NSG 4100 (AH III) Exam 2
1. The nurse is caring for a client with Liver Cirrhosis who has developed Ascites. Which of the
following is the priority nursing intervention?
A. Encouraging a high-sodium diet to increase blood volume B. Monitoring respiratory
status and abdominal girth C. Administering IV fluids at a rapid rate D. Encouraging the
client to perform vigorous exercise
Annotation: ASCITES = FLUID IN THE BELLY. It pushes on the diaphragm, making it
hard to breathe. Monitor for SOB and measure girth daily to track fluid buildup.
2. A client with Cirrhosis is experiencing Hepatic Encephalopathy. The nurse should anticipate
which of the following orders?
A. High-protein diet to promote liver healing B. Administration of Lactulose and
Neomycin C. Administration of Vitamin K for bleeding D. Fluid restriction to 500 mL/day
Annotation: ENCEPHALOPATHY = AMMONIA BUILDUP. Lactulose makes them poop
out the ammonia. Neomycin kills the bacteria that make ammonia. Watch for
confusion and asterixis (hand flapping).
3. The nurse is assessing a client with Acute Pancreatitis. Which of the following findings is
most characteristic?
A. Pain in the right lower quadrant (RLQ) B. Severe epigastric pain radiating to the back
C. Pain relieved by eating a high-fat meal D. Pain that is worse when lying on the left side
Annotation: PANCREATITIS = “AUTODIGESTION.” The enzymes eat the pancreas. It’s
extremely painful! Keep them NPO to rest the pancreas.
4. A client with Pancreatitis has a positive Cullen’s sign. What does this indicate?
A. Obstruction of the common bile duct B. Inflammation of the gallbladder C. Intra-
abdominal hemorrhage (Bruising around the umbilicus) D. Rupture of the pancreatic
duct
Annotation: CULLEN’S = CIRCLE (Umbilicus). TURNER’S = TURN (Flank). Both mean
internal bleeding. This is a medical emergency!
, 5. The nurse is caring for a client with Type 1 Diabetes who is experiencing Diabetic
Ketoacidosis (DKA). Which of the following is the priority intervention?
A. Rapid IV fluid resuscitation with Normal Saline B. Administration of IV Regular
Insulin C. Administration of Sodium Bicarbonate for acidosis D. Monitoring for signs of
hypoglycemia
Annotation: DKA = DEHYDRATION + ACIDOSIS. They are severely dehydrated! Fluids
(NS) come FIRST to restore volume. Insulin comes second to stop the ketones.
6. A client with Type 2 Diabetes is admitted with Hyperosmolar Hyperglycemic State (HHS).
Which of the following findings is consistent with this diagnosis?
A. Ketonuria and metabolic acidosis B. Severe hyperglycemia (>600 mg/dL) and
profound dehydration C. Kussmaul’s respirations and fruity breath D. Rapid onset of
symptoms within hours
Annotation: HHS = NO KETONES. They have just enough insulin to prevent ketones,
but their sugar goes SKY HIGH. They are even more dehydrated than DKA patients.
7. The nurse is assessing a client with Esophageal Varices. Which of the following is the
priority risk?
A. Malnutrition and weight loss B. Massive hemorrhage and airway obstruction C.
Chronic cough and dysphagia D. Ascites and peripheral edema
Annotation: VARICES = “HEMORRHOIDS” in the throat. If they burst, the patient can
bleed to death in minutes. Avoid coughing, straining, or rough foods.
8. A client is 1 hour post-op from a Paracentesis. The nurse should monitor for which of the
following complications?
A. Hypertension and tachycardia B. Hypotension and signs of hypovolemic shock C.
Increased abdominal girth D. Fever and chills
Annotation: PARACENTESIS = DRAINING FLUID. If you pull too much fluid too fast,
the blood pressure drops (Hypovolemic Shock). Monitor VS closely!
9. The nurse is caring for a client with Cholecystitis. Which of the following findings is most
characteristic?
A. Pain in the left upper quadrant (LUQ) B. Pain in the right upper quadrant (RUQ)
radiating to the right shoulder C. Pain relieved by eating a high-fat meal D. Pain that is
worse when the stomach is empty
1. The nurse is caring for a client with Liver Cirrhosis who has developed Ascites. Which of the
following is the priority nursing intervention?
