NRSG 201 Exam 4 V3 | NRSG 201 Med
Surg 1 | Actual Q&A with Rationale
(NRSG201 Exam 4) | Ivy Tech
1. A patient is admitted with a blood glucose level of 600 mg/dL and is diagnosed with
Diabetic Ketoacidosis (DKA). Which clinical finding should the nurse anticipate during the
assessment?
A. Bradypnea
B. Fluid volume excess
C. Kussmaul respirations
D. Peripheral edema
Correct Answer: C
Kussmaul respirations are deep, rapid breaths that occur as the body attempts to
compensate for metabolic acidosis by blowing off excess carbon dioxide. In DKA, the
accumulation of ketones leads to a drop in pH, triggering this compensatory mechanism.
The nurse must recognize this as a critical indicator of severe acidosis rather than a
primary respiratory issue.
2. Which electrolyte imbalance is the most critical priority for a nurse to monitor in a patient
suffering from an Addisonian crisis?
A. Hyperkalemia
,B. Hypercalcemia
C. Hypomagnesemia
D. Hypokalemia
Correct Answer: A
An Addisonian crisis results from an acute insufficiency of adrenocortical hormones,
leading to significant electrolyte disturbances. Potassium levels rise sharply because the
lack of aldosterone prevents the kidneys from excreting potassium properly. This
hyperkalemia can lead to lethal cardiac dysrhythmias, making it the highest priority for
nursing intervention and monitoring.
3. A nurse is caring for a patient who underwent a total thyroidectomy 6 hours ago. Which
assessment finding requires immediate notification of the healthcare provider?
A. Slight hoarseness when speaking
B. Laryngeal stridor
C. Pain at the incision site
D. Complaints of thirst
Correct Answer: B
Laryngeal stridor is a harsh, high-pitched sound heard on inspiration that indicates acute
airway obstruction. Following a thyroidectomy, this may be caused by edema, tetany from
, hypocalcemia, or laryngeal nerve damage. This is a life-threatening emergency that
necessitates immediate intervention to secure the airway.
4. A patient with Chronic Kidney Disease (CKD) has a serum potassium level of 6.8 mEq/L.
Which medication should the nurse be prepared to administer to provide the fastest
protection for the heart?
A. Sodium Polystyrene Sulfonate (Kayexalate)
B. Calcium Gluconate
C. Regular Insulin with Dextrose
D. Furosemide (Lasix)
Correct Answer: B
Calcium gluconate does not lower the potassium level but stabilizes the myocardial cell
membrane to prevent lethal dysrhythmias. While insulin and Kayexalate help reduce serum
potassium, they take longer to act compared to the protective effect of calcium. In the
presence of severe hyperkalemia, cardiac stabilization is the immediate pharmacological
priority.
5. A patient presents with a Trousseau’s sign and Chvostek’s sign. Which electrolyte
deficiency does the nurse suspect?
A. Hypocalcemia
B. Hyperkalemia
C. Hyponatremia
Surg 1 | Actual Q&A with Rationale
(NRSG201 Exam 4) | Ivy Tech
1. A patient is admitted with a blood glucose level of 600 mg/dL and is diagnosed with
Diabetic Ketoacidosis (DKA). Which clinical finding should the nurse anticipate during the
assessment?
A. Bradypnea
B. Fluid volume excess
C. Kussmaul respirations
D. Peripheral edema
Correct Answer: C
Kussmaul respirations are deep, rapid breaths that occur as the body attempts to
compensate for metabolic acidosis by blowing off excess carbon dioxide. In DKA, the
accumulation of ketones leads to a drop in pH, triggering this compensatory mechanism.
The nurse must recognize this as a critical indicator of severe acidosis rather than a
primary respiratory issue.
2. Which electrolyte imbalance is the most critical priority for a nurse to monitor in a patient
suffering from an Addisonian crisis?
A. Hyperkalemia
,B. Hypercalcemia
C. Hypomagnesemia
D. Hypokalemia
Correct Answer: A
An Addisonian crisis results from an acute insufficiency of adrenocortical hormones,
leading to significant electrolyte disturbances. Potassium levels rise sharply because the
lack of aldosterone prevents the kidneys from excreting potassium properly. This
hyperkalemia can lead to lethal cardiac dysrhythmias, making it the highest priority for
nursing intervention and monitoring.
3. A nurse is caring for a patient who underwent a total thyroidectomy 6 hours ago. Which
assessment finding requires immediate notification of the healthcare provider?
A. Slight hoarseness when speaking
B. Laryngeal stridor
C. Pain at the incision site
D. Complaints of thirst
Correct Answer: B
Laryngeal stridor is a harsh, high-pitched sound heard on inspiration that indicates acute
airway obstruction. Following a thyroidectomy, this may be caused by edema, tetany from
, hypocalcemia, or laryngeal nerve damage. This is a life-threatening emergency that
necessitates immediate intervention to secure the airway.
4. A patient with Chronic Kidney Disease (CKD) has a serum potassium level of 6.8 mEq/L.
Which medication should the nurse be prepared to administer to provide the fastest
protection for the heart?
A. Sodium Polystyrene Sulfonate (Kayexalate)
B. Calcium Gluconate
C. Regular Insulin with Dextrose
D. Furosemide (Lasix)
Correct Answer: B
Calcium gluconate does not lower the potassium level but stabilizes the myocardial cell
membrane to prevent lethal dysrhythmias. While insulin and Kayexalate help reduce serum
potassium, they take longer to act compared to the protective effect of calcium. In the
presence of severe hyperkalemia, cardiac stabilization is the immediate pharmacological
priority.
5. A patient presents with a Trousseau’s sign and Chvostek’s sign. Which electrolyte
deficiency does the nurse suspect?
A. Hypocalcemia
B. Hyperkalemia
C. Hyponatremia
