NU 192 Final Exam V3 | NU 192 Medical-
Surgical Nursing II-B | NCLEX (NGN) Q&A
with Rationale (NU192 Final Exam) | Galen
1. A nurse is assessing a client for potential prerenal causes of acute kidney injury (AKI).
Which conditions should the nurse identify as increasing the risk for prerenal AKI? Select all
that apply.
A. Hypovolemia
B. Cardiogenic shock
C. Nephrotoxic medications
D. Anaphylaxis
E. Renal calculi
F. Severe dehydration
Correct Answer: A, B, D, F
Explanation: Prerenal AKI is caused by factors that reduce systemic circulation, causing a
decrease in renal blood flow. Common causes include hypovolemia, decreased cardiac
output, and systemic vasodilation such as shock. Identifying these causes early allows for
prompt restoration of perfusion to prevent permanent kidney damage.
,2. A client is admitted to the emergency department with suspected ischemic stroke. Which is
the priority nursing assessment to perform within the first 10 minutes of arrival?
A. Assess lung sounds and oxygen saturation
B. Obtain a full set of vital signs
C. Perform a rapid neurological assessment using the NIHSS
D. Check the client’s blood glucose level
Correct Answer: C
Explanation: A rapid neurological assessment is essential to establish baseline data and
determine the severity of the stroke. The NIH Stroke Scale (NIHSS) is the gold standard for
quantifying stroke-related neurological deficits. Rapid identification of symptoms allows
for the timely administration of thrombolytic therapy if indicated.
3. The nurse is providing care for a client diagnosed with Cushing’s syndrome. Which clinical
manifestations should the nurse expect to observe? Select all that apply.
A. Trunk obesity with thin extremities
B. Hypotension and bradycardia
C. Purple striae on the abdomen
D. Hyperpigmentation of the skin
E. Moon face and buffalo hump
Correct Answer: A, C, E
,Explanation: Cushing’s syndrome is characterized by an excess of corticosteroids,
specifically cortisol. Typical physical findings include a moon-shaped face, a buffalo hump
on the upper back, and central obesity. The skin also becomes fragile, leading to the
development of broad purple striae and bruising.
4. A client in the emergent phase of a major burn injury has a blood pressure of 88/50 mmHg
and a heart rate of 122 bpm. Which intervention is the priority for the nurse to implement?
A. Administer prescribed IV pain medication
B. Initiate fluid resuscitation with Lactated Ringer’s
C. Apply topical antimicrobial ointment to the wounds
D. Obtain a sputum culture and sensitivity
Correct Answer: B
Explanation: Fluid resuscitation is the primary intervention during the emergent phase of
burn management to prevent hypovolemic shock. Lactated Ringer’s is the preferred
isotonic crystalloid solution for initial volume expansion. Hemodynamic stability must be
achieved before focusing on wound care or secondary interventions.
5. A nurse is caring for a client with a spinal cord injury at the T6 level. The client reports a
sudden, pounding headache and the blood pressure is 190/100 mmHg. Which action should
the nurse take first?
A. Administer a PRN dose of hydralazine
B. Notify the healthcare provider immediately
, C. Place the client in a high-Fowler’s position
D. Check the client for bladder distention
Correct Answer: C
Explanation: The client is exhibiting signs of autonomic dysreflexia, which is a medical
emergency. The first priority is to elevate the head of the bed to 45 degrees or higher to
utilize gravity to help lower the blood pressure. After positioning the client, the nurse
should then identify and eliminate the triggering stimulus, such as a distended bladder or
impacted bowel.
6. The nurse is preparing to discharge a client newly diagnosed with Addison’s disease. Which
instruction is most important for the nurse to include in the teaching plan?
A. Limit sodium intake to less than 2 grams per day
B. Monitor for signs of hypernatremia and hypertension
C. Carry an emergency kit with injectable hydrocortisone
D. Stop the medication immediately if weight gain occurs
Correct Answer: C
Explanation: Clients with Addison’s disease require lifelong hormone replacement therapy
and must be prepared for an adrenal crisis. Carrying an emergency hydrocortisone kit is
vital for management during periods of acute stress or illness. Abruptly stopping steroids
can precipitate a life-threatening adrenal crisis and must be avoided.
