NURS 201; Medical Surgical Theory –
General Questions and Answers
The nurse is caring for a client with deficient fluid volume caused by a massive burn injury.
Which of the following assessment data will be of greatest concern to the nurse?
A. Blood pressure is 90/40 mm Hg.
B. Urine output is 30 mL over the last hour.
C. Oral fluid intake is 100 mL for the last 8 hours.
D. There is prolonged skin tenting over the sternum. - <CORRECT ANSWER >>ANS: A
The blood pressure indicates that the client may be developing hypovolemic shock as a result of
fluid loss.
The nurse is caring for a client recently admitted with small cell carcinoma of the lung and the
syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following assessments
should the nurse carefully monitor?
A. Increased total urinary output.
B. Elevation of serum hematocrit
C. Decreased serum sodium level
D. Rapid and unexpected weight loss - <CORRECT ANSWER >>ANS: C
SIADH causes water retention and hyponatremia—a decrease in serum sodium level.
The nurse is teaching a client about spironolactone as a diuretic. Which statement by the client
indicates that the teaching about this medication has been effective?
,A. "I will try to drink at least 8 glasses of water every day."
B. "I will use a salt substitute to decrease my sodium intake."
C. "I will increase my intake of potassium-containing foods."
D. "I will drink apple juice instead of orange juice for breakfast." - <CORRECT ANSWER >>ANS: D
Since spironolactone is a potassium-sparing diuretic, clients should be taught to choose low
potassium foods such as apple juice rather than foods that have higher levels of potassium,
such as citrus fruits. Because the client is using spironolactone as a diuretic, the nurse would
not encourage the client to increase fluid intake. Teach clients to avoid salt substitutes, which
are high in potassium.
The nurse is caring for a client admitted with hyponatremia. Which of the following actions
should the nurse anticipate implementing?
A. Restrict client's oral free water intake.
B. Avoid use of electrolyte-containing drinks.
C. Infuse a solution of 5% dextrose in 0.45% saline.
D. Administer vasopressin (antidiuretic hormone, ADH). - <CORRECT ANSWER >>ANS: A
To help improve serum sodium levels, water intake is restricted.
The nurse is caring for a client with severe hypokalemia and is preparing to administer
intravenous potassium chloride (KCl) 40 mmol as prescribed by the health care provider. Which
of the following actions should the nurse take?
A. Administer the KCl as a rapid IV bolus.
B. Infuse the KCl at a rate of 20 mEq/hour.
C. Give the KCl only through a central venous line.
A. Add no more than 40 mEq/L to a litre of IV fluid. - <CORRECT ANSWER >>ANS: B
, Intravenous KCl is administered at a maximal rate of 20 mEq/hour. Rapid IV infusion of KCl can
cause cardiac arrest.
The nurse is caring for a client who has required prolonged mechanical ventilation and has the
following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25
mmol/L. Which of the following interpretations would the nurse document?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis - <CORRECT ANSWER >>ANS: D
The pH indicates that the client has alkalosis and the low PaCO2 indicates a respiratory cause.
The other responses are incorrect based on the pH and the normal HCO3.
The nurse is caring for a client who was admitted with diabetic ketoacidosis and has rapid, deep
respirations. Which of the following actions should the nurse implement?
A. Notify the client's health care provider.
B. Give the prescribed PRN lorazepam.
C. Start the prescribed PRN oxygen at 2-4 L/min.
D. Encourage the client to take deep, slow breaths. - <CORRECT ANSWER >>ANS: A
The rapid, deep (Kussmaul's) respirations indicate a metabolic acidosis and the need for actions
such as administration of sodium bicarbonate, which will require a prescription by the health
care provider
The nurse is caring for a client with hypercalcemia. Which of the following actions would be
included in the client's nursing care plan?
General Questions and Answers
The nurse is caring for a client with deficient fluid volume caused by a massive burn injury.
Which of the following assessment data will be of greatest concern to the nurse?
A. Blood pressure is 90/40 mm Hg.
B. Urine output is 30 mL over the last hour.
C. Oral fluid intake is 100 mL for the last 8 hours.
D. There is prolonged skin tenting over the sternum. - <CORRECT ANSWER >>ANS: A
The blood pressure indicates that the client may be developing hypovolemic shock as a result of
fluid loss.
The nurse is caring for a client recently admitted with small cell carcinoma of the lung and the
syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following assessments
should the nurse carefully monitor?
A. Increased total urinary output.
B. Elevation of serum hematocrit
C. Decreased serum sodium level
D. Rapid and unexpected weight loss - <CORRECT ANSWER >>ANS: C
SIADH causes water retention and hyponatremia—a decrease in serum sodium level.
The nurse is teaching a client about spironolactone as a diuretic. Which statement by the client
indicates that the teaching about this medication has been effective?
,A. "I will try to drink at least 8 glasses of water every day."
B. "I will use a salt substitute to decrease my sodium intake."
C. "I will increase my intake of potassium-containing foods."
D. "I will drink apple juice instead of orange juice for breakfast." - <CORRECT ANSWER >>ANS: D
Since spironolactone is a potassium-sparing diuretic, clients should be taught to choose low
potassium foods such as apple juice rather than foods that have higher levels of potassium,
such as citrus fruits. Because the client is using spironolactone as a diuretic, the nurse would
not encourage the client to increase fluid intake. Teach clients to avoid salt substitutes, which
are high in potassium.
The nurse is caring for a client admitted with hyponatremia. Which of the following actions
should the nurse anticipate implementing?
A. Restrict client's oral free water intake.
B. Avoid use of electrolyte-containing drinks.
C. Infuse a solution of 5% dextrose in 0.45% saline.
D. Administer vasopressin (antidiuretic hormone, ADH). - <CORRECT ANSWER >>ANS: A
To help improve serum sodium levels, water intake is restricted.
The nurse is caring for a client with severe hypokalemia and is preparing to administer
intravenous potassium chloride (KCl) 40 mmol as prescribed by the health care provider. Which
of the following actions should the nurse take?
A. Administer the KCl as a rapid IV bolus.
B. Infuse the KCl at a rate of 20 mEq/hour.
C. Give the KCl only through a central venous line.
A. Add no more than 40 mEq/L to a litre of IV fluid. - <CORRECT ANSWER >>ANS: B
, Intravenous KCl is administered at a maximal rate of 20 mEq/hour. Rapid IV infusion of KCl can
cause cardiac arrest.
The nurse is caring for a client who has required prolonged mechanical ventilation and has the
following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25
mmol/L. Which of the following interpretations would the nurse document?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis - <CORRECT ANSWER >>ANS: D
The pH indicates that the client has alkalosis and the low PaCO2 indicates a respiratory cause.
The other responses are incorrect based on the pH and the normal HCO3.
The nurse is caring for a client who was admitted with diabetic ketoacidosis and has rapid, deep
respirations. Which of the following actions should the nurse implement?
A. Notify the client's health care provider.
B. Give the prescribed PRN lorazepam.
C. Start the prescribed PRN oxygen at 2-4 L/min.
D. Encourage the client to take deep, slow breaths. - <CORRECT ANSWER >>ANS: A
The rapid, deep (Kussmaul's) respirations indicate a metabolic acidosis and the need for actions
such as administration of sodium bicarbonate, which will require a prescription by the health
care provider
The nurse is caring for a client with hypercalcemia. Which of the following actions would be
included in the client's nursing care plan?
