NU 192 Exam 4 V2 | NU 192 Medical-
Surgical Nursing II-B | NCLEX (NGN) Q&A
with Rationale (NU192 Exam 4) | Galen
1. A nurse is planning care for a client with Stage 4 Chronic Kidney Disease (CKD). Which
dietary interventions should the nurse expect to implement? (Select all that apply.)
A. Restrict sodium intake to less than 2 grams per day.
B. Encourage a high-protein diet to prevent muscle wasting.
C. Limit intake of phosphorus-rich foods like dairy and nuts.
D. Monitor and restrict potassium intake.
E. Encourage the use of salt substitutes.
F. Implement a fluid restriction based on daily output.
Correct Answer: A, C, D, F
Explanation: Clients with Stage 4 CKD require strict management of electrolytes and
metabolic waste because the kidneys can no longer filter effectively. Restricting sodium
and fluid prevents volume overload and hypertension, while phosphorus and potassium
restrictions prevent bone disease and cardiac dysrhythmias. Salt substitutes should be
avoided because they often contain potassium chloride, which can lead to life-threatening
hyperkalemia.
,2. A client is admitted with acute pancreatitis. Which assessment finding requires the most
immediate intervention by the nurse?
A. Presence of Cullen’s sign.
B. Pain level of 8 out of 10 in the epigastric region.
C. Amylase level of 450 U/L.
D. Absence of bowel sounds in all quadrants.
Correct Answer: A
Explanation: Cullen’s sign, which is bluish discoloration around the umbilicus, indicates
retroperitoneal hemorrhage and severe necrotizing pancreatitis. This is a critical finding
that suggests vascular instability and potential shock, requiring immediate notification of
the healthcare provider. While pain and elevated amylase are expected in pancreatitis, they
do not indicate active internal bleeding like Cullen’s sign does.
3. The nurse is caring for a client with cirrhosis who has developed hepatic encephalopathy.
Which medication should the nurse anticipate administering to reduce the client’s ammonia
levels?
A. Spironolactone
B. Lactulose
C. Propranolol
D. Furosemide
,Correct Answer: B
Explanation: Lactulose is the primary treatment for hepatic encephalopathy as it
promotes the excretion of ammonia through the stool by creating an acidic environment in
the bowel. The goal of therapy is typically two to three soft stools per day to ensure
effective detoxification. The nurse must monitor for dehydration and electrolyte
imbalances resulting from the increased frequency of bowel movements.
4. A client with a T4 spinal cord injury suddenly reports a severe, throbbing headache and has
a blood pressure of 190/110 mmHg. What is the priority nursing action?
A. Administer an ordered antihypertensive medication.
B. Place the client in a high-Fowler’s position.
C. Assess the client’s bladder for distension.
D. Notify the healthcare provider immediately.
Correct Answer: B
Explanation: The client is exhibiting classic signs of autonomic dysreflexia, a medical
emergency triggered by noxious stimuli below the level of injury. The immediate priority is
to sit the client up to 90 degrees (high-Fowler’s) to cause an orthostatic drop in blood
pressure. After positioning, the nurse should then identify and remove the triggering
stimulus, such as a full bladder or impacted bowel.
, 5. A nurse is assessing a client with Cushing’s syndrome. Which clinical manifestations should
the nurse expect to find? (Select all that apply.)
A. Truncal obesity
B. Hypotension
C. Hirsutism
D. Thin, fragile skin
E. Hyperkalemia
F. Moon face
Correct Answer: A, C, D, F
Explanation: Cushing’s syndrome results from an excess of cortisol, which leads to
characteristic physical changes like truncal obesity, a moon face, and a buffalo hump.
Cortisol excess also causes thinning of the skin and increased androgen activity, leading to
hirsutism. In contrast, hypotension and hyperkalemia are characteristic of Addison’s
disease, not Cushing’s syndrome.
6. The nurse is calculating the fluid resuscitation requirements for a client with 40% total
body surface area (TBSA) burns weighing 70 kg using the Parkland Formula (4 mL/kg/TBSA%).
How many milliliters of fluid should be administered in the first 8 hours?
