NSG430 Exam 2 V1 | NSG 430 Adult Health
Nursing II | Grand Canyon University
1. A nurse is caring for a patient with hepatic encephalopathy. Which medication should the
nurse anticipate administering to decrease the patient’s ammonia levels?
A. Loperamide
B. Spironolactone
C. Lactulose
D. Furosemide
Answer: C
Rationale: Lactulose is the primary treatment for hepatic encephalopathy as it traps
ammonia in the gut and promotes its excretion through stools. The nurse must monitor the
patient for frequent bowel movements to ensure the medication is effective. Reducing
ammonia levels is critical to improving the patient’s neurological status and preventing
coma.
2. A patient with acute pancreatitis reports severe abdominal pain. Which position should the
nurse suggest to help alleviate the discomfort?
A. Supine with legs extended
B. Side-lying with knees flexed
C. Prone with a pillow under the chest
,D. High-Fowler’s position
Answer: B
Rationale: The fetal or side-lying position with knees flexed helps relieve the tension on
the abdominal muscles and the pancreas. Supine positioning often increases pain because it
stretches the peritoneum over the inflamed pancreas. Nursing care for pancreatitis focus
on comfort measures and reducing pancreatic enzyme stimulation.
3. Which laboratory finding is most indicative of a diagnosis of acute kidney injury (AKI)?
A. Increased serum creatinine
B. Decreased blood urea nitrogen (BUN)
C. Increased hemoglobin
D. Decreased serum potassium
Answer: A
Rationale: Serum creatinine is the most reliable indicator of renal function and increases
significantly when the glomerular filtration rate drops. BUN can be influenced by
dehydration or high protein intake, making it less specific than creatinine. In AKI, the nurse
should expect creatinine levels to rise rapidly over hours or days.
4. A patient is diagnosed with Diabetes Insipidus (DI) after a head injury. Which assessment
finding should the nurse prioritize?
A. Urine specific gravity of 1.030
, B. Urine output of 500 mL/hr
C. Serum sodium of 130 mEq/L
D. Blood glucose of 200 mg/dL
Answer: B
Rationale: Diabetes Insipidus is characterized by a deficiency of ADH, leading to massive
polyuria and dilute urine. A urine output of 500 mL/hr indicates a severe risk for
hypovolemic shock and dehydration. The nurse must monitor fluid balance and prepare to
administer vasopressin or desmopressin.
5. When caring for a patient with a newly created arteriovenous (AV) fistula for hemodialysis,
which action should the nurse include in the plan of care?
A. Auscultate for a bruit and palpate for a thrill
B. Take blood pressure on the arm with the fistula
C. Draw routine lab samples from the fistula
D. Apply a tight pressure dressing to the site
Answer: A
Rationale: The presence of a bruit and thrill indicates that the AV fistula is patent and
functioning properly. No blood pressures, IV starts, or blood draws should ever be
performed on the affected arm to prevent thrombosis or damage. Ensuring the patency of
the access site is a vital nursing responsibility for patients requiring dialysis.
Nursing II | Grand Canyon University
1. A nurse is caring for a patient with hepatic encephalopathy. Which medication should the
nurse anticipate administering to decrease the patient’s ammonia levels?
A. Loperamide
B. Spironolactone
C. Lactulose
D. Furosemide
Answer: C
Rationale: Lactulose is the primary treatment for hepatic encephalopathy as it traps
ammonia in the gut and promotes its excretion through stools. The nurse must monitor the
patient for frequent bowel movements to ensure the medication is effective. Reducing
ammonia levels is critical to improving the patient’s neurological status and preventing
coma.
2. A patient with acute pancreatitis reports severe abdominal pain. Which position should the
nurse suggest to help alleviate the discomfort?
A. Supine with legs extended
B. Side-lying with knees flexed
C. Prone with a pillow under the chest
,D. High-Fowler’s position
Answer: B
Rationale: The fetal or side-lying position with knees flexed helps relieve the tension on
the abdominal muscles and the pancreas. Supine positioning often increases pain because it
stretches the peritoneum over the inflamed pancreas. Nursing care for pancreatitis focus
on comfort measures and reducing pancreatic enzyme stimulation.
3. Which laboratory finding is most indicative of a diagnosis of acute kidney injury (AKI)?
A. Increased serum creatinine
B. Decreased blood urea nitrogen (BUN)
C. Increased hemoglobin
D. Decreased serum potassium
Answer: A
Rationale: Serum creatinine is the most reliable indicator of renal function and increases
significantly when the glomerular filtration rate drops. BUN can be influenced by
dehydration or high protein intake, making it less specific than creatinine. In AKI, the nurse
should expect creatinine levels to rise rapidly over hours or days.
4. A patient is diagnosed with Diabetes Insipidus (DI) after a head injury. Which assessment
finding should the nurse prioritize?
A. Urine specific gravity of 1.030
, B. Urine output of 500 mL/hr
C. Serum sodium of 130 mEq/L
D. Blood glucose of 200 mg/dL
Answer: B
Rationale: Diabetes Insipidus is characterized by a deficiency of ADH, leading to massive
polyuria and dilute urine. A urine output of 500 mL/hr indicates a severe risk for
hypovolemic shock and dehydration. The nurse must monitor fluid balance and prepare to
administer vasopressin or desmopressin.
5. When caring for a patient with a newly created arteriovenous (AV) fistula for hemodialysis,
which action should the nurse include in the plan of care?
A. Auscultate for a bruit and palpate for a thrill
B. Take blood pressure on the arm with the fistula
C. Draw routine lab samples from the fistula
D. Apply a tight pressure dressing to the site
Answer: A
Rationale: The presence of a bruit and thrill indicates that the AV fistula is patent and
functioning properly. No blood pressures, IV starts, or blood draws should ever be
performed on the affected arm to prevent thrombosis or damage. Ensuring the patency of
the access site is a vital nursing responsibility for patients requiring dialysis.
