NU 186 Exam 4 V2 | NU 186 Medical-
Surgical Nursing II-A | NCLEX (NGN) Q&A
with Rationale (NU186 Exam 4) | Galen
1. A nurse is caring for a client with Chronic Kidney Disease (CKD) who has a potassium level
of 6.2 mEq/L. Which medication should the nurse expect to administer to provide the fastest
protection to the heart?
A. Sodium polystyrene sulfonate
B. Regular insulin with D50
C. Calcium gluconate
D. Furosemide
Correct Answer: C
Explanation; Calcium gluconate is administered to stabilize the myocardial cell membrane
in the presence of hyperkalemia. While it does not lower the potassium level, it prevents
life-threatening arrhythmias by antagonizing the effects of potassium on the heart. The
nurse must monitor the ECG continuously during administration.
2. A client is being discharged after receiving chemotherapy and is at risk for neutropenia.
Which of the following instructions should the nurse include in the teaching plan? (Select All
That Apply)
A. Avoid crowds and people who are sick.
,B. Wash your hands frequently with antimicrobial soap.
C. Eat fresh fruits and vegetables daily to boost immunity.
D. Do not perform any yard work or gardening.
E. Check your temperature at least once daily.
F. Change the water in flower vases every day.
Correct Answer: A, B, D, E
Explanation; Neutropenic precautions are essential for clients with low white blood cell
counts to prevent infection. Clients should avoid fresh fruits and vegetables unless they are
peeled or cooked because they can harbor bacteria. Additionally, items like stagnant vase
water and soil from gardening are high-risk sources of pathogens.
3. A nurse is assessing a client with Diabetic Ketoacidosis (DKA). Which clinical manifestation
is most characteristic of this condition?
A. Kussmaul respirations
B. Hypoventilation
C. Bradycardia
D. Increased urine specific gravity
Correct Answer: A
Explanation; Kussmaul respirations are deep, rapid breaths that the body uses to blow off
excess carbon dioxide in an attempt to compensate for metabolic acidosis. This occurs
, because DKA results in the accumulation of ketones, which are acidic. Other signs include a
fruity breath odor and dehydration.
4. The nurse is preparing to administer levothyroxine to a client with hypothyroidism. Which
assessment finding would require the nurse to hold the medication and notify the healthcare
provider?
A. Patient reporting feeling cold
B. Blood pressure of 100/60 mmHg
C. Temperature of 97.8 F
D. Heart rate of 110 beats per minute
Correct Answer: D
Explanation; Levothyroxine is a thyroid hormone replacement that can increase the
metabolic rate and heart rate. A heart rate over 100 bpm indicates potential toxicity or an
excessive dose, which could lead to cardiac complications. The nurse should assess for
other signs of hyperthyroidism like palpitations or tremors.
5. A client with an Arteriovenous (AV) fistula in the left arm is being prepared for
hemodialysis. Which action by the nurse is appropriate?
A. Draw blood samples from the left arm for laboratory tests.
B. Obtain blood pressure readings using the left arm.
C. Palpate for a thrill and auscultate for a bruit over the fistula.
Surgical Nursing II-A | NCLEX (NGN) Q&A
with Rationale (NU186 Exam 4) | Galen
1. A nurse is caring for a client with Chronic Kidney Disease (CKD) who has a potassium level
of 6.2 mEq/L. Which medication should the nurse expect to administer to provide the fastest
protection to the heart?
A. Sodium polystyrene sulfonate
B. Regular insulin with D50
C. Calcium gluconate
D. Furosemide
Correct Answer: C
Explanation; Calcium gluconate is administered to stabilize the myocardial cell membrane
in the presence of hyperkalemia. While it does not lower the potassium level, it prevents
life-threatening arrhythmias by antagonizing the effects of potassium on the heart. The
nurse must monitor the ECG continuously during administration.
2. A client is being discharged after receiving chemotherapy and is at risk for neutropenia.
Which of the following instructions should the nurse include in the teaching plan? (Select All
That Apply)
A. Avoid crowds and people who are sick.
,B. Wash your hands frequently with antimicrobial soap.
C. Eat fresh fruits and vegetables daily to boost immunity.
D. Do not perform any yard work or gardening.
E. Check your temperature at least once daily.
F. Change the water in flower vases every day.
Correct Answer: A, B, D, E
Explanation; Neutropenic precautions are essential for clients with low white blood cell
counts to prevent infection. Clients should avoid fresh fruits and vegetables unless they are
peeled or cooked because they can harbor bacteria. Additionally, items like stagnant vase
water and soil from gardening are high-risk sources of pathogens.
3. A nurse is assessing a client with Diabetic Ketoacidosis (DKA). Which clinical manifestation
is most characteristic of this condition?
A. Kussmaul respirations
B. Hypoventilation
C. Bradycardia
D. Increased urine specific gravity
Correct Answer: A
Explanation; Kussmaul respirations are deep, rapid breaths that the body uses to blow off
excess carbon dioxide in an attempt to compensate for metabolic acidosis. This occurs
, because DKA results in the accumulation of ketones, which are acidic. Other signs include a
fruity breath odor and dehydration.
4. The nurse is preparing to administer levothyroxine to a client with hypothyroidism. Which
assessment finding would require the nurse to hold the medication and notify the healthcare
provider?
A. Patient reporting feeling cold
B. Blood pressure of 100/60 mmHg
C. Temperature of 97.8 F
D. Heart rate of 110 beats per minute
Correct Answer: D
Explanation; Levothyroxine is a thyroid hormone replacement that can increase the
metabolic rate and heart rate. A heart rate over 100 bpm indicates potential toxicity or an
excessive dose, which could lead to cardiac complications. The nurse should assess for
other signs of hyperthyroidism like palpitations or tremors.
5. A client with an Arteriovenous (AV) fistula in the left arm is being prepared for
hemodialysis. Which action by the nurse is appropriate?
A. Draw blood samples from the left arm for laboratory tests.
B. Obtain blood pressure readings using the left arm.
C. Palpate for a thrill and auscultate for a bruit over the fistula.
