MedSurg II Exam 2
A client with acute liver failure exhibits confusion, a declining level of
consciousness,
and slowed respirations. The nurse finds him very difficult to arouse. The
information which best explains the client's
diagnostic
behavior is:
a) elevated liver enzymes and low serum
protein level.
b) subnormal serum glucose and elevated serum
ammonia levels.
c) subnormal clotting factors and platelet
count.
d) elevated blood urea nitrogen and creatinine levels and
hyperglycemia.
answers correct
b
A nurse is caring for an elderly male client who complains that he can't
pass urine.
bladder scanA reveals 600 ml of urine present in the bladder. The nurse
attempts
place the to
indwelling catheter the physician ordered, but resistance
preventsit.him
placing A serum
from prostate-specific antigen (PSA) test indicates a level of
29 g/L. The
physician places an indwelling catheter and the urine specimen returns
positive leukocytes,
nitrites, for and bacteriuria. Which conditions should the nurse
suspect?
all that Select
apply.
a) Prostate
problems
b) Urinary tract infection
(UTI)
c) Acute renal
failure
d) Vitamin K
deficiency
e) Liver failure correct
answersa, b
The nurse is assessing a client who is in the early stages of cirrhosis of the
liver. Which
focused assessment is
appropriate?
a) Peripheral
edema.
b)
Ascites.
c)
Anorexia.
d)Jaundice. correct
answersc
, When caring for a client with acute pancreatitis, the nurse should use
which comfort
measure
?
a) Administering an analgesic once per shift, as ordered, to prevent
drug addiction
b) Positioning the client on the side with the
knees flexed
c) Encouraging frequent visits from family and
friends
d) Administering frequent oral feedings correct
answersb
A client diagnosed with acute pancreatitis 5 days ago is experiencing
distress. The nurse should report which of the following to the health
respiratory
care provider?
a) Arterial oxygen level of 46
mm Hg.
b) Respirations of
12.
c) Lack of adventitious lung
sounds.
d) Oxygen saturation of 96% on room air. correct
answersa
Which finding will the nurse assess in a client diagnosed with
peritonitis?
a) Abdominal wall
rigidity
b) Absence of bowel
sounds
c) Positive Cullen's
sign
d) Battle's sign correct
answersa
Which of the following goals is most important for a client with acute
pancreatitis?
a) The client reports minimal
abdominal pain.
b) The client regains a normal pattern for bowel
movements.
c) The client limits alcohol intake to two to three drinks
per week.
d) The client maintains normal liver function. correct
answersa
A client with acute pancreatitis has a blood pressure of 88/40, heart rate of
128 minute,
per beats respirations of 28 per minute, and Grey Turner's sign. What
action
the nurse
should
perform
first?
A client with acute liver failure exhibits confusion, a declining level of
consciousness,
and slowed respirations. The nurse finds him very difficult to arouse. The
information which best explains the client's
diagnostic
behavior is:
a) elevated liver enzymes and low serum
protein level.
b) subnormal serum glucose and elevated serum
ammonia levels.
c) subnormal clotting factors and platelet
count.
d) elevated blood urea nitrogen and creatinine levels and
hyperglycemia.
answers correct
b
A nurse is caring for an elderly male client who complains that he can't
pass urine.
bladder scanA reveals 600 ml of urine present in the bladder. The nurse
attempts
place the to
indwelling catheter the physician ordered, but resistance
preventsit.him
placing A serum
from prostate-specific antigen (PSA) test indicates a level of
29 g/L. The
physician places an indwelling catheter and the urine specimen returns
positive leukocytes,
nitrites, for and bacteriuria. Which conditions should the nurse
suspect?
all that Select
apply.
a) Prostate
problems
b) Urinary tract infection
(UTI)
c) Acute renal
failure
d) Vitamin K
deficiency
e) Liver failure correct
answersa, b
The nurse is assessing a client who is in the early stages of cirrhosis of the
liver. Which
focused assessment is
appropriate?
a) Peripheral
edema.
b)
Ascites.
c)
Anorexia.
d)Jaundice. correct
answersc
, When caring for a client with acute pancreatitis, the nurse should use
which comfort
measure
?
a) Administering an analgesic once per shift, as ordered, to prevent
drug addiction
b) Positioning the client on the side with the
knees flexed
c) Encouraging frequent visits from family and
friends
d) Administering frequent oral feedings correct
answersb
A client diagnosed with acute pancreatitis 5 days ago is experiencing
distress. The nurse should report which of the following to the health
respiratory
care provider?
a) Arterial oxygen level of 46
mm Hg.
b) Respirations of
12.
c) Lack of adventitious lung
sounds.
d) Oxygen saturation of 96% on room air. correct
answersa
Which finding will the nurse assess in a client diagnosed with
peritonitis?
a) Abdominal wall
rigidity
b) Absence of bowel
sounds
c) Positive Cullen's
sign
d) Battle's sign correct
answersa
Which of the following goals is most important for a client with acute
pancreatitis?
a) The client reports minimal
abdominal pain.
b) The client regains a normal pattern for bowel
movements.
c) The client limits alcohol intake to two to three drinks
per week.
d) The client maintains normal liver function. correct
answersa
A client with acute pancreatitis has a blood pressure of 88/40, heart rate of
128 minute,
per beats respirations of 28 per minute, and Grey Turner's sign. What
action
the nurse
should
perform
first?
