NUR 170 Exam 4 V2 | NUR 170 Medical-Surgical Nursing | Actual Q&A
with Rationale (NUR 170 Exam 4) | Galen
1. A 54-year-old male patient, Mr. Miller, is admitted to the medical unit with a diagnosis of
Acute Kidney Injury (AKI) following a severe bout of dehydration. The nurse notes that the
patient’s urine output has dropped to 300 mL in the last 24 hours. Which phase of AKI is the
patient currently experiencing, and what is the nurse’s priority assessment?
A. Initiation phase; assess for tachycardia and hypotension.
B. Oliguric phase; assess for fluid volume excess and electrolyte imbalances.
C. Diuretic phase; assess for dehydration and hypokalemia.
D. Recovery phase; assess for improved GFR and BUN levels.
Answer: B
Rationale: The patient is in the oliguric phase because his urine output is less than 400
mL/day. During this phase, the kidneys are unable to excrete waste products or maintain
fluid and electrolyte balance, leading to fluid retention and potential hyperkalemia. The
nurse must prioritize monitoring for symptoms of fluid overload such as crackles in the
lungs, edema, and cardiac arrhythmias related to rising potassium levels.
2. Mrs. Thompson is a 62-year-old patient with Type 2 Diabetes Mellitus who is scheduled for
a CT scan with intravenous contrast to investigate a suspected abdominal mass. The nurse
reviews her medication list and notes she is taking metformin 1000 mg twice daily. What is
the most critical nursing action regarding this medication?
A. Administer the metformin as scheduled to ensure blood glucose remains stable during
the procedure.
B. Increase the dose of metformin for 24 hours prior to the scan to compensate for NPO
status.
C. Hold the metformin for 48 hours before and after the procedure to prevent lactic
acidosis.
D. Switch the patient to subcutaneous insulin immediately and discontinue metformin
permanently.
Answer: C
Rationale: Metformin must be withheld for 48 hours before and after procedures involving
IV contrast dye because the combination increases the risk of contrast-induced
nephropathy and lactic acidosis. If renal function is impaired by the dye, metformin can
accumulate to toxic levels. The nurse should verify renal function through creatinine levels
before the patient resumes metformin therapy.
,3. Mr. Rodriguez, a 48-year-old patient with Chronic Kidney Disease (CKD) Stage 4, presents
to the clinic with a potassium level of 6.2 mEq/L. The nurse is preparing to administer sodium
polystyrene sulfonate (Kayexalate). Which assessment finding would require the nurse to
hold the medication and notify the provider?
A. Hyperactive bowel sounds in all four quadrants.
B. A serum sodium level of 136 mEq/L.
C. A blood pressure reading of 150/90 mmHg.
D. Absence of bowel sounds or signs of a paralytic ileus.
Answer: D
Rationale: Sodium polystyrene sulfonate (Kayexalate) works in the bowel to exchange
sodium for potassium ions, which are then excreted in the feces. If the patient has an ileus
or absent bowel sounds, the medication will not be excreted, increasing the risk of bowel
necrosis. The nurse must ensure the gastrointestinal tract is functioning before
administration to prevent life-threatening complications.
4. A 28-year-old female, Ms. Carter, is admitted to the ICU with Diabetic Ketoacidosis (DKA).
Her initial lab results show a blood glucose of 550 mg/dL, arterial pH of 7.15, and positive
ketones in the urine. The nurse has started a continuous regular insulin infusion. What is the
nurse’s priority when the blood glucose reaches 250 mg/dL?
A. Discontinue the insulin infusion and switch to subcutaneous glargine.
B. Increase the insulin infusion rate to clear the remaining ketones.
C. Administer 15 grams of simple carbohydrates orally to the patient.
D. Add 5% dextrose to the intravenous fluids to prevent hypoglycemia.
Answer: D
Rationale: When blood glucose levels drop to approximately 250 mg/dL during the
treatment of DKA, dextrose is added to the IV fluids to prevent a rapid drop in glucose and
subsequent cerebral edema. The insulin infusion continues to resolve the acidosis and
suppress ketone production even as glucose levels normalize. This transition ensures a
controlled decline in serum osmolality and maintains patient safety.
5. Mr. Henderson is post-operative day 1 following a total thyroidectomy for Grave’s Disease.
During the morning assessment, the nurse notes that the patient is complaining of tingling
around his mouth and in his fingertips. Which action should the nurse take first?
