NSG223/NSG 223 Exam 3 V3 | Medical-
Surgical Nursing II Q&A with Rationale |
Herzing University
1. A patient with advanced cirrhosis presents with an enlarged abdomen and respiratory
distress. Which intervention should the nurse prioritize to improve the patient’s breathing?
A. Place the patient in a High-Fowler’s position.
B. Administer a prescribed bolus of intravenous fluids.
C. Encourage deep breathing and coughing exercises.
D. Increase the dietary sodium intake immediately.
Correct Answer: A
Rationale: High-Fowler’s position helps alleviate respiratory distress by allowing the
diaphragm to expand more easily against the pressure of ascites. Elevating the head of the
bed reduces the upward pressure on the lungs from the abdominal fluid. This is a non-
invasive immediate action to improve ventilation in patients with severe abdominal
distension.
2. Which laboratory finding is most indicative of acute pancreatitis in a patient reporting
severe epigastric pain radiating to the back?
A. Decreased serum calcium levels.
B. Elevated serum amylase and lipase levels.
,C. Decreased white blood cell count.
D. Increased serum albumin levels.
Correct Answer: B
Rationale: Serum amylase and lipase are the primary biochemical markers used to
diagnose acute pancreatitis. Lipase is generally considered more specific to the pancreas
and stays elevated longer than amylase. These enzymes leak into the bloodstream when
pancreatic cells are damaged or inflamed.
3. A nurse is caring for a patient in the oliguric phase of acute kidney injury (AKI). Which
clinical manifestation should the nurse expect to observe?
A. Urinary output of less than 400 mL per 24 hours.
B. Metabolic alkalosis and hypokalemia.
C. Increased urine output exceeding 2 liters per day.
D. Significantly decreased serum creatinine levels.
Correct Answer: A
Rationale: The oliguric phase is characterized by a significant decrease in urine output,
typically defined as less than 400 mL in 24 hours. During this phase, the kidneys are unable
to excrete metabolic wastes, leading to azotemia and fluid volume excess. Nurses must
monitor for signs of fluid overload and electrolyte imbalances like hyperkalemia.
, 4. A patient with chronic kidney disease (CKD) is prescribed erythropoietin injections. What is
the primary goal of this therapy?
A. To increase the production of white blood cells.
B. To stimulate the bone marrow to produce red blood cells.
C. To treat underlying hypertension and fluid overload.
D. To lower serum potassium and phosphorus levels.
Correct Answer: B
Rationale: Patients with CKD often develop anemia because the kidneys produce less
erythropoietin, which is necessary for red blood cell production. Erythropoietin therapy
aims to increase hemoglobin and hematocrit levels to improve oxygen delivery to tissues.
This treatment helps reduce the need for blood transfusions and decreases fatigue
associated with anemia.
5. A nurse is teaching a patient about lactulose therapy for hepatic encephalopathy. Which
statement by the patient indicates understanding of the medication’s purpose?
A. I am taking this to help me have two to three soft stools a day.
B. This medicine will help stop the bleeding in my esophagus.
C. Lactulose will help my kidneys filter out more protein.
D. This medication will increase my blood sugar levels.
Correct Answer: A
Surgical Nursing II Q&A with Rationale |
Herzing University
1. A patient with advanced cirrhosis presents with an enlarged abdomen and respiratory
distress. Which intervention should the nurse prioritize to improve the patient’s breathing?
A. Place the patient in a High-Fowler’s position.
B. Administer a prescribed bolus of intravenous fluids.
C. Encourage deep breathing and coughing exercises.
D. Increase the dietary sodium intake immediately.
Correct Answer: A
Rationale: High-Fowler’s position helps alleviate respiratory distress by allowing the
diaphragm to expand more easily against the pressure of ascites. Elevating the head of the
bed reduces the upward pressure on the lungs from the abdominal fluid. This is a non-
invasive immediate action to improve ventilation in patients with severe abdominal
distension.
2. Which laboratory finding is most indicative of acute pancreatitis in a patient reporting
severe epigastric pain radiating to the back?
A. Decreased serum calcium levels.
B. Elevated serum amylase and lipase levels.
,C. Decreased white blood cell count.
D. Increased serum albumin levels.
Correct Answer: B
Rationale: Serum amylase and lipase are the primary biochemical markers used to
diagnose acute pancreatitis. Lipase is generally considered more specific to the pancreas
and stays elevated longer than amylase. These enzymes leak into the bloodstream when
pancreatic cells are damaged or inflamed.
3. A nurse is caring for a patient in the oliguric phase of acute kidney injury (AKI). Which
clinical manifestation should the nurse expect to observe?
A. Urinary output of less than 400 mL per 24 hours.
B. Metabolic alkalosis and hypokalemia.
C. Increased urine output exceeding 2 liters per day.
D. Significantly decreased serum creatinine levels.
Correct Answer: A
Rationale: The oliguric phase is characterized by a significant decrease in urine output,
typically defined as less than 400 mL in 24 hours. During this phase, the kidneys are unable
to excrete metabolic wastes, leading to azotemia and fluid volume excess. Nurses must
monitor for signs of fluid overload and electrolyte imbalances like hyperkalemia.
, 4. A patient with chronic kidney disease (CKD) is prescribed erythropoietin injections. What is
the primary goal of this therapy?
A. To increase the production of white blood cells.
B. To stimulate the bone marrow to produce red blood cells.
C. To treat underlying hypertension and fluid overload.
D. To lower serum potassium and phosphorus levels.
Correct Answer: B
Rationale: Patients with CKD often develop anemia because the kidneys produce less
erythropoietin, which is necessary for red blood cell production. Erythropoietin therapy
aims to increase hemoglobin and hematocrit levels to improve oxygen delivery to tissues.
This treatment helps reduce the need for blood transfusions and decreases fatigue
associated with anemia.
5. A nurse is teaching a patient about lactulose therapy for hepatic encephalopathy. Which
statement by the patient indicates understanding of the medication’s purpose?
A. I am taking this to help me have two to three soft stools a day.
B. This medicine will help stop the bleeding in my esophagus.
C. Lactulose will help my kidneys filter out more protein.
D. This medication will increase my blood sugar levels.
Correct Answer: A