A. Encouraging a high-sodium diet to increase blood volume B. Monitoring respiratory
status and abdominal girth C. Administering IV fluids at a rapid rate D. Encouraging the
client to perform vigorous exercise
Annotation: ASCITES = FLUID IN THE BELLY. It pushes on the diaphragm, making it
hard to breathe. Monitor for SOB and measure girth daily to track fluid buildup.
2. A client with Cirrhosis is experiencing Hepatic Encephalopathy. The nurse should anticipate
which of the following orders?
A. High-protein diet to promote liver healing B. Administration of Lactulose and
Neomycin C. Administration of Vitamin K for bleeding D. Fluid restriction to 500 mL/day
Annotation: ENCEPHALOPATHY = AMMONIA BUILDUP. Lactulose makes them poop
out the ammonia. Neomycin kills the bacteria that make ammonia. Watch for
confusion and asterixis (hand flapping).
3. The nurse is assessing a client with Acute Pancreatitis. Which of the following findings is
most characteristic?
A. Pain in the right lower quadrant (RLQ) B. Severe epigastric pain radiating to the back
C. Pain relieved by eating a high-fat meal D. Pain that is worse when lying on the left side
Annotation: PANCREATITIS = “AUTODIGESTION.” The enzymes eat the pancreas. It’s
extremely painful! Keep them NPO to rest the pancreas.
4. A client with Pancreatitis has a positive Cullen’s sign. What does this indicate?
A. Obstruction of the common bile duct B. Inflammation of the gallbladder C. Intra-
abdominal hemorrhage (Bruising around the umbilicus) D. Rupture of the pancreatic
duct
Annotation: CULLEN’S = CIRCLE (Umbilicus). TURNER’S = TURN (Flank). Both mean
internal bleeding. This is a medical emergency!
, 5. The nurse is caring for a client with Type 1 Diabetes who is experiencing Diabetic
Ketoacidosis (DKA). Which of the following is the priority intervention?
A. Rapid IV fluid resuscitation with Normal Saline B. Administration of IV Regular
Insulin C. Administration of Sodium Bicarbonate for acidosis D. Monitoring for signs of
hypoglycemia
Annotation: DKA = DEHYDRATION + ACIDOSIS. They are severely dehydrated! Fluids
(NS) come FIRST to restore volume. Insulin comes second to stop the ketones.
6. A client with Type 2 Diabetes is admitted with Hyperosmolar Hyperglycemic State (HHS).
Which of the following findings is consistent with this diagnosis?
A. Ketonuria and metabolic acidosis B. Severe hyperglycemia (>600 mg/dL) and
profound dehydration C. Kussmaul’s respirations and fruity breath D. Rapid onset of
symptoms within hours
Annotation: HHS = NO KETONES. They have just enough insulin to prevent ketones,
but their sugar goes SKY HIGH. They are even more dehydrated than DKA patients.
7. The nurse is assessing a client with Esophageal Varices. Which of the following is the
priority risk?
A. Malnutrition and weight loss B. Massive hemorrhage and airway obstruction C.
Chronic cough and dysphagia D. Ascites and peripheral edema
Annotation: VARICES = “HEMORRHOIDS” in the throat. If they burst, the patient can
bleed to death in minutes. Avoid coughing, straining, or rough foods.
8. A client is 1 hour post-op from a Paracentesis. The nurse should monitor for which of the
following complications?
A. Hypertension and tachycardia B. Hypotension and signs of hypovolemic shock C.
Increased abdominal girth D. Fever and chills
Annotation: PARACENTESIS = DRAINING FLUID. If you pull too much fluid too fast,
the blood pressure drops (Hypovolemic Shock). Monitor VS closely!
9. The nurse is caring for a client with Cholecystitis. Which of the following findings is most
characteristic?
A. Pain in the left upper quadrant (LUQ) B. Pain in the right upper quadrant (RUQ)
radiating to the right shoulder C. Pain relieved by eating a high-fat meal D. Pain that is
worse when the stomach is empty
