PNR 201/PNR201 Exam 4 V1 | Medical-Surgical
Nursing Q&A with Rationale | Fortis College
1. A patient with Chronic Kidney Disease (CKD) has a serum potassium level of 6.4 mEq/L.
Which medication should the nurse anticipate administering immediately to shift potassium
into the cells?
A. Sodium Polystyrene Sulfonate (Kayexalate)
B. Furosemide (Lasix)
C. Regular Insulin and Dextrose 50%
D. Spironolactone (Aldactone)
Correct Answer: C
Explanation: Regular insulin given intravenously along with dextrose 50% causes
potassium to shift from the extracellular fluid into the cells. This is a temporary but rapid
measure used in emergent hyperkalemia situations. The nurse must monitor for
hypoglycemia following the administration of the insulin.
2. During a post-operative assessment of a patient who underwent a thyroidectomy, the
nurse notes positive Trousseau’s and Chvostek’s signs. Which electrolyte imbalance is most
likely occurring?
A. Hypercalcemia
B. Hypokalemia
,C. Hypocalcemia
D. Hypermagnesemia
Correct Answer: C
Explanation: Hypocalcemia can occur after a thyroidectomy if the parathyroid glands are
accidentally removed or damaged during surgery. Positive Trousseau’s and Chvostek’s
signs are classic indicators of neuromuscular irritability caused by low calcium levels. The
nurse must have calcium gluconate readily available for intravenous administration if
tetany develops.
3. A patient with Type 1 Diabetes Mellitus presents with Kussmaul respirations, a blood
glucose of 550 mg/dL, and fruity-smelling breath. Which condition is the patient likely
experiencing?
A. Diabetic Ketoacidosis (DKA)
B. Hypoglycemic Unawareness
C. Hyperosmolar Hyperglycemic Syndrome (HHS)
D. Somogyi Effect
Correct Answer: A
Explanation: DKA is characterized by hyperglycemia, metabolic acidosis, and the presence
of ketones in the blood and urine. Kussmaul respirations are a compensatory mechanism
where the body attempts to blow off excess carbon dioxide to correct the acidic state.
, Fruity breath is caused by the presence of acetone, which is a byproduct of ketone
metabolism.
4. A nurse is caring for a patient who is 4 hours post-operative following a Transurethral
Resection of the Prostate (TURP). The patient has a Continuous Bladder Irrigation (CBI)
running, and the nurse observes bright red blood with numerous large clots in the drainage
bag. What is the priority nursing action?
A. Increase the rate of the irrigation
B. Document the findings as normal
C. Notify the surgeon immediately
D. Clamp the catheter to stop the bleeding
Correct Answer: C
Explanation: While some blood is expected post-TURP, bright red drainage with heavy
clotting (arterial bleeding) is an abnormal finding that requires surgical intervention.
Increasing the irrigation may help clear clots, but it will not stop an arterial bleed. The
nurse must monitor the patient for signs of hypovolemic shock while waiting for the
surgeon.
5. A patient with cirrhosis of the liver has developed hepatic encephalopathy. Which
medication should the nurse expect to administer to decrease the patient’s serum ammonia
level?
A. Spironolactone
Nursing Q&A with Rationale | Fortis College
1. A patient with Chronic Kidney Disease (CKD) has a serum potassium level of 6.4 mEq/L.
Which medication should the nurse anticipate administering immediately to shift potassium
into the cells?
A. Sodium Polystyrene Sulfonate (Kayexalate)
B. Furosemide (Lasix)
C. Regular Insulin and Dextrose 50%
D. Spironolactone (Aldactone)
Correct Answer: C
Explanation: Regular insulin given intravenously along with dextrose 50% causes
potassium to shift from the extracellular fluid into the cells. This is a temporary but rapid
measure used in emergent hyperkalemia situations. The nurse must monitor for
hypoglycemia following the administration of the insulin.
2. During a post-operative assessment of a patient who underwent a thyroidectomy, the
nurse notes positive Trousseau’s and Chvostek’s signs. Which electrolyte imbalance is most
likely occurring?
A. Hypercalcemia
B. Hypokalemia
,C. Hypocalcemia
D. Hypermagnesemia
Correct Answer: C
Explanation: Hypocalcemia can occur after a thyroidectomy if the parathyroid glands are
accidentally removed or damaged during surgery. Positive Trousseau’s and Chvostek’s
signs are classic indicators of neuromuscular irritability caused by low calcium levels. The
nurse must have calcium gluconate readily available for intravenous administration if
tetany develops.
3. A patient with Type 1 Diabetes Mellitus presents with Kussmaul respirations, a blood
glucose of 550 mg/dL, and fruity-smelling breath. Which condition is the patient likely
experiencing?
A. Diabetic Ketoacidosis (DKA)
B. Hypoglycemic Unawareness
C. Hyperosmolar Hyperglycemic Syndrome (HHS)
D. Somogyi Effect
Correct Answer: A
Explanation: DKA is characterized by hyperglycemia, metabolic acidosis, and the presence
of ketones in the blood and urine. Kussmaul respirations are a compensatory mechanism
where the body attempts to blow off excess carbon dioxide to correct the acidic state.
, Fruity breath is caused by the presence of acetone, which is a byproduct of ketone
metabolism.
4. A nurse is caring for a patient who is 4 hours post-operative following a Transurethral
Resection of the Prostate (TURP). The patient has a Continuous Bladder Irrigation (CBI)
running, and the nurse observes bright red blood with numerous large clots in the drainage
bag. What is the priority nursing action?
A. Increase the rate of the irrigation
B. Document the findings as normal
C. Notify the surgeon immediately
D. Clamp the catheter to stop the bleeding
Correct Answer: C
Explanation: While some blood is expected post-TURP, bright red drainage with heavy
clotting (arterial bleeding) is an abnormal finding that requires surgical intervention.
Increasing the irrigation may help clear clots, but it will not stop an arterial bleed. The
nurse must monitor the patient for signs of hypovolemic shock while waiting for the
surgeon.
5. A patient with cirrhosis of the liver has developed hepatic encephalopathy. Which
medication should the nurse expect to administer to decrease the patient’s serum ammonia
level?
A. Spironolactone
