Fluid and electrolyte imbalances underlie much of med-surg nursing, and the CMSRN tests them hard. Practice the sodium, potassium, and calcium scenarios below, each with a full rationale.
Question 1
A 68-year-old with heart failure (ejection fraction 30%) and stage 3 CKD reports 3.5 kg weight gain over 48 hours and dyspnea at rest. Vital signs: BP 160/92 mmHg, O2 sat 89% on room air. Furosemide was increased yesterday without effect. Which care plan revision is most appropriate?
- A) A) Add hydrochlorothiazide and schedule daily weights
- B) B) Initiate IV bumetanide and continuous pulse oximetry✓
- C) C) Increase furosemide dosage and restrict fluid to 1L/day
- D) D) Maintain current diuretic and order renal function tests
Show rationale
B is correct due to acute decompensation (rapid weight gain, dyspnea at rest, hypoxia) and CKD limiting oral diuretic efficacy. IV bumetanide achieves faster diuresis in renal impairment. Continuous oximetry monitors respiratory compromise. A is inadequate: hydrochlorothiazide is less effective in CKD and ignores hypoxia. C is unsafe: further oral furosemide may cause toxicity without addressing oxygenation. D delays intervention despite worsening symptoms. CMSRN standards prioritize rapid response to acute fluid overload with renal considerations.
Question 2
A patient with heart failure (Morse: secondary diagnosis=15) and 10-lb weight gain overnight has "weak gait" (Morse gait=10). Which clinical change most significantly increases fall risk?
- A) A) New prescription for furosemide IV
- B) B) Oxygen saturation dropping to 88% on room air✓
- C) C) Complaints of bilateral ankle edema
- D) D) Order for daily weights before breakfast
Show rationale
Hypoxia (B) directly exacerbates gait weakness and mental status, increasing fall risk per Morse parameters. A (furosemide) reduces fluid overload long-term but may cause acute orthostasis. C (edema) and D (daily weights) monitor heart failure but don't indicate immediate mobility impairment like hypoxia.
Question 3
An alert patient with heart failure refuses daily weights, stating "It's pointless." The nurse explains risks of fluid overload, but the patient persists. Laboratory results show rising BNP levels. Which documentation best supports legal defensibility?
- A) A) Patient educated on weight monitoring importance. Continued refusal despite explanation of decompensation risks.✓
- B) B) Daily weights declined. Provider notified. Will continue encouraging compliance tomorrow.
- C) C) Refused weight. BNP elevated. Suspect nonadherence will worsen prognosis.
- D) D) Patient noncompliant with weights. Risks explained but unwilling to participate in care.
Show rationale
Option A objectively captures patient capacity, education provided, and persistent refusal without judgment—key for legal protection against abandonment claims. It includes two cues: refusal rationale and risk explanation. Option B omits patient reasoning. Option C uses speculative language ("suspect") and diagnoses prognosis, which is inappropriate. Option D employs punitive terms ("noncompliant") that may imply bias. AMSN guidelines require documenting refusals with specific education, patient understanding, and behaviors without labeling.
Question 4
During hypoglycemia management for a diabetic patient (glucose 52 mg/dL), an LPN administers D50 IV per protocol. Which subsequent action must the RN perform personally?
- A) A) Rechecking glucose in 15 minutes
- B) B) Providing peanut butter crackers
- C) C) Assessing cardiac rhythm via monitor✓
- D) D) Documenting the treatment response
Show rationale
Cardiac monitoring requires RN expertise to evaluate arrhythmia risks from rapid glucose shifts. Glucose checks (A) and documentation (D) are within LPN scope. Providing snacks (B) can be delegated. Cues (severe hypoglycemia, IV dextrose) necessitate RN assessment for electrolyte imbalances affecting cardiac function per AMSN guidelines.
Question 5
A 68-year-old patient with heart failure (EF 35%) and chronic kidney disease is admitted with acute dyspnea. The nurse documents: "BP 150/90, RR 32, SpO₂ 89% on RA, crackles bilaterally, +3 pitting edema." Which subsequent documentation entry best demonstrates analysis of clinical data?
- A) A) Administered furosemide 40 mg IV as ordered. Will monitor urine output hourly.
- B) B) Positioned patient in high Fowler's. Initiated oxygen at 2L/min via nasal cannula.
- C) C) Fluid volume excess evidenced by hypertension, tachypnea, and peripheral edema.✓
- D) D) Reviewed dietary sodium restrictions with patient and family. Education understood.
Show rationale
Option C analyzes assessment findings to identify fluid overload, aligning with the patient's heart failure and kidney disease. Option A documents intervention without analysis. Option B records actions but doesn't interpret data. Option D focuses on education rather than clinical interpretation. Documentation must link cues to clinical judgment per NANDA-I standards.