A. Check the patient’s temperature to rule out a thyroid storm.
B. Assess for Trousseau’s sign and Chvostek’s sign.
C. Administer the scheduled dose of levothyroxine.
D. Encourage the patient to cough and deep breathe to improve oxygenation.
, Answer: B
Rationale: Paresthesia (tingling) around the mouth and fingertips is an early sign of
hypocalcemia, which can occur if the parathyroid glands are accidentally damaged or
removed during a thyroidectomy. Trousseau’s sign (carpal spasm with BP cuff inflation)
and Chvostek’s sign (facial twitching) are clinical indicators of neuromuscular irritability
due to low calcium. The nurse must identify these signs quickly to prevent laryngospasm
and seizures.
6. A patient with End-Stage Renal Disease (ESRD) is receiving hemodialysis through a left
arteriovenous (AV) fistula. Which nursing action is appropriate for the care of this patient?
A. Take blood pressure readings on the left arm to ensure accuracy of the fistula flow.
B. Apply a tight pressure dressing to the site after each dialysis treatment.
C. Use the AV fistula for routine intravenous fluid administration and lab draws.
D. Palpate for a thrill and auscultate for a bruit over the fistula site every shift.
Answer: D
Rationale: Assessing for a thrill (palpable vibration) and a bruit (audible rushing sound)
confirms the patency of the AV fistula. The extremity with the fistula should never be used
for blood pressures, venipuncture, or IV access to prevent thrombosis or damage to the
vessel. Maintaining the integrity of this access is vital for the patient’s long-term survival on
dialysis.
7. Mrs. Bennett, a 70-year-old patient with Chronic Kidney Disease, is prescribed Epoetin alfa
(Epogen) injections. What is the primary therapeutic goal of this medication?
A. To lower serum potassium levels by increasing renal excretion.
B. To stimulate the production of red blood cells and treat anemia.
C. To bind phosphate in the gastrointestinal tract and prevent bone disease.
D. To increase the glomerular filtration rate and improve kidney function.
Answer: B
Rationale: In CKD, the kidneys fail to produce adequate amounts of erythropoietin, the
hormone responsible for stimulating RBC production in the bone marrow. Epoetin alfa is a
synthetic version of this hormone used to manage the chronic anemia associated with renal
failure. Successful therapy is measured by an increase in hemoglobin and hematocrit levels,
reducing the need for blood transfusions.
8. A nurse is providing discharge instructions to a patient newly diagnosed with Addison’s
disease. Which statement by the patient indicates a need for further teaching regarding their
corticosteroid replacement therapy?
A. I will need to carry a medical alert identification at all times.
with Rationale (NUR 170 Exam 4) | Galen
1. A 54-year-old male patient, Mr. Miller, is admitted to the medical unit with a diagnosis of
Acute Kidney Injury (AKI) following a severe bout of dehydration. The nurse notes that the
patient’s urine output has dropped to 300 mL in the last 24 hours. Which phase of AKI is the
patient currently experiencing, and what is the nurse’s priority assessment?
A. Initiation phase; assess for tachycardia and hypotension.
B. Oliguric phase; assess for fluid volume excess and electrolyte imbalances.
C. Diuretic phase; assess for dehydration and hypokalemia.
D. Recovery phase; assess for improved GFR and BUN levels.
Answer: B
Rationale: The patient is in the oliguric phase because his urine output is less than 400
mL/day. During this phase, the kidneys are unable to excrete waste products or maintain
fluid and electrolyte balance, leading to fluid retention and potential hyperkalemia. The
nurse must prioritize monitoring for symptoms of fluid overload such as crackles in the
lungs, edema, and cardiac arrhythmias related to rising potassium levels.
2. Mrs. Thompson is a 62-year-old patient with Type 2 Diabetes Mellitus who is scheduled for
a CT scan with intravenous contrast to investigate a suspected abdominal mass. The nurse
reviews her medication list and notes she is taking metformin 1000 mg twice daily. What is
the most critical nursing action regarding this medication?
A. Administer the metformin as scheduled to ensure blood glucose remains stable during
the procedure.
B. Increase the dose of metformin for 24 hours prior to the scan to compensate for NPO
status.
C. Hold the metformin for 48 hours before and after the procedure to prevent lactic
acidosis.
D. Switch the patient to subcutaneous insulin immediately and discontinue metformin
permanently.
Answer: C
Rationale: Metformin must be withheld for 48 hours before and after procedures involving
IV contrast dye because the combination increases the risk of contrast-induced
nephropathy and lactic acidosis. If renal function is impaired by the dye, metformin can
accumulate to toxic levels. The nurse should verify renal function through creatinine levels
before the patient resumes metformin therapy.
,3. Mr. Rodriguez, a 48-year-old patient with Chronic Kidney Disease (CKD) Stage 4, presents
to the clinic with a potassium level of 6.2 mEq/L. The nurse is preparing to administer sodium
polystyrene sulfonate (Kayexalate). Which assessment finding would require the nurse to
hold the medication and notify the provider?
