Medical-Surgical Nursing
11th Edition
Author(s)Donna D. Ignatavicius;
Cherie R. Rebar; Nicole M.
Heimgartner
Publisher Published by Elsevier
UK Copyright© 2024
Print ISBN: 9780323878265
TEST BANK
Exam Revision Question Bank
,Chapter: Fluid, Electrolyte, and Acid–Base Balance
Topic: Fluid & Electrolyte Imbalances and Acid–Base Disorders
Subtopics:
Fluid volume deficit & excess
Sodium, potassium, calcium imbalances
Acid–base disorders (ABGs)
IV fluid therapy
Nursing assessment & interventions
Patient safety and monitoring
Difficulty: Mixed
Question Distribution:
MCQ: 8
SATA: 5
NGN Case Study: 3
Bow-Tie: 2
Matrix/Grid: 2
Question 1 (MCQ)
Clinical Scenario:
A 72-year-old patient with vomiting and diarrhea for 3 days is
admitted. Vital signs: BP 88/54 mmHg, HR 118 bpm, dry
mucous membranes, decreased urine output.
,Question Stem:
Which finding is the nurse’s priority concern?
Options:
A. Dry mucous membranes
B. Hypotension
C. Tachycardia
D. Decreased urine output
Correct Answer:
B. Hypotension
Rationale:
Hypotension indicates significant intravascular volume
depletion and compromised perfusion, making it the highest
priority.
Incorrect Option Analysis:
A: Expected in dehydration but not immediately life-
threatening
C: Compensatory response
D: Important but secondary to perfusion
Nursing Process: Assessment
NCJMM: Recognize Cues, Prioritize Hypotheses
Difficulty: Moderate
Bloom’s Level: Analyze
NCLEX Category: Physiological Adaptation
Learning Objective: Prioritize signs of hypovolemia
, Question 2 (SATA)
Clinical Scenario:
A patient is diagnosed with hyperkalemia (K⁺ 6.2 mEq/L).
Question Stem:
Which interventions should the nurse anticipate? (Select all
that apply)
Options:
A. Administer IV calcium gluconate
B. Provide potassium supplements
C. Administer insulin with glucose
D. Initiate cardiac monitoring
E. Encourage high-potassium foods
Correct Answer:
A, C, D
Rationale:
Calcium stabilizes cardiac membranes
Insulin shifts potassium intracellularly
Cardiac monitoring prevents dysrhythmias
Incorrect Analysis:
B: Worsens hyperkalemia
E: Increases potassium further
11th Edition
Author(s)Donna D. Ignatavicius;
Cherie R. Rebar; Nicole M.
Heimgartner
Publisher Published by Elsevier
UK Copyright© 2024
Print ISBN: 9780323878265
TEST BANK
Exam Revision Question Bank
,Chapter: Fluid, Electrolyte, and Acid–Base Balance
Topic: Fluid & Electrolyte Imbalances and Acid–Base Disorders
Subtopics:
Fluid volume deficit & excess
Sodium, potassium, calcium imbalances
Acid–base disorders (ABGs)
IV fluid therapy
Nursing assessment & interventions
Patient safety and monitoring
Difficulty: Mixed
Question Distribution:
MCQ: 8
SATA: 5
NGN Case Study: 3
Bow-Tie: 2
Matrix/Grid: 2
Question 1 (MCQ)
Clinical Scenario:
A 72-year-old patient with vomiting and diarrhea for 3 days is
admitted. Vital signs: BP 88/54 mmHg, HR 118 bpm, dry
mucous membranes, decreased urine output.
,Question Stem:
Which finding is the nurse’s priority concern?
Options:
A. Dry mucous membranes
B. Hypotension
C. Tachycardia
D. Decreased urine output
Correct Answer:
B. Hypotension
Rationale:
Hypotension indicates significant intravascular volume
depletion and compromised perfusion, making it the highest
priority.
Incorrect Option Analysis:
A: Expected in dehydration but not immediately life-
threatening
C: Compensatory response
D: Important but secondary to perfusion
Nursing Process: Assessment
NCJMM: Recognize Cues, Prioritize Hypotheses
Difficulty: Moderate
Bloom’s Level: Analyze
NCLEX Category: Physiological Adaptation
Learning Objective: Prioritize signs of hypovolemia
, Question 2 (SATA)
Clinical Scenario:
A patient is diagnosed with hyperkalemia (K⁺ 6.2 mEq/L).
Question Stem:
Which interventions should the nurse anticipate? (Select all
that apply)
Options:
A. Administer IV calcium gluconate
B. Provide potassium supplements
C. Administer insulin with glucose
D. Initiate cardiac monitoring
E. Encourage high-potassium foods
Correct Answer:
A, C, D
Rationale:
Calcium stabilizes cardiac membranes
Insulin shifts potassium intracellularly
Cardiac monitoring prevents dysrhythmias
Incorrect Analysis:
B: Worsens hyperkalemia
E: Increases potassium further