Surgical Nursing II-B | NCLEX (NGN) Q&A
with Rationale (NU192 Final Exam) | Galen
1. A nurse is assessing a client for potential prerenal causes of acute kidney injury (AKI).
Which conditions should the nurse identify as increasing the risk for prerenal AKI? Select all
that apply.
A. Hypovolemia
B. Cardiogenic shock
C. Nephrotoxic medications
D. Anaphylaxis
E. Renal calculi
F. Severe dehydration
Correct Answer: A, B, D, F
Explanation: Prerenal AKI is caused by factors that reduce systemic circulation, causing a
decrease in renal blood flow. Common causes include hypovolemia, decreased cardiac
output, and systemic vasodilation such as shock. Identifying these causes early allows for
prompt restoration of perfusion to prevent permanent kidney damage.
,2. A client is admitted to the emergency department with suspected ischemic stroke. Which is
the priority nursing assessment to perform within the first 10 minutes of arrival?
A. Assess lung sounds and oxygen saturation
B. Obtain a full set of vital signs
C. Perform a rapid neurological assessment using the NIHSS
D. Check the client’s blood glucose level
Correct Answer: C
Explanation: A rapid neurological assessment is essential to establish baseline data and
determine the severity of the stroke. The NIH Stroke Scale (NIHSS) is the gold standard for
quantifying stroke-related neurological deficits. Rapid identification of symptoms allows
for the timely administration of thrombolytic therapy if indicated.
3. The nurse is providing care for a client diagnosed with Cushing’s syndrome. Which clinical
manifestations should the nurse expect to observe? Select all that apply.
A. Trunk obesity with thin extremities
B. Hypotension and bradycardia
C. Purple striae on the abdomen
D. Hyperpigmentation of the skin
E. Moon face and buffalo hump
Correct Answer: A, C, E
,Explanation: Cushing’s syndrome is characterized by an excess of corticosteroids,
specifically cortisol. Typical physical findings include a moon-shaped face, a buffalo hump
on the upper back, and central obesity. The skin also becomes fragile, leading to the
development of broad purple striae and bruising.
4. A client in the emergent phase of a major burn injury has a blood pressure of 88/50 mmHg
and a heart rate of 122 bpm. Which intervention is the priority for the nurse to implement?
A. Administer prescribed IV pain medication
B. Initiate fluid resuscitation with Lactated Ringer’s
C. Apply topical antimicrobial ointment to the wounds
D. Obtain a sputum culture and sensitivity
Correct Answer: B
Explanation: Fluid resuscitation is the primary intervention during the emergent phase of
burn management to prevent hypovolemic shock. Lactated Ringer’s is the preferred
isotonic crystalloid solution for initial volume expansion. Hemodynamic stability must be
achieved before focusing on wound care or secondary interventions.
5. A nurse is caring for a client with a spinal cord injury at the T6 level. The client reports a
sudden, pounding headache and the blood pressure is 190/100 mmHg. Which action should
the nurse take first?
A. Administer a PRN dose of hydralazine
B. Notify the healthcare provider immediately
, C. Place the client in a high-Fowler’s position
D. Check the client for bladder distention
Correct Answer: C
Explanation: The client is exhibiting signs of autonomic dysreflexia, which is a medical
emergency. The first priority is to elevate the head of the bed to 45 degrees or higher to
utilize gravity to help lower the blood pressure. After positioning the client, the nurse
should then identify and eliminate the triggering stimulus, such as a distended bladder or
impacted bowel.
6. The nurse is preparing to discharge a client newly diagnosed with Addison’s disease. Which
instruction is most important for the nurse to include in the teaching plan?
A. Limit sodium intake to less than 2 grams per day
B. Monitor for signs of hypernatremia and hypertension
C. Carry an emergency kit with injectable hydrocortisone
D. Stop the medication immediately if weight gain occurs
Correct Answer: C
Explanation: Clients with Addison’s disease require lifelong hormone replacement therapy
and must be prepared for an adrenal crisis. Carrying an emergency hydrocortisone kit is
vital for management during periods of acute stress or illness. Abruptly stopping steroids
can precipitate a life-threatening adrenal crisis and must be avoided.
