NURS 101 Final Exam 2025 Questions and Answers with Rationales

A client is prone to hyponatremia. Which factors should the nurse identify that can precipitate hyponatremia? Select all that apply. Wound drainage Diuretic therapy Gastrointestinal (GI) suction Parenteral infusion of 0.9% sodium chloride Inappropriate anti-diuretic hormone (ADH) secretion - Correct Ans-Wound Drainage Diuretic Therapy GI Suction Inappropriate Anti-Diuretic Hormone Secretion Rationale: Wound drainage can result in hyponatremia from loss of sodium ions. Most diuretics interfere with sodium reabsorption in the nephrons and have the side effect of hyponatremia. Gastrointestinal fluids are rich in sodium ions, which are lost by GI suction. With the syndrome of inappropriate anti-diuretic hormone (SIADH), high levels of the anti-diuretic hormone (ADH) are produced, causing the body to retain water instead of excreting it normally in the urine. Parenteral infusion of 0.9% sodium chloride, an isotonic solution, should be compatible with body fluids; if given in excess, it may lead to hypernatremia. The nurse is assessing the respiratory status of the client at 2-hour intervals as a nursing safety priority. Which condition is affecting the client? Hypokalemia Hyperkalemia Hyponatremia Hypernatremia - Correct Ans-Hypokalemia Rationale: Nurs 101 Nurs 101 Nurs 101 In case of hypokalemia, the nurse should assess the respiratory status of the client every 2 hours. In case of hyperkalemia, the nurse should notify the healthcare team if the heart rate falls below 60 beats per minute or T waves become spiked. In case of hyponatremia, the nurse should be aware of muscle weakness in the client and immediately check respiratory effectiveness. In case of hypernatremia, the nurse should assess the client hourly for excessive losses of fluid, sodium, or potassium. The nurse is preparing a blood transfusion for a client with renal failure. Why does anemia often complicate renal failure? 1. Increase in blood pressure 2. Decrease in erythropoietin 3. Increase in serum phosphate levels 4. Decrease in serum sodium concentration - Correct Ans-2. Decrease in erythropoietin Rationale: The hormone erythropoietin, produced by the kidneys, stimulates the bone marrow to produce red blood cells. In renal failure there is a deficiency of erythropoietin that often results in the client developing anemia. Therefore the nurse is instructed to administer blood. In renal failure, increased blood pressure is due to impairment of renal vasodilator factors and is not treated by administration of blood. Phosphate is retained in the body during renal failure, causing binding of calcium leading to done demineralization, not anemia. Increase in urinary sodium concentration and decrease in serum sodium concentration trigger the release of renin from the juxtaglomerular cells. A client's serum potassium level has increased to 5.8 mEq/L (5.8 mmol/L). What action should the nurse implement first? 1. Call the laboratory to repeat the test. 2. Take vital signs and notify the healthcare provider. 3. Inform the cardiac arrest team to place them on alert. 4. Take an electrocardiogram and have lidocaine available - Correct Ans-2. take vs and notify healthcare provider rationale: Vital signs monitor cardiorespiratory status; hyperkalemia causes cardiac dysrhythmias. The healthcare provider should be notified because medical intervention may be necessary. A repeat laboratory test will take time and probably reaffirm the original results; the client needs immediate attention. The cardiac arrest team is always on alert and will respond when called for a cardiac arrest. Taking an electrocardiogram and having lidocaine available are insufficient interventions. A nurse is caring for a client with a diagnosis of chronic kidney failure who has just been told by the primary healthcare provider that hemodialysis is necessary. Which clinical manifestation indicates the need for hemodialysis? 1. Ascites Nurs 101 Nurs 101 2. Acidosis 3. Hypertension 4. Hyperkalemia - Correct Ans-4. Hyperkalemia Rationale: Protein breakdown liberates cellular potassium ions, leading to hyperkalemia, which can cause a cardiac dysrhythmia and standstill. The failure of the kidneys to maintain a balance of potassium is one of the main indications for dialysis. Ascites occurs in liver disease and is not an indication for dialysis. Dialysis is not the usual treatment for acidosis; usually this responds to administration of alkaline drugs. Dialysis is not a treatment for hypertension; this is usually controlled by antihypertensive medication and diet. Which electrolyte deficiency triggers the secretion of renin? 