NSG430 Exam 2 V2 | NSG 430 Adult Health
Nursing II | Grand Canyon University
1. A nurse is caring for a patient with Chronic Kidney Disease (CKD) whose GFR has dropped
to 14 mL/min. Which stage of CKD is this patient experiencing?
A. Stage 2
B. Stage 3
C. Stage 5
D. Stage 4
Answer: C
Rationale: Stage 5 CKD, also known as end-stage renal disease (ESRD), is defined by a GFR
less than 15 mL/min. At this stage, the kidneys have lost nearly all ability to function
effectively. Renal replacement therapy, such as dialysis or transplant, is necessary for
survival.
2. Which clinical manifestation should the nurse prioritize when assessing a patient in the
oliguric phase of Acute Kidney Injury (AKI)?
A. Hypokalemia
B. Fluid volume excess
C. Metabolic alkalosis
,D. Hypouricemia
Answer: B
Rationale: During the oliguric phase of AKI, urine output decreases significantly, leading to
fluid retention. The nurse must prioritize assessment for fluid volume excess, which can
manifest as edema, hypertension, and pulmonary crackles. This phase often requires strict
fluid restriction and monitoring of intake and output.
3. A patient with an arteriovenous (AV) fistula in the left arm is admitted. Which action by the
nurse is appropriate?
A. Taking the blood pressure on the left arm
B. Palpating for a thrill over the fistula site
C. Drawing blood from the left cephalic vein
D. Checking the radial pulse on the right arm only
Answer: B
Rationale: Assessment of a patent AV fistula includes palpating for a thrill and auscultating
for a bruit. The nurse must never take blood pressure or perform venipunctures on the
affected arm to prevent thrombosis or damage. Ensuring the site is functional is a critical
nursing responsibility for dialysis patients.
4. While performing peritoneal dialysis, the nurse notices that the outflow drainage is cloudy.
What is the most likely cause of this finding?
A. Normal fibrin presence
, B. Peritonitis
C. High protein intake
D. Bladder perforation
Answer: B
Rationale: Cloudy or opaque dialysate outflow is the earliest sign of peritonitis, a serious
complication of peritoneal dialysis. The nurse should also assess for abdominal pain,
rebound tenderness, and fever. Immediate culture and sensitivity of the fluid are required
to initiate appropriate antibiotic therapy.
5. Which medication should the nurse expect to administer to a patient with hyperkalemia
and peaked T-waves?
A. Lisinopril
B. Spironolactone
C. Furosemide
D. Calcium Gluconate
Answer: D
Rationale: Calcium gluconate is administered intravenously to stabilize the myocardial cell
membrane in the presence of hyperkalemia. While it does not lower the potassium level, it
prevents life-threatening arrhythmias. Other treatments like insulin with dextrose or
sodium polystyrene sulfonate are used subsequently to actually reduce potassium levels.
Nursing II | Grand Canyon University
1. A nurse is caring for a patient with Chronic Kidney Disease (CKD) whose GFR has dropped
to 14 mL/min. Which stage of CKD is this patient experiencing?
A. Stage 2
B. Stage 3
C. Stage 5
D. Stage 4
Answer: C
Rationale: Stage 5 CKD, also known as end-stage renal disease (ESRD), is defined by a GFR
less than 15 mL/min. At this stage, the kidneys have lost nearly all ability to function
effectively. Renal replacement therapy, such as dialysis or transplant, is necessary for
survival.
2. Which clinical manifestation should the nurse prioritize when assessing a patient in the
oliguric phase of Acute Kidney Injury (AKI)?
A. Hypokalemia
B. Fluid volume excess
C. Metabolic alkalosis
,D. Hypouricemia
Answer: B
Rationale: During the oliguric phase of AKI, urine output decreases significantly, leading to
fluid retention. The nurse must prioritize assessment for fluid volume excess, which can
manifest as edema, hypertension, and pulmonary crackles. This phase often requires strict
fluid restriction and monitoring of intake and output.
3. A patient with an arteriovenous (AV) fistula in the left arm is admitted. Which action by the
nurse is appropriate?
A. Taking the blood pressure on the left arm
B. Palpating for a thrill over the fistula site
C. Drawing blood from the left cephalic vein
D. Checking the radial pulse on the right arm only
Answer: B
Rationale: Assessment of a patent AV fistula includes palpating for a thrill and auscultating
for a bruit. The nurse must never take blood pressure or perform venipunctures on the
affected arm to prevent thrombosis or damage. Ensuring the site is functional is a critical
nursing responsibility for dialysis patients.
4. While performing peritoneal dialysis, the nurse notices that the outflow drainage is cloudy.
What is the most likely cause of this finding?
A. Normal fibrin presence
, B. Peritonitis
C. High protein intake
D. Bladder perforation
Answer: B
Rationale: Cloudy or opaque dialysate outflow is the earliest sign of peritonitis, a serious
complication of peritoneal dialysis. The nurse should also assess for abdominal pain,
rebound tenderness, and fever. Immediate culture and sensitivity of the fluid are required
to initiate appropriate antibiotic therapy.
5. Which medication should the nurse expect to administer to a patient with hyperkalemia
and peaked T-waves?
A. Lisinopril
B. Spironolactone
C. Furosemide
D. Calcium Gluconate
Answer: D
Rationale: Calcium gluconate is administered intravenously to stabilize the myocardial cell
membrane in the presence of hyperkalemia. While it does not lower the potassium level, it
prevents life-threatening arrhythmias. Other treatments like insulin with dextrose or
sodium polystyrene sulfonate are used subsequently to actually reduce potassium levels.