A. 5,600 mL
B. 11,200 mL
Surgical Nursing II-B | NCLEX (NGN) Q&A
with Rationale (NU192 Exam 4) | Galen
1. A nurse is planning care for a client with Stage 4 Chronic Kidney Disease (CKD). Which
dietary interventions should the nurse expect to implement? (Select all that apply.)
A. Restrict sodium intake to less than 2 grams per day.
B. Encourage a high-protein diet to prevent muscle wasting.
C. Limit intake of phosphorus-rich foods like dairy and nuts.
D. Monitor and restrict potassium intake.
E. Encourage the use of salt substitutes.
F. Implement a fluid restriction based on daily output.
Correct Answer: A, C, D, F
Explanation: Clients with Stage 4 CKD require strict management of electrolytes and
metabolic waste because the kidneys can no longer filter effectively. Restricting sodium
and fluid prevents volume overload and hypertension, while phosphorus and potassium
restrictions prevent bone disease and cardiac dysrhythmias. Salt substitutes should be
avoided because they often contain potassium chloride, which can lead to life-threatening
hyperkalemia.
,2. A client is admitted with acute pancreatitis. Which assessment finding requires the most
immediate intervention by the nurse?
A. Presence of Cullen’s sign.
B. Pain level of 8 out of 10 in the epigastric region.
C. Amylase level of 450 U/L.
D. Absence of bowel sounds in all quadrants.
Correct Answer: A
Explanation: Cullen’s sign, which is bluish discoloration around the umbilicus, indicates
retroperitoneal hemorrhage and severe necrotizing pancreatitis. This is a critical finding
that suggests vascular instability and potential shock, requiring immediate notification of
the healthcare provider. While pain and elevated amylase are expected in pancreatitis, they
do not indicate active internal bleeding like Cullen’s sign does.
3. The nurse is caring for a client with cirrhosis who has developed hepatic encephalopathy.
Which medication should the nurse anticipate administering to reduce the client’s ammonia
levels?
A. Spironolactone
B. Lactulose
C. Propranolol
D. Furosemide
,Correct Answer: B
Explanation: Lactulose is the primary treatment for hepatic encephalopathy as it
promotes the excretion of ammonia through the stool by creating an acidic environment in
the bowel. The goal of therapy is typically two to three soft stools per day to ensure
effective detoxification. The nurse must monitor for dehydration and electrolyte
imbalances resulting from the increased frequency of bowel movements.
4. A client with a T4 spinal cord injury suddenly reports a severe, throbbing headache and has
a blood pressure of 190/110 mmHg. What is the priority nursing action?
A. Administer an ordered antihypertensive medication.
B. Place the client in a high-Fowler’s position.
C. Assess the client’s bladder for distension.
D. Notify the healthcare provider immediately.
Correct Answer: B
Explanation: The client is exhibiting classic signs of autonomic dysreflexia, a medical
emergency triggered by noxious stimuli below the level of injury. The immediate priority is
to sit the client up to 90 degrees (high-Fowler’s) to cause an orthostatic drop in blood
pressure. After positioning, the nurse should then identify and remove the triggering
stimulus, such as a full bladder or impacted bowel.
, 5. A nurse is assessing a client with Cushing’s syndrome. Which clinical manifestations should
the nurse expect to find? (Select all that apply.)
A. Truncal obesity
B. Hypotension
C. Hirsutism
D. Thin, fragile skin
E. Hyperkalemia
F. Moon face
Correct Answer: A, C, D, F
Explanation: Cushing’s syndrome results from an excess of cortisol, which leads to
characteristic physical changes like truncal obesity, a moon face, and a buffalo hump.
Cortisol excess also causes thinning of the skin and increased androgen activity, leading to
hirsutism. In contrast, hypotension and hyperkalemia are characteristic of Addison’s
disease, not Cushing’s syndrome.
6. The nurse is calculating the fluid resuscitation requirements for a client with 40% total
body surface area (TBSA) burns weighing 70 kg using the Parkland Formula (4 mL/kg/TBSA%).
How many milliliters of fluid should be administered in the first 8 hours?
A. 5,600 mL
B. 11,200 mL