1. Sodium 2. Calcium 3. Chloride 4. Potassium - Correct Ans-1. Sodium Rationale: Low sodium ion concentration causes decreased blood volume, thereby resulting in decreased perfusion. Decreased blood volume triggers the release of renin from the juxtaglomerular cells. Deficiencies of calcium, chloride, and potassium do not stimulate the secretion of renin. A client with small cell carcinoma of the lung develops the syndrome of inappropriate antidiuretic hormone (SIADH). What signs should the nurse expect to observe? Select all that apply. 1. Oliguria 2. Seizures 3. Vomiting 4. Polydipsia 5. Polyphagia - Correct Ans-1. Oliguria 2. Seizures 3. Vomiting Rationale: Cancerous cells of small cell lung cancer can produce antidiuretic hormone, which causes fluid retention, resulting in increased blood volume and decreased urine volume. Fluid retention associated with SIADH can cause cerebral edema, resulting in confusion and seizures. Fluid retention resulting in hyponatremia causes nausea and vomiting. The client will have nausea and vomiting, resulting in a decreased oral fluid and food intake A client is admitted for dehydration and an intravenous (IV) infusion of normal saline at 125 mL/hr has been started. One hour after the IV initiation the client begins screaming, "I can't breathe!" What is the nurse's priority action? Nurs 101 Nurs 101 1. Elevate the head of the bed and obtain vital signs. 2. Discontinue the IV site and contact the primary healthcare provider. 3. Change the IV to an intermittent infusion device. 4. Contact the primary healthcare provider to obtain a prescription for a sedative - Correct Ans-1. Elevate the head of the bed and obtain vital signs Rationale: The client's ability to speak indicates that the client is breathing. Elevating the head of the bed facilitates breathing by decreasing pressure against the diaphragm. Checking the vital signs after this is the first step in assessing the cause of the distress. Discontinuing the IV access line may cause unnecessary discomfort if it must be restarted; there are too few data to call the healthcare provider at this time. There is not enough information to support calling the healthcare provider and obtaining a prescription for a sedative; further assessment is required. There is no information to support changing the IV to an intermittent infusion device. An intravenous solution containing potassium inadvertently has infused too rapidly. The healthcare provider prescribes insulin added to a 10% dextrose in water solution. What does the nurse identify as the purpose of the insulin? 1. Potassium follows insulin and glucose into the cells of the body, thereby raising the intracellular potassium level. 2. Increased insulin accelerates excretion of glucose and potassium, thereby decreasing the serum potassium level. 3. Glucose with insulin increases metabolism, which accelerates potassium excretion. 4. Increased potassium causes a temporary slowing of pancreatic production of insulin. - Correct Ans-1. Potassium follows insulin and glucose into the cells of the body, thereby raising the intracellular potassium level. Rationale: Potassium follows insulin into the cells of the body, thereby raising the intracellular potassium level and preventing fatal dysrhythmias. Insulin does not cause excretion of these substances. Potassium is not excreted as a result of this therapy; it shifts into the intracellular compartment. The potassium level has no effect on pancreatic insulin production. An intravenous piggyback (IVPB) of cefazolin 500 mg in 50 mL of 5% dextrose in water is to be administered over a 20-minute period. The tubing has a drop factor of 15 drops/mL. At what rate per minute should the nurse regulate the infusion to run? Record your answer using a whole number. Do not include units in your answer. ______ gtt/min - Correct Ans-The total volume to be infused is 50 mL. The total infusion time is 20 minutes. The drop factor of the tubing is 15 gtt/mL. Using dimensional analysis, the rate in drops (gtt)/minute can be calculated like this: 50 mL/20 min x 15 gtt/mL = (50 x 15)/20 = 750/20 = 75/2 = 37.5 gtt/min Note: Because drops (gtt) cannot be accurately measured as fractions in most clinical settings, rounding will be necessary; therefore, 37.5 gtt/min = 38 gtt/min Nurs 101 Nurs 101 A cachectic adolescent with the diagnoses of anorexia nervosa, dehydration, and electrolyte imbalances is admitted to a mental health facility. The adolescent has been obsessed with weight, has exercised for hours every day, has taken enemas and laxatives several times a week, and has engaged in self-induced vomiting. What outcome is a priority for the nurse planning care for this client? 