NU 155 EXAM Medical Surgical Nursing
Questions and Answers GALEN
1. While monitoring a patient who has fluid overload, the nurse
would be most concerned about which assessment finding?
A. Pitting edema in the feet
B. Neck vein distention
C. Bounding pulse
D. Presence of crackles in the lungs:
ANS D
Rationale: Fluid overload may lead to pulmonary edema and heart failure. Any patient with fluid overload,
regardless of age, is at risk for these complications. Older adults or those with cardiac problems, kidney
problems, pulmonary problems, or liver problems are at greater risk. The presence of crackles in the
lungs may be indicative of pulmonary edema, which can occur very quickly and lead to death in
patients with fluid overload.
2. A patient has been having frequent liquid diarrhea for the last
24 hours. A stool sample was sent to the laboratory to confirm
whether the patient has a Clostridium difficileinfection. The
nurse should monitor the patient for which electrolyte
imbalance?
A. Hypokalemia
B.Hyponatremia
,C.Dehydration
D.Hypocalcemia:
ANS A
Rationale: Potassium re-absorption primarily occurs through the renal system. However, approximately
10% of potas- sium regulation occurs in the gut. Hypokalemia can result when clients experience
significant diarrhea.
3. A 25-year-old student has been taken to an urgent care clinic
because of dehydration. She says she has had "the flu," with
vomiting and diarrhea "all night" and admits that she has had very
little to eat or drink. She now says the GI symptoms have subsided
but she feels weak. The nurse expects which type of rehydration to
occur?
Ï
A. Oral rehydration therapy with water
B. Oral rehydration therapy with a solution containing glucose and
electrolytes
C. Oral rehydration therapy with tea
D. IV fluid replacement:
ANS B
Rationale: Whenever possible, fluids are replaced by the oral route. When dehydration is severe or life
threatening,
or the patient is not able to tolerate oral fluids, IV fluid replacement is needed. Oral rehydration therapy
(ORT) is a cost-effective way to replace fluids for the patient with dehydration. Specifically formulated
,solutions containing glucose and electrolytes are absorbed even when the patient is vomiting or has
diarrhea.
4. A patient is brought to the ED after being hit by a car while
biking. He is unresponsive, has shallow breathing, and has an open
femur fracture from which he has lost a significant amount of
blood. The nurse anticipates which acid-base imbalance?
A. Metabolic
alkalosis
B.Respiratory
acidosis
C.Metabolic alkalosis and respiratory alkalosis
D.Metabolic acidosis and respiratory acidosis:
ANS D
Rationale: Hypoperfusion associated with significant shift in intravascular volume and/or blood loss
that may be experienced by patients with significant trauma, burn injuries, sepsis, shock states, or
cardiac arrest are examples of problems leading to metabolic acidosis. Shallow breathing or ineffective
ventilation causes respiratory acidosis. Combined acidosis is more severe than either metabolic
acidosis or respiratory acidosis alone.
5. The nurse is evaluating the laboratory work of a patient who has
uncontrolled metabolic acidosis. Which outcome would result from
this condition?
A. pH 7.40
, B. Bicarbonate 38 mEq/L
C. Pao298 mm Hg
D. Serum potassium 5.7 mEq/L(body attempting to
electroneutrallycorrect dur- ing buffering>:
ANS D
Rationale:Metabolic acidosisis reflected by several changes in ABG values. The pH is low (<7.35). The
bicarbonate level is low (<21 mEq/L). The partial pressure of arterial oxygen (Pao2) is normal because
gas exchange is adequate. The serum potassium level is often high in acidosis as the body attempts to
maintain electroneutrality during buttering
6. The nurse is reviewing the standing orders for a patient who
was admitted for evaluation of chest pain. The patient has a
history of chronic obstructive pulmonary disease (COPD), and his
laboratory results and assessment reveal that he has mild
respiratory acidosis. The nurse would question which order?
A. Encourage oral fluids
B. Oxygen therapy at 4 L/min as
needed C.Keep head of bed
elevated
Bedrest with bathroom privileges only:
ANS B
Rationale: The bedrest order will help the patient conserve energy. The upright position (mid-Fowler's to
high-Fowler's position) helps increase lung expansion. Increasing fluid intake may reduce the thickness
of lung secretions and assist in their removal. Oxygen therapy helps promote gas exchange for patients
Questions and Answers GALEN
1. While monitoring a patient who has fluid overload, the nurse
would be most concerned about which assessment finding?
