PNR 206/PNR206 Exam 3 V3 | Medical-
Surgical Nursing II Q&A with Rationale |
Fortis College
1. A nurse is caring for a client with acute pancreatitis. Which laboratory result should the
nurse expect to find?
A. Decreased serum bilirubin
B. Increased serum calcium
C. Elevated serum amylase
D. Decreased white blood cell count
Answer: C
Rationale: Serum amylase levels rise significantly within 12 to 24 hours of the onset of
acute pancreatitis. This enzyme is released from the inflamed pancreas into the
bloodstream. Lipase levels also typically rise and remain elevated longer than amylase.
2. Which clinical manifestation is a hallmark sign of a small bowel obstruction?
A. Right lower quadrant pain
B. Bloody diarrhea
C. Profuse projectile vomiting
D. Decreased abdominal girth
,Answer: C
Rationale: Projectile vomiting is a classic sign of high-level small bowel obstruction as
contents cannot pass through the intestines. Patients may also experience metabolic
alkalosis due to the loss of gastric acids. Abdominal distention is also common, but
projectile vomiting is highly characteristic of small bowel issues.
3. A client is diagnosed with Cholecystitis. Where does the nurse expect the client to report
the most intense pain?
A. Right upper quadrant radiating to the right shoulder
B. Epigastric area radiating to the left shoulder
C. Left lower quadrant
D. Periumbilical area
Answer: A
Rationale: Pain associated with cholecystitis is typically located in the right upper
quadrant and can radiate to the right scapula or shoulder. This is often referred to as
Murphy’s sign when palpation causes the patient to catch their breath. The pain often
occurs after consuming a high-fat meal.
4. A nurse is monitoring a client with cirrhosis for signs of hepatic encephalopathy. Which
assessment finding is indicative of this complication?
A. Hypotension
B. Increased appetite
, C. Asterixis
D. Tachycardia
Answer: C
Rationale: Asterixis, also known as ‘liver flap,’ is a flapping tremor of the hands when the
arms are extended and is a classic sign of hepatic encephalopathy. This condition is caused
by the accumulation of ammonia in the blood crossing the blood-brain barrier. Other signs
include confusion, altered mental status, and fetor hepaticus.
5. What is the primary purpose of administering Lactulose to a client with advanced liver
disease?
A. To promote the excretion of ammonia
B. To reduce portal hypertension
C. To treat metabolic acidosis
D. To increase serum protein levels
Answer: A
Rationale: Lactulose is an osmotic laxative that works by trapping ammonia in the gut and
promoting its excretion via feces. It acidifies the colon, which converts ammonia into
ammonium, which is poorly absorbed. Success is measured by the improvement in the
client’s mental status.
Surgical Nursing II Q&A with Rationale |
Fortis College
1. A nurse is caring for a client with acute pancreatitis. Which laboratory result should the
nurse expect to find?
A. Decreased serum bilirubin
B. Increased serum calcium
C. Elevated serum amylase
D. Decreased white blood cell count
Answer: C
Rationale: Serum amylase levels rise significantly within 12 to 24 hours of the onset of
acute pancreatitis. This enzyme is released from the inflamed pancreas into the
bloodstream. Lipase levels also typically rise and remain elevated longer than amylase.
2. Which clinical manifestation is a hallmark sign of a small bowel obstruction?
A. Right lower quadrant pain
B. Bloody diarrhea
C. Profuse projectile vomiting
D. Decreased abdominal girth
,Answer: C
Rationale: Projectile vomiting is a classic sign of high-level small bowel obstruction as
contents cannot pass through the intestines. Patients may also experience metabolic
alkalosis due to the loss of gastric acids. Abdominal distention is also common, but
projectile vomiting is highly characteristic of small bowel issues.
3. A client is diagnosed with Cholecystitis. Where does the nurse expect the client to report
the most intense pain?
A. Right upper quadrant radiating to the right shoulder
B. Epigastric area radiating to the left shoulder
C. Left lower quadrant
D. Periumbilical area
Answer: A
Rationale: Pain associated with cholecystitis is typically located in the right upper
quadrant and can radiate to the right scapula or shoulder. This is often referred to as
Murphy’s sign when palpation causes the patient to catch their breath. The pain often
occurs after consuming a high-fat meal.
4. A nurse is monitoring a client with cirrhosis for signs of hepatic encephalopathy. Which
assessment finding is indicative of this complication?
A. Hypotension
B. Increased appetite
, C. Asterixis
D. Tachycardia
Answer: C
Rationale: Asterixis, also known as ‘liver flap,’ is a flapping tremor of the hands when the
arms are extended and is a classic sign of hepatic encephalopathy. This condition is caused
by the accumulation of ammonia in the blood crossing the blood-brain barrier. Other signs
include confusion, altered mental status, and fetor hepaticus.
5. What is the primary purpose of administering Lactulose to a client with advanced liver
disease?
A. To promote the excretion of ammonia
B. To reduce portal hypertension
C. To treat metabolic acidosis
D. To increase serum protein levels
Answer: A
Rationale: Lactulose is an osmotic laxative that works by trapping ammonia in the gut and
promoting its excretion via feces. It acidifies the colon, which converts ammonia into
ammonium, which is poorly absorbed. Success is measured by the improvement in the
client’s mental status.
