NSG223/NSG 223 Exam 4 V2 | Medical-
Surgical Nursing II Q&A with Rationale |
Herzing University
1. A patient with acute kidney injury (AKI) is in the oliguric phase. Which clinical
manifestation should the nurse expect to find during the assessment?
A. Increased serum creatinine and BUN levels
B. Urine output of 2 liters per day
C. Hypokalemia and metabolic alkalosis
D. Improved glomerular filtration rate
Correct Answer: A
Rationale: During the oliguric phase of AKI, the kidneys are unable to effectively filter
metabolic waste products. This leads to an accumulation of nitrogenous wastes, resulting in
elevated serum creatinine and blood urea nitrogen (BUN) levels. The nurse must also
monitor for hyperkalemia and fluid volume excess during this critical stage.
2. The nurse is caring for a patient with liver cirrhosis who has developed hepatic
encephalopathy. Which medication should the nurse anticipate administering to reduce
serum ammonia levels?
A. Spironolactone
B. Propranolol
,C. Lactulose
D. Vitamin K
Correct Answer: C
Rationale: Lactulose is a disaccharide that acts as an osmotic laxative to promote the
excretion of ammonia through the stool. It creates an acidic environment in the bowel that
converts ammonia into ammonium, which is poorly absorbed. The nurse must monitor the
patient for frequent bowel movements as this indicates the medication is achieving its
therapeutic goal.
3. A patient is admitted to the emergency department with a suspected spinal cord injury at
the C4 level. What is the priority nursing assessment?
A. Assessment of deep tendon reflexes
B. Evaluation of respiratory effort and rate
C. Monitoring for signs of neurogenic shock
D. Assessment of bowel sounds
Correct Answer: B
Rationale: Injuries at or above the C4 level affect the phrenic nerve, which controls the
diaphragm and respiratory function. The priority for the nurse is to maintain a patent
airway and monitor for respiratory failure or insufficiency. While neurogenic shock is a
concern, immediate airway and breathing management takes precedence in the initial
trauma phase.
, 4. The nurse observes a patient with a head injury exhibiting ‘Cushing’s Triad.’ Which set of
vital signs is consistent with this finding?
A. Tachycardia, hypotension, and tachypnea
B. Tachycardia, hypertension, and Cheyne-Stokes respirations
C. Bradycardia, hypotension, and bradypnea
D. Bradycardia, widened pulse pressure, and irregular respirations
Correct Answer: D
Rationale: Cushing’s Triad is a late sign of increased intracranial pressure (ICP) indicating
brainstem compression. It is characterized by a decrease in heart rate, an increase in
systolic blood pressure with a widening pulse pressure, and altered respiratory patterns.
Prompt recognition is vital as it signifies a medical emergency requiring immediate
intervention to prevent brain herniation.
5. A patient with Chronic Kidney Disease (CKD) is scheduled for hemodialysis. Which
assessment finding requires immediate intervention by the nurse before the procedure?
A. Serum potassium level of 5.2 mEq/L
B. Absence of a thrill or bruit over the AV fistula
C. Weight gain of 2 kg since the last session
D. Blood pressure of 150/90 mmHg
Correct Answer: B
Surgical Nursing II Q&A with Rationale |
Herzing University
1. A patient with acute kidney injury (AKI) is in the oliguric phase. Which clinical
manifestation should the nurse expect to find during the assessment?
A. Increased serum creatinine and BUN levels
B. Urine output of 2 liters per day
C. Hypokalemia and metabolic alkalosis
D. Improved glomerular filtration rate
Correct Answer: A
Rationale: During the oliguric phase of AKI, the kidneys are unable to effectively filter
metabolic waste products. This leads to an accumulation of nitrogenous wastes, resulting in
elevated serum creatinine and blood urea nitrogen (BUN) levels. The nurse must also
monitor for hyperkalemia and fluid volume excess during this critical stage.
2. The nurse is caring for a patient with liver cirrhosis who has developed hepatic
encephalopathy. Which medication should the nurse anticipate administering to reduce
serum ammonia levels?
A. Spironolactone
B. Propranolol
,C. Lactulose
D. Vitamin K
Correct Answer: C
Rationale: Lactulose is a disaccharide that acts as an osmotic laxative to promote the
excretion of ammonia through the stool. It creates an acidic environment in the bowel that
converts ammonia into ammonium, which is poorly absorbed. The nurse must monitor the
patient for frequent bowel movements as this indicates the medication is achieving its
therapeutic goal.
3. A patient is admitted to the emergency department with a suspected spinal cord injury at
the C4 level. What is the priority nursing assessment?
A. Assessment of deep tendon reflexes
B. Evaluation of respiratory effort and rate
C. Monitoring for signs of neurogenic shock
D. Assessment of bowel sounds
Correct Answer: B
Rationale: Injuries at or above the C4 level affect the phrenic nerve, which controls the
diaphragm and respiratory function. The priority for the nurse is to maintain a patent
airway and monitor for respiratory failure or insufficiency. While neurogenic shock is a
concern, immediate airway and breathing management takes precedence in the initial
trauma phase.
, 4. The nurse observes a patient with a head injury exhibiting ‘Cushing’s Triad.’ Which set of
vital signs is consistent with this finding?
A. Tachycardia, hypotension, and tachypnea
B. Tachycardia, hypertension, and Cheyne-Stokes respirations
C. Bradycardia, hypotension, and bradypnea
D. Bradycardia, widened pulse pressure, and irregular respirations
Correct Answer: D
Rationale: Cushing’s Triad is a late sign of increased intracranial pressure (ICP) indicating
brainstem compression. It is characterized by a decrease in heart rate, an increase in
systolic blood pressure with a widening pulse pressure, and altered respiratory patterns.
Prompt recognition is vital as it signifies a medical emergency requiring immediate
intervention to prevent brain herniation.
5. A patient with Chronic Kidney Disease (CKD) is scheduled for hemodialysis. Which
assessment finding requires immediate intervention by the nurse before the procedure?
A. Serum potassium level of 5.2 mEq/L
B. Absence of a thrill or bruit over the AV fistula
C. Weight gain of 2 kg since the last session
D. Blood pressure of 150/90 mmHg
Correct Answer: B