A. Pitting edema in the feet
B. Neck vein distention
C. Bounding pulse
D. Presence of crackles in the lungs:
ANS D
Rationale: Fluid overload may lead to pulmonary edema and heart failure. Any patient with fluid overload,
regardless of age, is at risk for these complications. Older adults or those with cardiac problems, kidney
problems, pulmonary problems, or liver problems are at greater risk. The presence of crackles in the
lungs may be indicative of pulmonary edema, which can occur very quickly and lead to death in
patients with fluid overload.
2. A patient has been having frequent liquid diarrhea for the last
24 hours. A stool sample was sent to the laboratory to confirm
whether the patient has a Clostridium difficileinfection. The
nurse should monitor the patient for which electrolyte
imbalance?
A. Hypokalemia
B.Hyponatremia
,C.Dehydration
D.Hypocalcemia:
ANS A
Rationale: Potassium re-absorption primarily occurs through the renal system. However, approximately
10% of potas- sium regulation occurs in the gut. Hypokalemia can result when clients experience
significant diarrhea.
3. A 25-year-old student has been taken to an urgent care clinic
because of dehydration. She says she has had "the flu," with
vomiting and diarrhea "all night" and admits that she has had very
little to eat or drink. She now says the GI symptoms have subsided
but she feels weak. The nurse expects which type of rehydration to
occur?
Ï
A. Oral rehydration therapy with water
B. Oral rehydration therapy with a solution containing glucose and
electrolytes
C. Oral rehydration therapy with tea
D. IV fluid replacement:
ANS B
Rationale: Whenever possible, fluids are replaced by the oral route. When dehydration is severe or life
threatening,
or the patient is not able to tolerate oral fluids, IV fluid replacement is needed. Oral rehydration therapy
(ORT) is a cost-effective way to replace fluids for the patient with dehydration. Specifically formulated
,solutions containing glucose and electrolytes are absorbed even when the patient is vomiting or has
diarrhea.
4. A patient is brought to the ED after being hit by a car while
biking. He is unresponsive, has shallow breathing, and has an open
femur fracture from which he has lost a significant amount of
blood. The nurse anticipates which acid-base imbalance?
A. Metabolic
alkalosis
B.Respiratory
acidosis
C.Metabolic alkalosis and respiratory alkalosis
D.Metabolic acidosis and respiratory acidosis:
ANS D
Rationale: Hypoperfusion associated with significant shift in intravascular volume and/or blood loss
that may be experienced by patients with significant trauma, burn injuries, sepsis, shock states, or
cardiac arrest are examples of problems leading to metabolic acidosis. Shallow breathing or ineffective
ventilation causes respiratory acidosis. Combined acidosis is more severe than either metabolic
acidosis or respiratory acidosis alone.
5. The nurse is evaluating the laboratory work of a patient who has
uncontrolled metabolic acidosis. Which outcome would result from
this condition?
A. pH 7.40
, B. Bicarbonate 38 mEq/L
C. Pao298 mm Hg
D. Serum potassium 5.7 mEq/L(body attempting to
electroneutrallycorrect dur- ing buffering>:
ANS D
Rationale:Metabolic acidosisis reflected by several changes in ABG values. The pH is low (<7.35). The
bicarbonate level is low (<21 mEq/L). The partial pressure of arterial oxygen (Pao2) is normal because
gas exchange is adequate. The serum potassium level is often high in acidosis as the body attempts to
maintain electroneutrality during buttering
6. The nurse is reviewing the standing orders for a patient who
was admitted for evaluation of chest pain. The patient has a
history of chronic obstructive pulmonary disease (COPD), and his
laboratory results and assessment reveal that he has mild
respiratory acidosis. The nurse would question which order?
A. Encourage oral fluids
B. Oxygen therapy at 4 L/min as
needed C.Keep head of bed
elevated
Bedrest with bathroom privileges only:
ANS B
Rationale: The bedrest order will help the patient conserve energy. The upright position (mid-Fowler's to
high-Fowler's position) helps increase lung expansion. Increasing fluid intake may reduce the thickness
of lung secretions and assist in their removal. Oxygen therapy helps promote gas exchange for patients