A. Hyperactive bowel sounds in all four quadrants.
B. A serum sodium level of 136 mEq/L.
C. A blood pressure reading of 150/90 mmHg.
D. Absence of bowel sounds or signs of a paralytic ileus.
Answer: D
Rationale: Sodium polystyrene sulfonate (Kayexalate) works in the bowel to exchange
sodium for potassium ions, which are then excreted in the feces. If the patient has an ileus
or absent bowel sounds, the medication will not be excreted, increasing the risk of bowel
necrosis. The nurse must ensure the gastrointestinal tract is functioning before
administration to prevent life-threatening complications.
4. A 28-year-old female, Ms. Carter, is admitted to the ICU with Diabetic Ketoacidosis (DKA).
Her initial lab results show a blood glucose of 550 mg/dL, arterial pH of 7.15, and positive
ketones in the urine. The nurse has started a continuous regular insulin infusion. What is the
nurse’s priority when the blood glucose reaches 250 mg/dL?
A. Discontinue the insulin infusion and switch to subcutaneous glargine.
B. Increase the insulin infusion rate to clear the remaining ketones.
C. Administer 15 grams of simple carbohydrates orally to the patient.
D. Add 5% dextrose to the intravenous fluids to prevent hypoglycemia.
Answer: D
Rationale: When blood glucose levels drop to approximately 250 mg/dL during the
treatment of DKA, dextrose is added to the IV fluids to prevent a rapid drop in glucose and
subsequent cerebral edema. The insulin infusion continues to resolve the acidosis and
suppress ketone production even as glucose levels normalize. This transition ensures a
controlled decline in serum osmolality and maintains patient safety.
5. Mr. Henderson is post-operative day 1 following a total thyroidectomy for Grave’s Disease.
During the morning assessment, the nurse notes that the patient is complaining of tingling
around his mouth and in his fingertips. Which action should the nurse take first?
A. Check the patient’s temperature to rule out a thyroid storm.
B. Assess for Trousseau’s sign and Chvostek’s sign.
C. Administer the scheduled dose of levothyroxine.
D. Encourage the patient to cough and deep breathe to improve oxygenation.
, Answer: B
Rationale: Paresthesia (tingling) around the mouth and fingertips is an early sign of
hypocalcemia, which can occur if the parathyroid glands are accidentally damaged or
removed during a thyroidectomy. Trousseau’s sign (carpal spasm with BP cuff inflation)
and Chvostek’s sign (facial twitching) are clinical indicators of neuromuscular irritability
due to low calcium. The nurse must identify these signs quickly to prevent laryngospasm
and seizures.
6. A patient with End-Stage Renal Disease (ESRD) is receiving hemodialysis through a left
arteriovenous (AV) fistula. Which nursing action is appropriate for the care of this patient?
A. Take blood pressure readings on the left arm to ensure accuracy of the fistula flow.
B. Apply a tight pressure dressing to the site after each dialysis treatment.
C. Use the AV fistula for routine intravenous fluid administration and lab draws.
D. Palpate for a thrill and auscultate for a bruit over the fistula site every shift.
Answer: D
Rationale: Assessing for a thrill (palpable vibration) and a bruit (audible rushing sound)
confirms the patency of the AV fistula. The extremity with the fistula should never be used
for blood pressures, venipuncture, or IV access to prevent thrombosis or damage to the
vessel. Maintaining the integrity of this access is vital for the patient’s long-term survival on
dialysis.
7. Mrs. Bennett, a 70-year-old patient with Chronic Kidney Disease, is prescribed Epoetin alfa
(Epogen) injections. What is the primary therapeutic goal of this medication?
A. To lower serum potassium levels by increasing renal excretion.
B. To stimulate the production of red blood cells and treat anemia.
C. To bind phosphate in the gastrointestinal tract and prevent bone disease.
D. To increase the glomerular filtration rate and improve kidney function.
Answer: B
Rationale: In CKD, the kidneys fail to produce adequate amounts of erythropoietin, the
hormone responsible for stimulating RBC production in the bone marrow. Epoetin alfa is a
synthetic version of this hormone used to manage the chronic anemia associated with renal
failure. Successful therapy is measured by an increase in hemoglobin and hematocrit levels,
reducing the need for blood transfusions.
8. A nurse is providing discharge instructions to a patient newly diagnosed with Addison’s
disease. Which statement by the patient indicates a need for further teaching regarding their
corticosteroid replacement therapy?
A. I will need to carry a medical alert identification at all times.