1. Identifying personal strengths 2. Controlling impulsive behaviors 3. Correcting electrolyte imbalances 4. Developing a contract for treatment goal - Correct Ans-3. Correcting electrolyte imbalances Rationale: Electrolyte imbalances can precipitate life-threatening dysrhythmias. Although clients with the diagnosis of anorexia nervosa have low self-esteem, and identifying and supporting strengths promote the development of a positive self-regard, this is not the priority at this time. Clients with anorexia are perfectionists who usually do not display impulsivity. Developing a contract for treatment outcomes is difficult to accomplish initially, because anorexic clients often deny the illness and evade therapeutic treatment. A client who has been immobile for a prolonged time develops hypercalcemia. Which findings are consistent with this condition? Select all that apply. 1. Bone pain 2. Convulsions 3. Muscle spasms 4. Tingling of extremities 5. Depressed deep tendon reflexes - Correct Ans-1. Bone pain 5. Depressed deep tendon reflexes Rationale: Increased serum calcium comes from bone demineralization, which results in bone pain. Depressed or absent deep tendon reflexes are associated with hypercalcemia. The body's excitable tissues are affected most (e.g., nerves, muscles, heart, intestinal smooth muscles). Convulsions are not a sign of hypercalcemia; convulsions can occur with hypocalcemia, hypernatremia, and hyponatremia. Muscle spasms are not a sign of hypercalcemia; muscle spasms can occur with hypocalcemia, hyponatremia, and hypokalemia. Tingling of extremities is not a sign of hypercalcemia; paresthesias are associated with hypocalcemia and hyperkalemia. During an 8-hour shift a client has a 6-oz (180 mL) cup of tea and 360 mL of water; the client vomits 100 mL, and the intravenous (IV) fluids instilled equal the urinary output. What is this client's fluid balance at the end of this 8-hour period that the nurse must document on the client's intake and output record? Nurs 101 Nurs 101 1. 240 mL 2. 340 mL 3. 440 mL 4. 540 mL - Correct Ans-3. 440 mL Rationale: 440 mL is the correct calculation. The client's intake was 180 mL of tea and 360 mL of water for a total fluid intake of 540 mL; the client vomited 100 mL, which when subtracted from 540 mL leaves 440 mL. The IV fluid intake and the urinary output are equal; therefore, they do not influence the final fluid balance. The options 240 mL, 340 mL, and 540 mL are incorrect calculations After surgical clipping of a cerebral aneurysm, the client develops the syndrome of inappropriate secretion of antidiuretic hormone (ADH). Which outcome would the nurse anticipate? 1. Increased blood urea nitrogen (BUN) 2. Increased serum sodium level 3. Decreased specific gravity 4. Decreased urine output - Correct Ans-4. Decreased urine output Rationale: ADH causes water retention, resulting in decreased urine output. Blood volume may increase, causing dilution of nitrogenous wastes in the blood. The client is overhydrated so that serum sodium is decreased, producing a dilution hyponatremia. ADH acts on nephrons to cause water to be reabsorbed from glomerular filtrate, leading to an increased specific gravity of urine. Which recommendation is most important for the nurse to include in a teaching program for a client who has been placed on a 2-gram sodium diet? 1. Use lemon juice to season meat. 2. Put condiments on food to add flavor. 3. Include canned vegetables in meal preparation. 4. Drink carbonated beverages instead of decaffeinated coffee - Correct Ans-1. Use lemon juice to season meat. Rationale: Lemon juice adds flavor and is low in sodium. Condiments (e.g., mustard, ketchup) are high in sodium and should be avoided. Canned vegetables contain a large amount of sodium; fresh vegetables should be encouraged. Carbonated beverages general