Question 6
A 68-year-old patient with COPD and heart failure is admitted with acute dyspnea. Oxygen saturation is 89% on room air, respiratory rate 28/min with accessory muscle use, and pedal edema +2. Which assessment should be prioritized while awaiting ABG results?
- A) A) Auscultate lung fields for crackles and wheezes✓
- B) B) Measure jugular venous distension with HOB at 45 degrees
- C) C) Assess calf symmetry and Homans' sign bilaterally
- D) D) Evaluate orientation using the Mini-Mental State Exam
Show rationale
Auscultation directly assesses acute respiratory compromise, differentiating between pulmonary edema (crackles) and bronchospasm (wheezes) to guide immediate intervention. Option B evaluates fluid overload but is less urgent than respiratory status. Option C assesses for DVT, which doesn't explain acute dyspnea. Option D evaluates mental status, but hypoxia is the primary concern over delirium here. ABG results pending increases reliance on physical assessment per respiratory distress protocols.
Question 7
A cirrhotic patient with ascites develops agitation and asterixis after aggressive paracentesis. Serum sodium is 128 mEq/L, potassium 3.0 mEq/L, and ammonia 120 µmol/L. Which management aligns with current evidence?
- A) A) Restrict protein to 40 g/day and start lactulose
- B) B) Administer 3% saline and potassium supplements
- C) C) Infuse albumin and correct potassium deficit✓
- D) D) Initiate broad-spectrum antibiotics immediately
Show rationale
Hyponatremia and hypokalemia here are secondary to post-paracentesis circulatory dysfunction and diuretic use, exacerbating hepatic encephalopathy. Albumin prevents intravascular depletion, and potassium correction (C) addresses alkalosis that worsens ammonia toxicity. Protein restriction/lactulose (A) is outdated for acute encephalopathy. Hypertonic saline (B) risks volume overload in cirrhosis. Antibiotics (D) are for confirmed infection. Cues (post-paracentesis, asterixis, electrolyte imbalances) prioritize volume/potassium correction per AASLD guidelines.
Question 8
Three hours post-total knee replacement, a patient with type 2 diabetes (HbA1c 8.2%) and BMI 34 has persistent shivering despite warm blankets. Core temperature is 35.1°C (95.2°F). Which action best addresses hypothermia risks per ASPAN standards?
- A) A) Administer IV meperidine 25mg and apply forced-air warming blanket✓
- B) B) Give warm oral fluids and increase ambient room temperature
- C) C) Initiate rapid IV fluid warming and monitor glucose levels
- D) D) Cover patient with additional warmed cotton blankets and reassess
Show rationale
Meperidine specifically treats shivering, while forced-air warming actively reverses hypothermia per ASPAN guidelines. Option B is inadequate for moderate hypothermia and risks aspiration. Option C misprioritizes fluid warming (for severe hypovolemia) and misses shivering intervention. Option D uses passive warming insufficient for core temperature <35.5°C. BMI and diabetes increase hypothermia risks, requiring active rewarming and shivering control.
Question 9
A telehealth nurse notes a patient with heart failure has gained 3 lbs in 48 hours and reports ankle swelling. Home BP is 150/92 mmHg. Which action demonstrates appropriate telemedicine triage?
- A) A) Advise doubling diuretic dose and report changes in 3 days
- B) B) Instruct to hold all antihypertensives until seen in person
- C) C) Arrange clinic visit within 24 hours for assessment✓
- D) D) Request daily weight logs and sodium intake records via portal
Show rationale
Rapid weight gain with hypertension suggests decompensation, needing prompt evaluation per AHA guidelines. Option C balances urgency and resource use. Option A risks electrolyte imbalance without provider input. Option B may cause rebound hypertension. Option D monitors but delays intervention for acute changes. Cues (3-lb gain, edema, hypertension) indicate instability.
Question 10
A 68-year-old with COPD and heart failure (ejection fraction 30%) reports increased dyspnea and fatigue over 3 days. Assessment reveals bilateral crackles to mid-lung fields, weight gain of 2.3 kg in 48 hours, and SpO₂ 90% on 2L NC. Which intervention requires immediate implementation?
- A) A) Administer prescribed PRN furosemide 40mg IV✓
- B) B) Increase oxygen flow rate to 4L per nasal cannula
- C) C) Obtain stat chest X-ray to evaluate pulmonary edema
- D) D) Initiate incentive spirometry every 2 hours while awake
Show rationale
The 2.3 kg weight gain, crackles, and dyspnea indicate acute fluid overload exacerbating heart failure, which is life-threatening with this EF. Diuresis (A) directly addresses fluid overload per heart failure guidelines. Increasing oxygen (B) risks CO₂ retention in COPD without resolving the cause. Chest X-ray (C) confirms but doesn't treat the emergency. Incentive spirometry (D) aids ventilation but doesn't reduce fluid volume. Furosemide aligns with both weight gain (cue 1) and crackles (cue 2), while distractors ignore either the acuity or COPD comorbidity.
