NRSG 110 Exam 4 V3 | NRSG 110 Medical
Surgical Nursing II | Actual Q&A with
Rationale (NRSG110 Exam 4) | Ivy Tech
1. A nurse is caring for a patient diagnosed with Diabetes Insipidus (DI). Which clinical
manifestation should the nurse expect to find during the assessment?
A. Specific gravity of 1.030
B. Elevated serum glucose
C. Large amounts of very dilute urine
D. Fluid volume excess
E. Decreased thirst
F. Bradycardia
Correct Answer: C
Diabetes Insipidus is characterized by a deficiency in Antidiuretic Hormone (ADH), which
leads to the inability of the kidneys to concentrate urine. As a result, the patient will excrete
large volumes of dilute urine with a low specific gravity, typically less than 1.005. The
nurse must monitor for signs of dehydration and hypovolemia due to this massive fluid
loss.
2. Which electrolyte imbalance is most commonly associated with a positive Chvostek’s sign?
A. Hyperkalemia
,B. Hyponatremia
C. Hypomagnesemia
D. Hypocalcemia
Correct Answer: D
Chvostek’s sign is a clinical indicator of hypocalcemia and is elicited by tapping the facial
nerve in front of the ear. A positive response consists of twitching of the facial muscles on
the same side as the stimulus. This occurs because low calcium levels increase
neuromuscular irritability and excitability.
3. A patient with Chronic Kidney Disease (CKD) presents with a potassium level of 6.2 mEq/L.
Which medication should the nurse anticipate administering first to stabilize the cardiac
membrane?
A. Sodium Polystyrene Sulfonate (Kayexalate)
B. Regular Insulin with Dextrose
C. Furosemide (Lasix)
D. Calcium Gluconate
Correct Answer: D
Calcium gluconate is the priority intervention for severe hyperkalemia when EKG changes
are present or the risk of arrhythmia is high because it stabilizes the myocardial cell
membrane. While insulin and Kayexalate help lower potassium levels, they do not provide
, the immediate cardiac protection required. The nurse must ensure continuous cardiac
monitoring while these treatments are being implemented.
4. A patient is admitted with Acute Renal Failure. The nurse notes the patient is in the oliguric
phase. What should the nurse expect to observe?
A. Urine output of 2500 mL/day
B. Urine output less than 400 mL/day
C. Improvement in BUN and Creatinine levels
D. Metabolic alkalosis
E. Hypovolemia
Correct Answer: B
The oliguric phase of acute kidney injury is characterized by a significant decrease in urine
output, typically defined as less than 400 mL per 24 hours. During this phase, waste
products such as urea and creatinine accumulate in the blood, leading to azotemia. Patients
are at high risk for fluid volume overload, hyperkalemia, and metabolic acidosis during this
period.
5. The nurse is evaluating a patient with Cushing’s Syndrome. Which set of clinical features is
most characteristic of this condition?
A. Trunkal obesity, moon face, and buffalo hump
B. Exophthalmos, tachycardia, and heat intolerance
Surgical Nursing II | Actual Q&A with
Rationale (NRSG110 Exam 4) | Ivy Tech
1. A nurse is caring for a patient diagnosed with Diabetes Insipidus (DI). Which clinical
manifestation should the nurse expect to find during the assessment?
A. Specific gravity of 1.030
B. Elevated serum glucose
C. Large amounts of very dilute urine
D. Fluid volume excess
E. Decreased thirst
F. Bradycardia
Correct Answer: C
Diabetes Insipidus is characterized by a deficiency in Antidiuretic Hormone (ADH), which
leads to the inability of the kidneys to concentrate urine. As a result, the patient will excrete
large volumes of dilute urine with a low specific gravity, typically less than 1.005. The
nurse must monitor for signs of dehydration and hypovolemia due to this massive fluid
loss.
2. Which electrolyte imbalance is most commonly associated with a positive Chvostek’s sign?
A. Hyperkalemia
,B. Hyponatremia
C. Hypomagnesemia
D. Hypocalcemia
Correct Answer: D
Chvostek’s sign is a clinical indicator of hypocalcemia and is elicited by tapping the facial
nerve in front of the ear. A positive response consists of twitching of the facial muscles on
the same side as the stimulus. This occurs because low calcium levels increase
neuromuscular irritability and excitability.
3. A patient with Chronic Kidney Disease (CKD) presents with a potassium level of 6.2 mEq/L.
Which medication should the nurse anticipate administering first to stabilize the cardiac
membrane?
A. Sodium Polystyrene Sulfonate (Kayexalate)
B. Regular Insulin with Dextrose
C. Furosemide (Lasix)
D. Calcium Gluconate
Correct Answer: D
Calcium gluconate is the priority intervention for severe hyperkalemia when EKG changes
are present or the risk of arrhythmia is high because it stabilizes the myocardial cell
membrane. While insulin and Kayexalate help lower potassium levels, they do not provide
, the immediate cardiac protection required. The nurse must ensure continuous cardiac
monitoring while these treatments are being implemented.
4. A patient is admitted with Acute Renal Failure. The nurse notes the patient is in the oliguric
phase. What should the nurse expect to observe?
A. Urine output of 2500 mL/day
B. Urine output less than 400 mL/day
C. Improvement in BUN and Creatinine levels
D. Metabolic alkalosis
E. Hypovolemia
Correct Answer: B
The oliguric phase of acute kidney injury is characterized by a significant decrease in urine
output, typically defined as less than 400 mL per 24 hours. During this phase, waste
products such as urea and creatinine accumulate in the blood, leading to azotemia. Patients
are at high risk for fluid volume overload, hyperkalemia, and metabolic acidosis during this
period.
5. The nurse is evaluating a patient with Cushing’s Syndrome. Which set of clinical features is
most characteristic of this condition?
A. Trunkal obesity, moon face, and buffalo hump
B. Exophthalmos, tachycardia, and heat intolerance
