NU 186 Final Exam V2 | NU 186 Medical-
Surgical Nursing II-A | NCLEX (NGN) Q&A
with Rationale (NU186 Final Exam) | Galen
1. A patient with Type 2 Diabetes is admitted to the emergency department with a blood
glucose level of 850 mg/dL, profound dehydration, and no ketones in the urine. Which
condition does the nurse suspect the patient is experiencing?
A. Diabetic Ketoacidosis (DKA)
B. Hypoglycemic Unawareness
C. Somogyi Effect
D. Hyperosmolar Hyperglycemic Syndrome (HHS)
Correct Answer: D
Explanation: HHS is characterized by extreme hyperglycemia and profound dehydration
without significant ketosis. It typically occurs in patients with Type 2 diabetes who have
enough insulin to prevent the breakdown of fats into ketones but not enough to control
blood glucose levels. The absence of ketones and the high glucose level (often >600 mg/dL)
distinguish HHS from DKA.
2. A patient is admitted with a potassium level of 6.8 mEq/L. Which of the following
interventions should the nurse anticipate implementing? (Select All That Apply)
A. Administration of intravenous calcium gluconate
,B. Administration of intravenous regular insulin and 50% dextrose
C. Administration of oral spironolactone
D. Administration of sodium polystyrene sulfonate (Kayexalate)
E. Continuous cardiac monitoring
F. Initiation of emergency hemodialysis
Correct Answer: ABDEF
Explanation: Hyperkalemia above 6.5 mEq/L is a medical emergency that requires
stabilizing the cardiac membrane with calcium gluconate and shifting potassium into cells
with insulin/dextrose. Sodium polystyrene sulfonate or hemodialysis are used to physically
remove potassium from the body. Cardiac monitoring is essential to detect life-threatening
arrhythmias associated with high potassium levels.
3. A patient with cirrhosis is showing signs of hepatic encephalopathy. Which medication
should the nurse prioritize for administration to reduce serum ammonia levels?
A. Spironolactone
B. Lactulose
C. Propranolol
D. Furosemide
Correct Answer: B
, Explanation: Lactulose works by promoting the excretion of ammonia through the stool by
creating an acidic environment in the bowel. It is the primary treatment for hepatic
encephalopathy to prevent cognitive decline and coma. The nurse should monitor the
patient for 2 to 3 soft stools per day to ensure therapeutic effectiveness.
4. The nurse is caring for a patient following a head injury. Which assessment findings would
indicate the development of Cushing’s Triad? (Select All That Apply)
A. Tachycardia
B. Bradycardia
C. Systolic hypertension with widening pulse pressure
D. Irregular respirations
E. Hypotension
Correct Answer: BCD
Explanation: Cushing’s Triad is a late sign of increased intracranial pressure (ICP) and
indicates imminent brain herniation. It consists of bradycardia, systolic hypertension with
a widening pulse pressure, and irregular or slowed respirations. Tachycardia and
hypotension are usually signs of shock, not increased ICP.
5. A patient presents with arterial blood gas (ABG) results: pH 7.28, PaCO2 55 mmHg, and
HCO3 26 mEq/L. How does the nurse interpret these findings?
A. Metabolic acidosis
B. Respiratory alkalosis
Surgical Nursing II-A | NCLEX (NGN) Q&A
with Rationale (NU186 Final Exam) | Galen
1. A patient with Type 2 Diabetes is admitted to the emergency department with a blood
glucose level of 850 mg/dL, profound dehydration, and no ketones in the urine. Which
condition does the nurse suspect the patient is experiencing?
A. Diabetic Ketoacidosis (DKA)
B. Hypoglycemic Unawareness
C. Somogyi Effect
D. Hyperosmolar Hyperglycemic Syndrome (HHS)
Correct Answer: D
Explanation: HHS is characterized by extreme hyperglycemia and profound dehydration
without significant ketosis. It typically occurs in patients with Type 2 diabetes who have
enough insulin to prevent the breakdown of fats into ketones but not enough to control
blood glucose levels. The absence of ketones and the high glucose level (often >600 mg/dL)
distinguish HHS from DKA.
2. A patient is admitted with a potassium level of 6.8 mEq/L. Which of the following
interventions should the nurse anticipate implementing? (Select All That Apply)
A. Administration of intravenous calcium gluconate
,B. Administration of intravenous regular insulin and 50% dextrose
C. Administration of oral spironolactone
D. Administration of sodium polystyrene sulfonate (Kayexalate)
E. Continuous cardiac monitoring
F. Initiation of emergency hemodialysis
Correct Answer: ABDEF
Explanation: Hyperkalemia above 6.5 mEq/L is a medical emergency that requires
stabilizing the cardiac membrane with calcium gluconate and shifting potassium into cells
with insulin/dextrose. Sodium polystyrene sulfonate or hemodialysis are used to physically
remove potassium from the body. Cardiac monitoring is essential to detect life-threatening
arrhythmias associated with high potassium levels.
3. A patient with cirrhosis is showing signs of hepatic encephalopathy. Which medication
should the nurse prioritize for administration to reduce serum ammonia levels?
A. Spironolactone
B. Lactulose
C. Propranolol
D. Furosemide
Correct Answer: B
, Explanation: Lactulose works by promoting the excretion of ammonia through the stool by
creating an acidic environment in the bowel. It is the primary treatment for hepatic
encephalopathy to prevent cognitive decline and coma. The nurse should monitor the
patient for 2 to 3 soft stools per day to ensure therapeutic effectiveness.
4. The nurse is caring for a patient following a head injury. Which assessment findings would
indicate the development of Cushing’s Triad? (Select All That Apply)
A. Tachycardia
B. Bradycardia
C. Systolic hypertension with widening pulse pressure
D. Irregular respirations
E. Hypotension
Correct Answer: BCD
Explanation: Cushing’s Triad is a late sign of increased intracranial pressure (ICP) and
indicates imminent brain herniation. It consists of bradycardia, systolic hypertension with
a widening pulse pressure, and irregular or slowed respirations. Tachycardia and
hypotension are usually signs of shock, not increased ICP.
5. A patient presents with arterial blood gas (ABG) results: pH 7.28, PaCO2 55 mmHg, and
HCO3 26 mEq/L. How does the nurse interpret these findings?
A. Metabolic acidosis
B. Respiratory alkalosis
