NURS 201 Quiz 4 V2 | NURS 201 Medical
Surgical Nursing | Actual Q&A with
Rationale (NURS201 Quiz 4) | West Coast
University
1. A patient with chronic kidney disease (CKD) has a serum potassium level of 6.8 mEq/L.
Which prescribed intervention should the nurse implement first?
A. Administer sodium polystyrene sulfonate (Kayexalate) orally.
B. Obtain a 12-lead electrocardiogram (ECG).
C. Place the patient on a cardiac monitor.
D. Administer intravenous regular insulin and 50% dextrose.
Answer: D
Rationale: The administration of intravenous insulin and dextrose is the fastest way to
shift potassium from the extracellular fluid into the cells. This is a critical intervention for
severe hyperkalemia to prevent life-threatening arrhythmias. While cardiac monitoring is
essential, providing the medication to lower the potassium level directly addresses the
metabolic emergency.
2. Which clinical manifestation should the nurse expect to find in a patient during the oliguric
phase of acute kidney injury (AKI)?
A. A urine specific gravity fixed at 1.010.
,B. Hypokalemia and hypotension.
C. Metabolic alkalosis.
D. Urine output of 600 mL per day.
Answer: A
Rationale: During the oliguric phase, the kidneys lose the ability to concentrate urine,
leading to a fixed specific gravity of 1.010, which matches the plasma osmolarity. Patients
in this phase typically experience fluid volume excess, metabolic acidosis, and
hyperkalemia. Urine output is generally less than 400 mL/day during this specific stage of
AKI.
3. A nurse is caring for a patient who just returned from a hemodialysis session. The patient
reports a headache, nausea, and appears restless. What is the nurse’s priority action?
A. Notify the healthcare provider of suspected dialysis disequilibrium syndrome.
B. Administer a prescribed PRN analgesic for the headache.
C. Increase the rate of the patient’s intravenous maintenance fluids.
D. Place the patient in a Trendelenburg position.
Answer: A
Rationale: Dialysis disequilibrium syndrome (DDS) is a rare but serious complication
caused by the rapid removal of solutes from the blood, leading to cerebral edema.
Symptoms include headache, nausea, vomiting, and altered mental status. The nurse must
, notify the provider immediately as this is a medical emergency that may require slowing
the dialysis process or administering hypertonic solutions.
4. Which assessment finding in a patient receiving peritoneal dialysis (PD) is most concerning
and requires immediate intervention?
A. The outflow drainage appears cloudy or opaque.
B. The dialysate return is slower than the initial inflow rate.
C. The patient reports a feeling of abdominal fullness during inflow.
D. The patient has a small amount of drainage around the catheter exit site.
Answer: A
Rationale: Cloudy or opaque effluent is the primary clinical sign of peritonitis, a common
and potentially life-threatening complication of peritoneal dialysis. The nurse should
collect a sample for culture and sensitivity and notify the healthcare provider. Abdominal
fullness and slow drainage are often expected or manageable issues related to positioning
or volume.
5. The nurse is providing dietary teaching to a patient with Stage 4 Chronic Kidney Disease
(CKD). Which food choice by the patient indicates a need for further teaching?
A. White bread toast with a small amount of butter.
B. A baked potato with skin and a side of spinach.
C. Grilled chicken breast without added salt.
Surgical Nursing | Actual Q&A with
Rationale (NURS201 Quiz 4) | West Coast
University
1. A patient with chronic kidney disease (CKD) has a serum potassium level of 6.8 mEq/L.
Which prescribed intervention should the nurse implement first?
A. Administer sodium polystyrene sulfonate (Kayexalate) orally.
B. Obtain a 12-lead electrocardiogram (ECG).
C. Place the patient on a cardiac monitor.
D. Administer intravenous regular insulin and 50% dextrose.
Answer: D
Rationale: The administration of intravenous insulin and dextrose is the fastest way to
shift potassium from the extracellular fluid into the cells. This is a critical intervention for
severe hyperkalemia to prevent life-threatening arrhythmias. While cardiac monitoring is
essential, providing the medication to lower the potassium level directly addresses the
metabolic emergency.
2. Which clinical manifestation should the nurse expect to find in a patient during the oliguric
phase of acute kidney injury (AKI)?
A. A urine specific gravity fixed at 1.010.
,B. Hypokalemia and hypotension.
C. Metabolic alkalosis.
D. Urine output of 600 mL per day.
Answer: A
Rationale: During the oliguric phase, the kidneys lose the ability to concentrate urine,
leading to a fixed specific gravity of 1.010, which matches the plasma osmolarity. Patients
in this phase typically experience fluid volume excess, metabolic acidosis, and
hyperkalemia. Urine output is generally less than 400 mL/day during this specific stage of
AKI.
3. A nurse is caring for a patient who just returned from a hemodialysis session. The patient
reports a headache, nausea, and appears restless. What is the nurse’s priority action?
A. Notify the healthcare provider of suspected dialysis disequilibrium syndrome.
B. Administer a prescribed PRN analgesic for the headache.
C. Increase the rate of the patient’s intravenous maintenance fluids.
D. Place the patient in a Trendelenburg position.
Answer: A
Rationale: Dialysis disequilibrium syndrome (DDS) is a rare but serious complication
caused by the rapid removal of solutes from the blood, leading to cerebral edema.
Symptoms include headache, nausea, vomiting, and altered mental status. The nurse must
, notify the provider immediately as this is a medical emergency that may require slowing
the dialysis process or administering hypertonic solutions.
4. Which assessment finding in a patient receiving peritoneal dialysis (PD) is most concerning
and requires immediate intervention?
A. The outflow drainage appears cloudy or opaque.
B. The dialysate return is slower than the initial inflow rate.
C. The patient reports a feeling of abdominal fullness during inflow.
D. The patient has a small amount of drainage around the catheter exit site.
Answer: A
Rationale: Cloudy or opaque effluent is the primary clinical sign of peritonitis, a common
and potentially life-threatening complication of peritoneal dialysis. The nurse should
collect a sample for culture and sensitivity and notify the healthcare provider. Abdominal
fullness and slow drainage are often expected or manageable issues related to positioning
or volume.
5. The nurse is providing dietary teaching to a patient with Stage 4 Chronic Kidney Disease
(CKD). Which food choice by the patient indicates a need for further teaching?
A. White bread toast with a small amount of butter.
B. A baked potato with skin and a side of spinach.
C. Grilled chicken breast without added salt.
