MEDSURG TEST #3 QUESTIONS WITH VERIFIED
ANSWERS
1. A patient is receiving 3% NaCl solution for correction of hyponatremia. During
administration of the solution, the most important assessment for the nurse to monitor is
a. lung sounds.
b. urinary output.
c. peripheral pulses.
d. peripheral edema. - Answers - ANS: A lung sounds.
Hypertonic solutions cause water retention, so the patient should be monitored for
symptoms of fluid excess. Crackles in the lungs may indicate the onset of pulmonary
edema and are the most serious of the symptoms of fluid excess listed. Bounding
peripheral pulses, peripheral edema, or changes in urine output also are important to
monitor when administering hypertonic solutions, but they do not indicate acute
respiratory or cardiac decompensation.
2. A patient who has an infusion of 50% dextrose prescribed asks the nurse why a
peripherally inserted central catheter must be inserted. Which explanation by the nurse
is correct?
a. The prescribed infusion can be given much more rapidly when the patient has a
central line.
b. There is a decreased risk for infection when 50% dextrose is infused through a
central line.
c. The 50% dextrose is hypertonic and will be more rapidly diluted when given through a
central line.
d. The required blood glucose monitoring is more accurate when samples are obtained
from a central line. - Answers - ANS: C. The 50% dextrose is hypertonic and will be
more rapidly diluted when given through a central line. Shrinkage of red blood cells can
occur when solutions with dextrose concentrations greater than 10% are administered
intravenously. Blood glucose testing is not more accurate when samples are obtained
from a central line. The infection risk is higher with a central catheter than with
peripheral IV lines. Hypertonic or concentrated IV solutions are not given rapidly.
3. The following data are obtained by the nurse when assessing a pregnant patient with
eclampsia who is receiving IV magnesium sulfate. Which finding is most important to
report to the health care provider immediately?
a. The bibasilar breath sounds are decreased.
b. The patellar and triceps reflexes are absent.
c. The patient has been sleeping most of the day.
d. The patient reports feeling "sick to my stomach." - Answers - ANS: B The patellar and
triceps reflexes are absent.
The loss of the deep tendon reflexes indicates that the patient's magnesium level may
be reaching toxic levels. Nausea and lethargy also are side effects associated with
,magnesium elevation and should be reported, but they are not as significant as the loss
of deep tendon reflexes. The decreased breath sounds suggest that the patient needs
to cough and deep breathe to prevent atelectasis.
4. The nurse has administered 3% saline to a patient with hyponatremia. Which one of
these assessment data will require the most rapid response by the nurse?
a. The patient's radial pulse is 105 beats/minute.
b. There is sediment and blood in the patient's urine.
c. The blood pressure increases from 120/80 to 142/94.
d. There are crackles audible throughout both lung fields. - Answers - ANS: D There are
crackles audible throughout both lung fields.
Crackles throughout both lungs suggest that the patient may be experiencing pulmonary
edema, a life-threatening adverse effect of hypertonic solutions. The increased pulse
rate and blood pressure and the appearance of the urine also should be reported, but
they are not as dangerous as the presence of fluid in the alveoli.
5. A patient presents to the emergency department with the complaint of vomiting and
diarrhea for the past
48 hours. The nurse anticipates which fluid therapy initially?
a) 0.9% sodium chloride
b) Dextrose 10% in water
c) Dextrose 5% in water
d) 0.45% sodium chloride - Answers - ANS: A
6. Which assessment finding should cause a nurse to question administering a sodium-
containing isotonic
intravenous fluid?
a) Blood pressure 102/58
b) Dry mucous membranes
c) Poor skin turgor
d) Pitting edema - Answers - ANS: D
7. Which of these actions can the nurse who is caring for a critically ill patient with
multiple intravenous (IV) lines delegate to an experienced LPN?
a. Administer IV antibiotics through the implantable port.
b. Monitor the IV sites for redness, swelling, or tenderness.
c. Remove the patient's nontunneled subclavian central venous catheter.
d. Adjust the flow rate of the 0.9% normal saline in the peripheral IV line. - Answers -
ANS: B Monitor the IV sites for redness, swelling, or tenderness.
An experienced LPN has the education, experience, and scope of practice to monitor IV
sites for signs of infection. Administration of medications, adjustment of infusion rates,
and removal of central catheters in critically ill patients require RN level education and
scope of practice.
