PNR 206/PNR206 Exam 1 V2 | Medical-Surgical
Nursing II Q&A with Rationale | Fortis College
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 anticipate administering to promote the
excretion of potassium?
A. Magnesium hydroxide
B. Spironolactone
C. Calcium gluconate
D. Sodium polystyrene sulfonate
Correct Answer: D
Explanation: Sodium polystyrene sulfonate (Kayexalate) works in the bowel to exchange
sodium ions for potassium ions, allowing potassium to be excreted in the stool. This is a
common intervention for non-emergent hyperkalemia in renal patients. The nurse must
monitor for bowel sounds and potential constipation following administration of this
medication.
2. Which clinical manifestation should the nurse prioritize when assessing a client
immediately following a thyroidectomy?
A. Laryngeal stridor
B. Sore throat
,C. Mild hoarseness
D. Pain at the incision site
Correct Answer: A
Explanation: Laryngeal stridor is a harsh, high-pitched respiratory sound that indicates
acute airway obstruction, which is a life-threatening emergency. This can occur due to
laryngeal nerve damage or tetany from accidental parathyroid removal. The nurse must
have an emergency tracheostomy kit at the bedside for all post-thyroidectomy patients.
3. A client with Type 1 Diabetes Mellitus presents to the ED with Kussmaul respirations and a
fruity breath odor. Which laboratory finding is most consistent with this presentation?
A. Bicarbonate level of 28 mEq/L
B. Serum glucose of 110 mg/dL
C. Serum pH of 7.25
D. Negative urine ketones
Correct Answer: C
Explanation: Kussmaul respirations and fruity breath are classic signs of Diabetic
Ketoacidosis (DKA), which is characterized by metabolic acidosis. A serum pH below 7.35
indicates acidosis resulting from the accumulation of ketone bodies. The nurse should
anticipate aggressive fluid resuscitation and intravenous insulin therapy for this client.
, 4. The nurse is providing discharge teaching for a client with a new arteriovenous (AV) fistula
in the left arm. Which instruction is most important to include?
A. Avoid taking blood pressures or venipunctures in the left arm.
B. Keep the left arm immobilized for the first week.
C. Clean the fistula site with alcohol daily.
D. Sleep with the left arm in a dependent position.
Correct Answer: A
Explanation: Restricting blood pressures and needle sticks in the arm with the AV fistula is
critical to prevent thrombosis or damage to the access site. The nurse should also teach the
client to check for a ‘thrill’ or ‘bruit’ daily to ensure patency. Maintaining the integrity of the
vascular access is vital for the client’s long-term hemodialysis success.
5. A client is diagnosed with Cushing’s syndrome. Which physical assessment finding does the
nurse expect to observe?
A. Hyperactive deep tendon reflexes
B. Weight loss and hypotension
C. Bronze-colored skin pigmentation
D. Truncal obesity and moon face
Correct Answer: D
Nursing II Q&A with Rationale | Fortis College
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 anticipate administering to promote the
excretion of potassium?
A. Magnesium hydroxide
B. Spironolactone
C. Calcium gluconate
D. Sodium polystyrene sulfonate
Correct Answer: D
Explanation: Sodium polystyrene sulfonate (Kayexalate) works in the bowel to exchange
sodium ions for potassium ions, allowing potassium to be excreted in the stool. This is a
common intervention for non-emergent hyperkalemia in renal patients. The nurse must
monitor for bowel sounds and potential constipation following administration of this
medication.
2. Which clinical manifestation should the nurse prioritize when assessing a client
immediately following a thyroidectomy?
A. Laryngeal stridor
B. Sore throat
,C. Mild hoarseness
D. Pain at the incision site
Correct Answer: A
Explanation: Laryngeal stridor is a harsh, high-pitched respiratory sound that indicates
acute airway obstruction, which is a life-threatening emergency. This can occur due to
laryngeal nerve damage or tetany from accidental parathyroid removal. The nurse must
have an emergency tracheostomy kit at the bedside for all post-thyroidectomy patients.
3. A client with Type 1 Diabetes Mellitus presents to the ED with Kussmaul respirations and a
fruity breath odor. Which laboratory finding is most consistent with this presentation?
A. Bicarbonate level of 28 mEq/L
B. Serum glucose of 110 mg/dL
C. Serum pH of 7.25
D. Negative urine ketones
Correct Answer: C
Explanation: Kussmaul respirations and fruity breath are classic signs of Diabetic
Ketoacidosis (DKA), which is characterized by metabolic acidosis. A serum pH below 7.35
indicates acidosis resulting from the accumulation of ketone bodies. The nurse should
anticipate aggressive fluid resuscitation and intravenous insulin therapy for this client.
, 4. The nurse is providing discharge teaching for a client with a new arteriovenous (AV) fistula
in the left arm. Which instruction is most important to include?
A. Avoid taking blood pressures or venipunctures in the left arm.
B. Keep the left arm immobilized for the first week.
C. Clean the fistula site with alcohol daily.
D. Sleep with the left arm in a dependent position.
Correct Answer: A
Explanation: Restricting blood pressures and needle sticks in the arm with the AV fistula is
critical to prevent thrombosis or damage to the access site. The nurse should also teach the
client to check for a ‘thrill’ or ‘bruit’ daily to ensure patency. Maintaining the integrity of the
vascular access is vital for the client’s long-term hemodialysis success.
5. A client is diagnosed with Cushing’s syndrome. Which physical assessment finding does the
nurse expect to observe?
A. Hyperactive deep tendon reflexes
B. Weight loss and hypotension
C. Bronze-colored skin pigmentation
D. Truncal obesity and moon face
Correct Answer: D
