PNR 206/PNR206 Exam 4 V3 | Medical-Surgical
Nursing II Q&A with Rationale | Fortis College
1. A nurse is caring for a patient diagnosed with Hepatic Encephalopathy. Which medication
should the nurse anticipate administering to reduce the patient’s serum ammonia levels?
A. Spironolactone
B. Pantoprazole
C. Furosemide
D. Lactulose
Correct Answer: D
Explanation: Lactulose is a laxative used to decrease the amount of ammonia in the blood
by trapping it in the colon and expelling it through stool. The nurse should monitor for
frequent bowel movements, which indicate the medication is effectively pulling toxins from
the body. Reducing ammonia is critical to improving the patient’s neurological status and
preventing coma.
2. A patient with Type 1 Diabetes Mellitus presents with diaphoresis, tremors, and
tachycardia. What should be the nurse’s priority action?
A. Administer 10 units of regular insulin
B. Call the physician for a stat order of Metformin
C. Check the patient’s hemoglobin A1C
,D. Provide 4 ounces of orange juice
Correct Answer: D
Explanation: The patient is demonstrating clinical manifestations of hypoglycemia, which
is a medical emergency. According to the Rule of 15, the nurse should immediately provide
15 grams of fast-acting carbohydrates such as 4 ounces of juice. Blood glucose should be
rechecked in 15 minutes to determine if further treatment is required.
3. Which of the following dietary instructions is most appropriate for a patient newly
diagnosed with Chronic Kidney Disease (CKD)?
A. Limit protein intake to prevent nitrogenous waste buildup
B. Increase intake of high-potassium fruits like bananas
C. Increase sodium intake to maintain blood pressure
D. Consume at least 3 liters of fluid per day regardless of output
Correct Answer: A
Explanation: Restricting protein intake is essential in CKD patients because the kidneys
can no longer efficiently excrete nitrogenous waste products. Excessive protein leads to an
accumulation of urea, which can worsen uremic symptoms. Patients are also typically
placed on sodium and potassium restrictions to prevent fluid overload and cardiac
dysrhythmias.
, 4. A nurse is reviewing the laboratory results for a patient suspected of having acute
pancreatitis. Which enzyme elevation is the most specific indicator for this condition?
A. Serum Lipase
B. Serum Amylase
C. Alanine Aminotransferase (ALT)
D. Creatine Kinase (CK)
Correct Answer: A
Explanation: While both amylase and lipase levels rise in acute pancreatitis, serum lipase
remains elevated longer and is considered more specific to pancreatic damage. Amylase
can be elevated in other conditions such as mumps or intestinal obstructions. Monitoring
these levels helps the healthcare team evaluate the severity of the inflammation and the
effectiveness of the treatment plan.
5. A patient is scheduled for an intravenous pyelogram (IVP). Which patient statement should
the nurse report to the healthcare provider immediately?
A. “I am allergic to shellfish and iodine.”
B. “I haven’t eaten anything since midnight.”
C. “I am feeling nervous about the procedure.”
D. “I had a bowel movement this morning.”
Correct Answer: A
Nursing II Q&A with Rationale | Fortis College
1. A nurse is caring for a patient diagnosed with Hepatic Encephalopathy. Which medication
should the nurse anticipate administering to reduce the patient’s serum ammonia levels?
A. Spironolactone
B. Pantoprazole
C. Furosemide
D. Lactulose
Correct Answer: D
Explanation: Lactulose is a laxative used to decrease the amount of ammonia in the blood
by trapping it in the colon and expelling it through stool. The nurse should monitor for
frequent bowel movements, which indicate the medication is effectively pulling toxins from
the body. Reducing ammonia is critical to improving the patient’s neurological status and
preventing coma.
2. A patient with Type 1 Diabetes Mellitus presents with diaphoresis, tremors, and
tachycardia. What should be the nurse’s priority action?
A. Administer 10 units of regular insulin
B. Call the physician for a stat order of Metformin
C. Check the patient’s hemoglobin A1C
,D. Provide 4 ounces of orange juice
Correct Answer: D
Explanation: The patient is demonstrating clinical manifestations of hypoglycemia, which
is a medical emergency. According to the Rule of 15, the nurse should immediately provide
15 grams of fast-acting carbohydrates such as 4 ounces of juice. Blood glucose should be
rechecked in 15 minutes to determine if further treatment is required.
3. Which of the following dietary instructions is most appropriate for a patient newly
diagnosed with Chronic Kidney Disease (CKD)?
A. Limit protein intake to prevent nitrogenous waste buildup
B. Increase intake of high-potassium fruits like bananas
C. Increase sodium intake to maintain blood pressure
D. Consume at least 3 liters of fluid per day regardless of output
Correct Answer: A
Explanation: Restricting protein intake is essential in CKD patients because the kidneys
can no longer efficiently excrete nitrogenous waste products. Excessive protein leads to an
accumulation of urea, which can worsen uremic symptoms. Patients are also typically
placed on sodium and potassium restrictions to prevent fluid overload and cardiac
dysrhythmias.
, 4. A nurse is reviewing the laboratory results for a patient suspected of having acute
pancreatitis. Which enzyme elevation is the most specific indicator for this condition?
A. Serum Lipase
B. Serum Amylase
C. Alanine Aminotransferase (ALT)
D. Creatine Kinase (CK)
Correct Answer: A
Explanation: While both amylase and lipase levels rise in acute pancreatitis, serum lipase
remains elevated longer and is considered more specific to pancreatic damage. Amylase
can be elevated in other conditions such as mumps or intestinal obstructions. Monitoring
these levels helps the healthcare team evaluate the severity of the inflammation and the
effectiveness of the treatment plan.
5. A patient is scheduled for an intravenous pyelogram (IVP). Which patient statement should
the nurse report to the healthcare provider immediately?
A. “I am allergic to shellfish and iodine.”
B. “I haven’t eaten anything since midnight.”
C. “I am feeling nervous about the procedure.”
D. “I had a bowel movement this morning.”
Correct Answer: A
