NUR 425 Exam 2: Medical Surgical V2 - Arizona College
Updated and Latest Questions and Correct Answers with
Rationale
1. A patient with Type 1 Diabetes is admitted with Diabetic Ketoacidosis (DKA). Which of the following lab
findings is most consistent with this diagnosis?
A. Serum glucose of 150 mg/dL
B. Serum bicarbonate of 24 mEq/L
C. Arterial pH of 7.25
D. Negative urine ketones
Ans: C
Explanation: Diabetic Ketoacidosis is characterized by metabolic acidosis resulting from the buildup of
ketones. An arterial pH below 7.35 indicates an acidotic state common in these patients. In DKA, blood
glucose levels typically exceed 250 mg/dL, and bicarbonate levels are significantly lowered. Ketones will
also be present in both the blood and urine samples. The nurse must prioritize fluid resuscitation and
insulin administration to correct these metabolic imbalances.
2. When caring for a patient with Chronic Kidney Disease (CKD), which dietary restriction is most important
to manage hyperkalemia?
A. Replacing salt with potassium-based salt substitutes
B. Increasing the consumption of leafy green vegetables
C. Avoiding all forms of dietary protein
D. Limiting intake of citrus fruits and bananas
Ans: D
,Explanation: Hyperkalemia is a life-threatening complication of chronic kidney disease due to the
kidneys’ inability to excrete potassium. Citrus fruits and bananas are high in potassium and must be
restricted to prevent cardiac arrhythmias. Using potassium-based salt substitutes is dangerous because it
directly increases potassium levels. Protein is usually restricted to manage urea levels, but potassium
management is more critical for immediate cardiac safety. The nurse should educate the patient on low-
potassium food alternatives to maintain electrolyte balance.
3. A patient with liver cirrhosis presents with increased confusion and asterixis. Which medication should
the nurse anticipate administering?
A. Lactulose
B. Propranolol
C. Spironolactone
D. Vitamin K
Ans: A
Explanation: Increased confusion and asterixis are classic signs of hepatic encephalopathy caused by
high ammonia levels. Lactulose works by trapping ammonia in the gut and facilitating its excretion
through bowel movements. The nurse should monitor the patient for frequent soft stools, which indicates
the medication is effective. Spironolactone is used for ascites, and Propranolol is used to prevent
esophageal variceal bleeding. Timely administration of Lactulose is essential to improve the patient’s
neurological status.
4. Which clinical manifestation is a hallmark sign of Syndrome of Inappropriate Antidiuretic Hormone
(SIADH)?
A. Dilutional hyponatremia
B. High serum sodium levels
, C. Excessive thirst and polyuria
D. Low urine specific gravity
Ans: A
Explanation: SIADH involves the excessive release of ADH, leading to water retention and expanded
extracellular fluid volume. This results in dilutional hyponatremia, where the serum sodium
concentration drops significantly. Patients will typically exhibit low urine output with high urine specific
gravity due to concentrated urine. Unlike Diabetes Insipidus, SIADH does not present with polyuria or
extreme thirst. Management focuses on fluid restriction and monitoring for neurological changes related
to low sodium.
5. A patient is diagnosed with acute pancreatitis. Which nursing intervention is the highest priority during
the early phase of care?
A. Administering oral pancreatic enzymes with meals
B. Maintaining NPO status and providing IV fluids
C. Encouraging a high-fat diet for caloric intake
D. Placing the patient in a supine position to reduce pain
Ans: B
Explanation: Acute pancreatitis requires the patient to be NPO to rest the pancreas and reduce enzyme
secretion. Aggressive IV fluid resuscitation is necessary to prevent hypovolemic shock and maintain
organ perfusion. Pain management is also critical, as pancreatic pain can be severe and debilitating. Oral
enzymes are used for chronic pancreatitis, not during the acute inflammatory phase. Resting the GI tract
helps minimize the autodigestion of pancreatic tissue.
Updated and Latest Questions and Correct Answers with
Rationale
1. A patient with Type 1 Diabetes is admitted with Diabetic Ketoacidosis (DKA). Which of the following lab
findings is most consistent with this diagnosis?
A. Serum glucose of 150 mg/dL
B. Serum bicarbonate of 24 mEq/L
C. Arterial pH of 7.25
D. Negative urine ketones
Ans: C
Explanation: Diabetic Ketoacidosis is characterized by metabolic acidosis resulting from the buildup of
ketones. An arterial pH below 7.35 indicates an acidotic state common in these patients. In DKA, blood
glucose levels typically exceed 250 mg/dL, and bicarbonate levels are significantly lowered. Ketones will
also be present in both the blood and urine samples. The nurse must prioritize fluid resuscitation and
insulin administration to correct these metabolic imbalances.
2. When caring for a patient with Chronic Kidney Disease (CKD), which dietary restriction is most important
to manage hyperkalemia?
A. Replacing salt with potassium-based salt substitutes
B. Increasing the consumption of leafy green vegetables
C. Avoiding all forms of dietary protein
D. Limiting intake of citrus fruits and bananas
Ans: D
,Explanation: Hyperkalemia is a life-threatening complication of chronic kidney disease due to the
kidneys’ inability to excrete potassium. Citrus fruits and bananas are high in potassium and must be
restricted to prevent cardiac arrhythmias. Using potassium-based salt substitutes is dangerous because it
directly increases potassium levels. Protein is usually restricted to manage urea levels, but potassium
management is more critical for immediate cardiac safety. The nurse should educate the patient on low-
potassium food alternatives to maintain electrolyte balance.
3. A patient with liver cirrhosis presents with increased confusion and asterixis. Which medication should
the nurse anticipate administering?
A. Lactulose
B. Propranolol
C. Spironolactone
D. Vitamin K
Ans: A
Explanation: Increased confusion and asterixis are classic signs of hepatic encephalopathy caused by
high ammonia levels. Lactulose works by trapping ammonia in the gut and facilitating its excretion
through bowel movements. The nurse should monitor the patient for frequent soft stools, which indicates
the medication is effective. Spironolactone is used for ascites, and Propranolol is used to prevent
esophageal variceal bleeding. Timely administration of Lactulose is essential to improve the patient’s
neurological status.
4. Which clinical manifestation is a hallmark sign of Syndrome of Inappropriate Antidiuretic Hormone
(SIADH)?
A. Dilutional hyponatremia
B. High serum sodium levels
, C. Excessive thirst and polyuria
D. Low urine specific gravity
Ans: A
Explanation: SIADH involves the excessive release of ADH, leading to water retention and expanded
extracellular fluid volume. This results in dilutional hyponatremia, where the serum sodium
concentration drops significantly. Patients will typically exhibit low urine output with high urine specific
gravity due to concentrated urine. Unlike Diabetes Insipidus, SIADH does not present with polyuria or
extreme thirst. Management focuses on fluid restriction and monitoring for neurological changes related
to low sodium.
5. A patient is diagnosed with acute pancreatitis. Which nursing intervention is the highest priority during
the early phase of care?
A. Administering oral pancreatic enzymes with meals
B. Maintaining NPO status and providing IV fluids
C. Encouraging a high-fat diet for caloric intake
D. Placing the patient in a supine position to reduce pain
Ans: B
Explanation: Acute pancreatitis requires the patient to be NPO to rest the pancreas and reduce enzyme
secretion. Aggressive IV fluid resuscitation is necessary to prevent hypovolemic shock and maintain
organ perfusion. Pain management is also critical, as pancreatic pain can be severe and debilitating. Oral
enzymes are used for chronic pancreatitis, not during the acute inflammatory phase. Resting the GI tract
helps minimize the autodigestion of pancreatic tissue.
