NUR 242 EXAM 4: ADVANCED MED-
SURG NURSING (NEUROLOGICAL,
RENAL, AND HEMATOLOGICAL
DISORDERS) QUESTIONS & ANSWERS
100% GUARANTEE PASS
1. A nurse is caring for a patient with a T6 spinal cord injury. The patient reports a sudden,
severe headache and the nurse notes a blood pressure of 190/110 mmHg. What is the priority
nursing action?
A. Place the patient in a sitting position or elevate the head of the bed.
B. Notify the healthcare provider immediately.
C. Administer the prescribed PRN antihypertensive medication.
D. Perform a bladder scan to check for urinary retention.
Answer: A
Conceptual Explanation: The patient is exhibiting signs of Autonomic Dysreflexia. The
first action should be to sit the patient up to lower blood pressure via orthostatic effect,
followed by identifying and removing the noxious stimulus (usually bladder or bowel
distension).
,2. Which clinical manifestation would the nurse anticipate in a patient who has suffered a
right-brain stroke?
A. Aphasia and slow, cautious behavior
B. Right-sided hemiplegia
C. Impulsivity and impaired judgment
D. Anxiety and depression regarding deficits
Answer: C
Conceptual Explanation: Right-brain stroke patients tend to be impulsive, lack judgment,
and have a higher risk for injury. Left-brain strokes typically cause aphasia, cautiousness,
and awareness of deficits.
3. A patient with Chronic Kidney Disease (CKD) has a serum potassium level of 6.8 mEq/L and
ECG changes. Which medication is the most urgent to stabilize the cardiac membrane?
A. Sodium Polystyrene Sulfonate
B. Regular Insulin and D50
C. Calcium Gluconate
D. Sodium Bicarbonate
Answer: C
, Conceptual Explanation: While insulin and Kayexalate help lower potassium, Calcium
Gluconate is used to stabilize the myocardium to prevent lethal arrhythmias in the
presence of severe hyperkalemia.
4. The nurse is monitoring a patient with increased intracranial pressure (ICP). Which set of
vital signs (Cushing’s Triad) indicates brainstem compression?
A. BP 160/60, Pulse 50, irregular respirations
B. BP 90/50, Pulse 120, Rapid shallow respirations
C. BP 120/80, Pulse 80, regular respirations
D. BP 150/100, Pulse 110, Tachypnea
Answer: A
Conceptual Explanation: Cushing’s Triad consists of systolic hypertension with a
widening pulse pressure, bradycardia, and irregular/altered respirations. It is a late sign of
increased ICP.
5. During the oliguric phase of Acute Kidney Injury (AKI), which electrolyte imbalance is the
nurse most likely to observe?
A. Hypokalemia
B. Hypermagnesemia
C. Hypernatremia
D. Hypophosphatemia
SURG NURSING (NEUROLOGICAL,
RENAL, AND HEMATOLOGICAL
DISORDERS) QUESTIONS & ANSWERS
100% GUARANTEE PASS
1. A nurse is caring for a patient with a T6 spinal cord injury. The patient reports a sudden,
severe headache and the nurse notes a blood pressure of 190/110 mmHg. What is the priority
nursing action?
A. Place the patient in a sitting position or elevate the head of the bed.
B. Notify the healthcare provider immediately.
C. Administer the prescribed PRN antihypertensive medication.
D. Perform a bladder scan to check for urinary retention.
Answer: A
Conceptual Explanation: The patient is exhibiting signs of Autonomic Dysreflexia. The
first action should be to sit the patient up to lower blood pressure via orthostatic effect,
followed by identifying and removing the noxious stimulus (usually bladder or bowel
distension).
,2. Which clinical manifestation would the nurse anticipate in a patient who has suffered a
right-brain stroke?
A. Aphasia and slow, cautious behavior
B. Right-sided hemiplegia
C. Impulsivity and impaired judgment
D. Anxiety and depression regarding deficits
Answer: C
Conceptual Explanation: Right-brain stroke patients tend to be impulsive, lack judgment,
and have a higher risk for injury. Left-brain strokes typically cause aphasia, cautiousness,
and awareness of deficits.
3. A patient with Chronic Kidney Disease (CKD) has a serum potassium level of 6.8 mEq/L and
ECG changes. Which medication is the most urgent to stabilize the cardiac membrane?
A. Sodium Polystyrene Sulfonate
B. Regular Insulin and D50
C. Calcium Gluconate
D. Sodium Bicarbonate
Answer: C
, Conceptual Explanation: While insulin and Kayexalate help lower potassium, Calcium
Gluconate is used to stabilize the myocardium to prevent lethal arrhythmias in the
presence of severe hyperkalemia.
4. The nurse is monitoring a patient with increased intracranial pressure (ICP). Which set of
vital signs (Cushing’s Triad) indicates brainstem compression?
A. BP 160/60, Pulse 50, irregular respirations
B. BP 90/50, Pulse 120, Rapid shallow respirations
C. BP 120/80, Pulse 80, regular respirations
D. BP 150/100, Pulse 110, Tachypnea
Answer: A
Conceptual Explanation: Cushing’s Triad consists of systolic hypertension with a
widening pulse pressure, bradycardia, and irregular/altered respirations. It is a late sign of
increased ICP.
5. During the oliguric phase of Acute Kidney Injury (AKI), which electrolyte imbalance is the
nurse most likely to observe?
A. Hypokalemia
B. Hypermagnesemia
C. Hypernatremia
D. Hypophosphatemia
