH indicates alkalosis. The elevated HCO3- (metabolic component)
is the primary disorder, with compensatory hypoventilation (elevated PaCO2). NG suction
1 RN FINAL EXAM | Complete
Solutions | Medical-Surgical
Nursing | A+ Graded | Pass
Guaranteed
[DOMAIN 1: FLUID & ELECTROLYTES, ACID-BASE BALANCE - 20 Questions]
uestion 1
Q
A client with heart failure has a serum sodium level of 128 mEq/L. Which clinical manifestation
should the nurse expect to assess first?
) Severe seizures and coma
A
B) Muscle weakness and fatigue
C) Confusion and headache **[CORRECT]**
D) Oliguria and thirst
* *Rationale:** Hyponatremia (serum sodium <135 mEq/L) causes water movement into cells,
leading to cerebral edema. Early symptoms include headache, confusion, and nausea. Severe
symptoms (seizures, coma) occur at levels <115 mEq/L. Muscle weakness is more
characteristic of potassium imbalances, while oliguria and thirst indicate hypernatremia.
---
# Question 2
#
The nurse is caring for a client receiving 3% saline for severe symptomatic hyponatremia. What
is the priority nursing intervention?
) Monitor neurological status every 15 minutes **[CORRECT]**
A
B) Assess for signs of fluid overload every hour
C) Check deep tendon reflexes every 4 hours
D) Measure abdominal girth daily
* *Rationale:** Rapid correction of hyponatremia can cause osmotic demyelination syndrome
(central pontine myelinolysis). The nurse must monitor neurological status closely to detect
, hanges in mental status, which indicates overly rapid sodium correction. While fluid overload is
c
a concern with hypertonic saline, neurological monitoring takes priority in severe symptomatic
hyponatremia.
---
## Question 3
#
A client with diabetes insipidus has a serum sodium of 152 mEq/L. Which nursing intervention is
most appropriate?
) Restrict fluid intake to 1,000 mL/day
A
B) Encourage oral fluid intake as tolerated **[CORRECT]**
C) Administer diuretics as ordered
D) Apply cooling blankets for hyperthermia
* *Rationale:** Hypernatremia in diabetes insipidus results from free water loss due to insufficient
ADH. Treatment focuses on replacing water deficit. Oral fluids are preferred if the client can
drink; otherwise, IV D5W is administered. Fluid restriction worsens hypernatremia. Diuretics
would exacerbate fluid loss.
---
## Question 4
#
A client receiving furosemide (Lasix) develops muscle weakness and cardiac arrhythmias. The
ECG shows flattened T waves and U waves. What is the priority nursing action?
) Administer potassium chloride IV push immediately
A
B) Obtain a serum potassium level and prepare for replacement **[CORRECT]**
C) Increase dietary sodium intake
D) Place the client on telemetry without intervention
* *Rationale:** These are classic signs of hypokalemia (serum potassium <3.5 mEq/L) caused by
loop diuretics. Flattened T waves and U waves are pathognomonic. The nurse must verify the
potassium level before replacement. Potassium is NEVER given IV push due to risk of cardiac
arrest; it must be infused slowly with cardiac monitoring.
---
## Question 5
#
The nurse is preparing to administer potassium chloride IV to a client with hypokalemia. Which
action demonstrates safe practice?
) Administer via IV push over 2 minutes
A
B) Add to IV solution and infuse over 1 hour without cardiac monitoring
, ) Dilute in IV fluid and administer via infusion pump with continuous cardiac monitoring
C
**[CORRECT]**
D) Mix with D5W solution for better absorption
* *Rationale:** IV potassium must be diluted (usually 10-20 mEq/L) and infused slowly (max 10
mEq/hour via peripheral line, 20 mEq/hour via central line) with continuous cardiac monitoring.
D5W stimulates insulin release, which drives potassium into cells, worsening hypokalemia. NS
is the preferred diluent.
---
## Question 6
#
A client with renal failure presents with peaked T waves on ECG, muscle weakness, and
paresthesia. Which medication should the nurse prepare to administer first?
) Sodium polystyrene sulfonate (Kayexalate)
A
B) Regular insulin with 50% glucose
C) Calcium gluconate **[CORRECT]**
D) Albuterol nebulizer
* *Rationale:** These are signs of hyperkalemia (serum potassium >5.0 mEq/L). Peaked T
waves indicate cardiotoxicity. Calcium gluconate is administered first to stabilize cardiac
membranes (cardioprotective effect), though it does not lower potassium levels. Other
treatments (insulin/glucose, Kayexalate, albuterol) shift or remove potassium but take longer to
protect the heart.
---
## Question 7
#
Following a massive blood transfusion, a client develops carpopedal spasm and a positive
Chvostek's sign. Which electrolyte imbalance is suspected?
) Hyperkalemia
A
B) Hypocalcemia **[CORRECT]**
C) Hyponatremia
D) Hypermagnesemia
* *Rationale:** Massive transfusions contain citrate (anticoagulant) that binds calcium.
Hypocalcemia (<8.5 mg/dL) causes neuromuscular irritability evidenced by Chvostek's sign
(facial twitching when tapping facial nerve) and Trousseau's sign (carpal spasm with BP cuff
inflation). Tetany and seizures may follow.
---
, ## Question 8
#
A client with hyperparathyroidism presents with constipation, polyuria, and confusion. Which
laboratory value supports this diagnosis?
) Serum calcium 7.2 mg/dL
A
B) Serum calcium 12.8 mg/dL **[CORRECT]**
C) Serum phosphorus 4.5 mg/dL
D) Serum magnesium 1.2 mEq/L
* *Rationale:** Hyperparathyroidism causes hypercalcemia (>10.5 mg/dL). Symptoms include
"bones, stones, abdominal groans, and psychic moans"—bone pain, kidney stones, constipation
(decreased GI motility), and mental status changes. Polyuria results from impaired renal
concentrating ability.
---
## Question 9
#
A client with alcoholism presents with tremors, tetany, and cardiac arrhythmias. Which
electrolyte imbalance should the nurse suspect?
) Hypernatremia
A
B) Hypomagnesemia **[CORRECT]**
C) Hyperkalemia
D) Hypochloremia
* *Rationale:** Alcoholism is a major risk factor for hypomagnesemia (<1.5 mEq/L) due to poor
nutrition, malabsorption, and increased renal excretion. Magnesium deficiency causes
neuromuscular irritability (tremors, tetany) and cardiac arrhythmias. It often coexists with
hypokalemia and hypocalcemia, which are refractory to treatment until magnesium is corrected.
---
## Question 10
#
A client with prolonged NG suction and vomiting has arterial blood gas results: pH 7.52, PaCO2
48 mmHg, HCO3- 35 mEq/L. Which acid-base disorder is present?
) Respiratory acidosis
A
B) Metabolic alkalosis **[CORRECT]**
C) Respiratory alkalosis
D) Metabolic acidosis
* *Rationale:** The elevated pH indicates alkalosis. The elevated HCO3- (metabolic component)
is the primary disorder, with compensatory hypoventilation (elevated PaCO2). NG suction