, 8. A patient who has been hospitalized for 2 days has been receiving normal saline IV
at 100 ml/hr, has a nasogastric tube to low suction, and is NPO. Which assessment
finding by the nurse is the priority to report to the health care provider?
a. Serum sodium level of 138 mEq/L (138 mmol/L)
b. Gradually decreasing level of consciousness (LOC)
c. Oral temperature of 100.1° F with bibasilar lung crackles
d. Weight gain of 2 pounds (1 kg) above the admission weight - Answers - ANS: B
Gradually decreasing level of consciousness (LOC) The patient's history and change in
LOC could be indicative of several fluid and electrolyte disturbances: extracellular fluid
(ECF) excess, ECF deficit, hyponatremia, hypernatremia, hypokalemia, or metabolic
alkalosis. Further diagnostic information will be ordered by the health care provider to
determine the cause of the change in LOC and the appropriate interventions. The
weight gain, elevated temperature, crackles, and serum sodium level also will be
reported, but do not indicate a need for rapid action to avoid complications.
9. When assessing a patient with increased extracellular fluid (ECF) osmolality, the
priority assessment for the nurse to obtain is
a. skin turgor.
b. heart sounds.
c. mental status.
d. capillary refill. - Answers - ANS: C mental status.
Changes in ECF osmolality lead to swelling or shrinking of cells in the central nervous
system, initially causing confusion, which may progress to coma or seizures. Although
skin turgor, capillary refill, and heart sounds also may be affected by ECF osmolality
changes and resultant fluid shifts, these are signs that occur later and do not have as
immediate an impact on patient outcomes.
10. Which assessment finding about a patient who has a serum calcium level of 7.0
mEq/L is most important for the nurse to report to the health care provider?
a. The patient is experiencing laryngeal stridor.
b. The patient complains of generalized fatigue.
c. The patient's bowels have not moved for 4 days.
d. The patient has numbness and tingling of the lips. - Answers - ANS: A The patient is
experiencing laryngeal stridor.
Laryngeal stridor may lead to respiratory arrest and requires rapid action to correct the
patient's calcium level. The other data also are consistent with hypocalcemia, but do not
indicate a need for immediate action.
11. A recently admitted patient has a small cell carcinoma of the lung, which is causing
the syndrome of inappropriate antidiuretic hormone (SIADH). The nurse will monitor
carefully for
a. increased total urinary output.
b. elevation of serum hematocrit.
c. decreased serum sodium level.
d. rapid and unexpected weight loss. - Answers - ANS: C decreased serum sodium
level.
ANSWERS
1. A patient is receiving 3% NaCl solution for correction of hyponatremia. During
administration of the solution, the most important assessment for the nurse to monitor is
a. lung sounds.
b. urinary output.
c. peripheral pulses.
d. peripheral edema. - Answers - ANS: A lung sounds.
Hypertonic solutions cause water retention, so the patient should be monitored for
symptoms of fluid excess. Crackles in the lungs may indicate the onset of pulmonary
edema and are the most serious of the symptoms of fluid excess listed. Bounding
peripheral pulses, peripheral edema, or changes in urine output also are important to
monitor when administering hypertonic solutions, but they do not indicate acute
respiratory or cardiac decompensation.
2. A patient who has an infusion of 50% dextrose prescribed asks the nurse why a
peripherally inserted central catheter must be inserted. Which explanation by the nurse
is correct?
a. The prescribed infusion can be given much more rapidly when the patient has a
central line.
b. There is a decreased risk for infection when 50% dextrose is infused through a
central line.
c. The 50% dextrose is hypertonic and will be more rapidly diluted when given through a
central line.
d. The required blood glucose monitoring is more accurate when samples are obtained
from a central line. - Answers - ANS: C. The 50% dextrose is hypertonic and will be
more rapidly diluted when given through a central line. Shrinkage of red blood cells can
occur when solutions with dextrose concentrations greater than 10% are administered
intravenously. Blood glucose testing is not more accurate when samples are obtained
from a central line. The infection risk is higher with a central catheter than with
peripheral IV lines. Hypertonic or concentrated IV solutions are not given rapidly.
3. The following data are obtained by the nurse when assessing a pregnant patient with
eclampsia who is receiving IV magnesium sulfate. Which finding is most important to
report to the health care provider immediately?
a. The bibasilar breath sounds are decreased.
b. The patellar and triceps reflexes are absent.
c. The patient has been sleeping most of the day.
d. The patient reports feeling "sick to my stomach." - Answers - ANS: B The patellar and
triceps reflexes are absent.
The loss of the deep tendon reflexes indicates that the patient's magnesium level may
be reaching toxic levels. Nausea and lethargy also are side effects associated with
,magnesium elevation and should be reported, but they are not as significant as the loss
of deep tendon reflexes. The decreased breath sounds suggest that the patient needs
to cough and deep breathe to prevent atelectasis.
