NUR 265 Exam 2 V1 | NUR 265 Advanced Concepts
of Medical–Surgical Nursing | Actual Q&A with
Rationale (NUR 265 Exam 2) | Galen
1. A 45-year-old male patient, Mr. Henderson, is admitted with Acute Kidney Injury (AKI) due
to severe dehydration. His serum potassium is 6.2 mEq/L. Which provider order should the
nurse implement first?
A. Administer Sodium Polystyrene Sulfonate (Kayexalate) 30g orally.
B. Obtain a 12-lead electrocardiogram (ECG) immediately.
C. Administer 10 units of regular insulin with 50% Dextrose intravenously.
D. Insert a foley catheter to monitor hourly urine output.
Correct Answer: B
Explanation: Hyperkalemia (potassium > 5.0 mEq/L) is a medical emergency that can lead
to lethal cardiac arrhythmias. The nurse’s first priority is to assess the cardiac rhythm
using an ECG to look for peaked T-waves or widened QRS complexes. While
insulin/dextrose and Kayexalate treat the potassium level, the safety and assessment of the
heart rhythm take precedence.
2. Mrs. Gable is being treated for Diabetes Insipidus (DI) following a transsphenoidal
hypophysectomy. Which clinical finding would indicate that the treatment with desmopressin
(DDAVP) is effective?
A. Serum sodium level increases to 150 mEq/L.
,B. Urine specific gravity increases from 1.002 to 1.015.
C. Urine output increases to 500 mL per hour.
D. Blood glucose level stabilizes at 110 mg/dL.
Correct Answer: B
Explanation: Desmopressin acts as synthetic antidiuretic hormone (ADH), which
facilitates water reabsorption in the kidneys. In DI, patients have dilute urine with low
specific gravity; a rise in specific gravity indicates the urine is becoming more
concentrated. Improved urine concentration and decreased volume are the primary goals
of therapy.
3. A patient with cirrhosis of the liver, Mr. Rodriguez, is experiencing increased confusion and
has a flapping tremor of the hands (asterixis). The nurse notes a serum ammonia level of 110
µmol/L. Which medication should the nurse anticipate administering?
A. Spironolactone
B. Lactulose
C. Propranolol
D. Vitamin K
Correct Answer: B
Explanation: Lactulose is the gold standard for treating hepatic encephalopathy by
promoting the excretion of ammonia through the stool. The presence of asterixis and
,elevated ammonia levels confirms the need for this osmotic laxative. The nurse should
monitor for 2 to 3 soft stools per day to ensure the medication is working effectively.
4. A 58-year-old female patient, Mrs. Jenkins, is 24 hours post-operative after a total
thyroidectomy. She complains of tingling around her mouth and fingertips. What is the
nurse’s priority action?
A. Check the patient’s blood pressure for hypertension.
B. Assess for Trousseau’s and Chvostek’s signs.
C. Notify the provider to request a STAT serum potassium level.
D. Administer an oral dose of Levothyroxine.
Correct Answer: B
Explanation: Tingling in the extremities and perioral area are early signs of hypocalcemia,
which can occur if the parathyroid glands are accidentally removed or damaged during a
thyroidectomy. The nurse must assess for Trousseau’s (carpal spasm) and Chvostek’s
(facial twitch) signs to confirm tetany risk. Early detection allows for rapid administration
of calcium gluconate to prevent seizures or laryngospasm.
5. A nurse is caring for a patient, Mr. Smith, who is receiving hemodialysis. The nurse notes
that the patient’s arteriovenous (AV) fistula has a palpable thrill and an audible bruit. How
should the nurse interpret these findings?
A. The fistula is clotted and requires surgical intervention.
B. The patient is developing an infection at the site.
, C. The patient is experiencing arterial insufficiency in the distal limb.
D. The fistula is patent and functioning normally.
Correct Answer: D
Explanation: A palpable thrill (vibration) and an audible bruit (whooshing sound) are
normal findings that indicate the AV fistula is patent. These signs confirm that blood flow is
moving from the high-pressure artery into the lower-pressure vein. The absence of these
signs would indicate a potential blockage or clot.
6. Which clinical manifestation would the nurse expect to find in a patient admitted with
Syndrome of Inappropriate Antidiuretic Hormone (SIADH)?
A. Increased urine output and dehydration.
B. Hyponatremia and fluid volume excess.
C. Hypotension and tachycardia.
D. Hyperglycemia and metabolic acidosis.
Correct Answer: B
Explanation: SIADH involves the excessive release of ADH, leading to water retention and
dilutional hyponatremia. The kidneys reabsorb too much water, which expands the
extracellular fluid volume but does not usually cause edema. Diluted serum sodium levels
are the hallmark of this condition, often leading to neurological changes.
of Medical–Surgical Nursing | Actual Q&A with
Rationale (NUR 265 Exam 2) | Galen
1. A 45-year-old male patient, Mr. Henderson, is admitted with Acute Kidney Injury (AKI) due
to severe dehydration. His serum potassium is 6.2 mEq/L. Which provider order should the
nurse implement first?