4. The nurse has administered 3% saline to a patient with hyponatremia. Which one of
these assessment data will require the most rapid response by the nurse?
a. The patient's radial pulse is 105 beats/minute.
b. There is sediment and blood in the patient's urine.
c. The blood pressure increases from 120/80 to 142/94.
d. There are crackles audible throughout both lung fields. - Answers - ANS: D There are
crackles audible throughout both lung fields.
Crackles throughout both lungs suggest that the patient may be experiencing pulmonary
edema, a life-threatening adverse effect of hypertonic solutions. The increased pulse
rate and blood pressure and the appearance of the urine also should be reported, but
they are not as dangerous as the presence of fluid in the alveoli.
5. A patient presents to the emergency department with the complaint of vomiting and
diarrhea for the past
48 hours. The nurse anticipates which fluid therapy initially?
a) 0.9% sodium chloride
b) Dextrose 10% in water
c) Dextrose 5% in water
d) 0.45% sodium chloride - Answers - ANS: A
6. Which assessment finding should cause a nurse to question administering a sodium-
containing isotonic
intravenous fluid?
a) Blood pressure 102/58
b) Dry mucous membranes
c) Poor skin turgor
d) Pitting edema - Answers - ANS: D
7. Which of these actions can the nurse who is caring for a critically ill patient with
multiple intravenous (IV) lines delegate to an experienced LPN?
a. Administer IV antibiotics through the implantable port.
b. Monitor the IV sites for redness, swelling, or tenderness.
c. Remove the patient's nontunneled subclavian central venous catheter.
d. Adjust the flow rate of the 0.9% normal saline in the peripheral IV line. - Answers -
ANS: B Monitor the IV sites for redness, swelling, or tenderness.
An experienced LPN has the education, experience, and scope of practice to monitor IV
sites for signs of infection. Administration of medications, adjustment of infusion rates,
and removal of central catheters in critically ill patients require RN level education and
scope of practice.
, 8. A patient who has been hospitalized for 2 days has been receiving normal saline IV
at 100 ml/hr, has a nasogastric tube to low suction, and is NPO. Which assessment
finding by the nurse is the priority to report to the health care provider?
a. Serum sodium level of 138 mEq/L (138 mmol/L)
b. Gradually decreasing level of consciousness (LOC)
c. Oral temperature of 100.1° F with bibasilar lung crackles
d. Weight gain of 2 pounds (1 kg) above the admission weight - Answers - ANS: B
Gradually decreasing level of consciousness (LOC) The patient's history and change in
LOC could be indicative of several fluid and electrolyte disturbances: extracellular fluid
(ECF) excess, ECF deficit, hyponatremia, hypernatremia, hypokalemia, or metabolic
alkalosis. Further diagnostic information will be ordered by the health care provider to
determine the cause of the change in LOC and the appropriate interventions. The
weight gain, elevated temperature, crackles, and serum sodium level also will be
reported, but do not indicate a need for rapid action to avoid complications.
9. When assessing a patient with increased extracellular fluid (ECF) osmolality, the
priority assessment for the nurse to obtain is
a. skin turgor.
b. heart sounds.
c. mental status.
d. capillary refill. - Answers - ANS: C mental status.
Changes in ECF osmolality lead to swelling or shrinking of cells in the central nervous
system, initially causing confusion, which may progress to coma or seizures. Although
skin turgor, capillary refill, and heart sounds also may be affected by ECF osmolality
changes and resultant fluid shifts, these are signs that occur later and do not have as
immediate an impact on patient outcomes.
10. Which assessment finding about a patient who has a serum calcium level of 7.0
mEq/L is most important for the nurse to report to the health care provider?
a. The patient is experiencing laryngeal stridor.
b. The patient complains of generalized fatigue.
c. The patient's bowels have not moved for 4 days.
d. The patient has numbness and tingling of the lips. - Answers - ANS: A The patient is
experiencing laryngeal stridor.
Laryngeal stridor may lead to respiratory arrest and requires rapid action to correct the
patient's calcium level. The other data also are consistent with hypocalcemia, but do not
indicate a need for immediate action.
11. A recently admitted patient has a small cell carcinoma of the lung, which is causing
the syndrome of inappropriate antidiuretic hormone (SIADH). The nurse will monitor
carefully for
a. increased total urinary output.
b. elevation of serum hematocrit.
c. decreased serum sodium level.
d. rapid and unexpected weight loss. - Answers - ANS: C decreased serum sodium
level.