A. Administer Sodium Polystyrene Sulfonate (Kayexalate) 30g orally.
B. Obtain a 12-lead electrocardiogram (ECG) immediately.
C. Administer 10 units of regular insulin with 50% Dextrose intravenously.
D. Insert a foley catheter to monitor hourly urine output.
Correct Answer: B
Explanation: Hyperkalemia (potassium > 5.0 mEq/L) is a medical emergency that can lead
to lethal cardiac arrhythmias. The nurse’s first priority is to assess the cardiac rhythm
using an ECG to look for peaked T-waves or widened QRS complexes. While
insulin/dextrose and Kayexalate treat the potassium level, the safety and assessment of the
heart rhythm take precedence.
2. Mrs. Gable is being treated for Diabetes Insipidus (DI) following a transsphenoidal
hypophysectomy. Which clinical finding would indicate that the treatment with desmopressin
(DDAVP) is effective?
A. Serum sodium level increases to 150 mEq/L.
,B. Urine specific gravity increases from 1.002 to 1.015.
C. Urine output increases to 500 mL per hour.
D. Blood glucose level stabilizes at 110 mg/dL.
Correct Answer: B
Explanation: Desmopressin acts as synthetic antidiuretic hormone (ADH), which
facilitates water reabsorption in the kidneys. In DI, patients have dilute urine with low
specific gravity; a rise in specific gravity indicates the urine is becoming more
concentrated. Improved urine concentration and decreased volume are the primary goals
of therapy.
3. A patient with cirrhosis of the liver, Mr. Rodriguez, is experiencing increased confusion and
has a flapping tremor of the hands (asterixis). The nurse notes a serum ammonia level of 110
µmol/L. Which medication should the nurse anticipate administering?
A. Spironolactone
B. Lactulose
C. Propranolol
D. Vitamin K
Correct Answer: B
Explanation: Lactulose is the gold standard for treating hepatic encephalopathy by
promoting the excretion of ammonia through the stool. The presence of asterixis and
,elevated ammonia levels confirms the need for this osmotic laxative. The nurse should
monitor for 2 to 3 soft stools per day to ensure the medication is working effectively.
4. A 58-year-old female patient, Mrs. Jenkins, is 24 hours post-operative after a total
thyroidectomy. She complains of tingling around her mouth and fingertips. What is the
nurse’s priority action?
A. Check the patient’s blood pressure for hypertension.
B. Assess for Trousseau’s and Chvostek’s signs.
C. Notify the provider to request a STAT serum potassium level.
D. Administer an oral dose of Levothyroxine.
Correct Answer: B
Explanation: Tingling in the extremities and perioral area are early signs of hypocalcemia,
which can occur if the parathyroid glands are accidentally removed or damaged during a
thyroidectomy. The nurse must assess for Trousseau’s (carpal spasm) and Chvostek’s
(facial twitch) signs to confirm tetany risk. Early detection allows for rapid administration
of calcium gluconate to prevent seizures or laryngospasm.
5. A nurse is caring for a patient, Mr. Smith, who is receiving hemodialysis. The nurse notes
that the patient’s arteriovenous (AV) fistula has a palpable thrill and an audible bruit. How
should the nurse interpret these findings?
A. The fistula is clotted and requires surgical intervention.
B. The patient is developing an infection at the site.
, C. The patient is experiencing arterial insufficiency in the distal limb.
D. The fistula is patent and functioning normally.
Correct Answer: D
Explanation: A palpable thrill (vibration) and an audible bruit (whooshing sound) are
normal findings that indicate the AV fistula is patent. These signs confirm that blood flow is
moving from the high-pressure artery into the lower-pressure vein. The absence of these
signs would indicate a potential blockage or clot.
6. Which clinical manifestation would the nurse expect to find in a patient admitted with
Syndrome of Inappropriate Antidiuretic Hormone (SIADH)?
A. Increased urine output and dehydration.
B. Hyponatremia and fluid volume excess.
C. Hypotension and tachycardia.
D. Hyperglycemia and metabolic acidosis.
Correct Answer: B
Explanation: SIADH involves the excessive release of ADH, leading to water retention and
dilutional hyponatremia. The kidneys reabsorb too much water, which expands the
extracellular fluid volume but does not usually cause edema. Diluted serum sodium levels
are the hallmark of this condition, often leading to neurological changes.
