NUR 215 Exam 3 Questions With Correct
Answers (Verified Answers) Plus Rationales
2026 Q&A | Instant Download Pdf
1. A nurse is caring for a client with acute pancreatitis. Which
laboratory finding is most indicative of this condition?
A. Decreased serum lipase
B. Elevated serum bilirubin only
C. Elevated serum amylase and lipase
D. Decreased white blood cell count
Rationale: Acute pancreatitis commonly causes inflammation and
autodigestion of the pancreas, leading to the release of digestive
enzymes into the bloodstream. Serum amylase rises within hours of
onset, while serum lipase is more specific and remains elevated
longer. Elevated lipase and amylase together strongly support the
diagnosis. Bilirubin may be elevated if gallstones are involved but is
not the hallmark finding. White blood cell counts are typically
elevated due to inflammation.
, 2. A client with chronic kidney disease asks why protein intake may
be limited. What is the nurse's best response?
A. Protein increases blood glucose levels.
B. Excess protein increases nitrogenous waste the kidneys must filter.
C. Protein causes fluid retention.
D. Protein prevents calcium absorption.
Rationale: In chronic kidney disease, damaged kidneys have difficulty
removing nitrogenous waste products produced during protein
metabolism. Moderating protein intake helps reduce uremic
symptoms while maintaining adequate nutrition. Protein does not
directly increase blood glucose, prevent calcium absorption, or
independently cause fluid retention.
3. Which assessment finding requires immediate intervention in a
client receiving a blood transfusion?
A. Mild anxiety
B. Temperature increase of 0.3°F
C. Sudden dyspnea and chest tightness
D. Slight fatigue
Rationale: Sudden dyspnea, chest tightness, tachycardia, hypotension,
or chills during a transfusion may indicate an acute hemolytic or
severe allergic transfusion reaction. The transfusion should be stopped
,immediately while maintaining IV access with normal saline. Mild
fatigue and minimal temperature changes are less concerning.
4. Which electrolyte imbalance places a client at greatest risk for life-
threatening cardiac dysrhythmias?
A. Mild hyponatremia
B. Hyperkalemia
C. Hypocalcemia
D. Hypermagnesemia
Rationale: Potassium plays a critical role in cardiac electrical
conduction. Elevated potassium levels can cause peaked T waves,
widened QRS complexes, ventricular dysrhythmias, and cardiac arrest.
While other electrolyte disturbances may also affect cardiac function,
hyperkalemia presents one of the greatest immediate threats.
5. A nurse is teaching a client about deep vein thrombosis
prevention after surgery. Which intervention is most effective?
A. Restrict oral fluids.
B. Remain on bed rest.
C. Ambulate as early as possible.
D. Massage the calves daily.
, Rationale: Early ambulation improves venous return, decreases
venous stasis, and significantly lowers the risk of deep vein
thrombosis. Calf massage is contraindicated because it may dislodge
an existing clot. Bed rest increases clot risk, and adequate hydration—
not restriction—is recommended.
6. Which finding is expected in a client experiencing left-sided heart
failure?
A. Peripheral edema only
B. Ascites
C. Crackles in the lungs
D. Jugular vein distention only
Rationale: Left-sided heart failure results in pulmonary congestion due
to blood backing up into the lungs. Crackles, dyspnea, orthopnea, and
pulmonary edema are characteristic findings. Peripheral edema and
jugular venous distention are more associated with right-sided heart
failure.
7. A client with diabetes reports shaking, sweating, and confusion.
What should the nurse do first?
A. Administer insulin.
B. Check the client's blood glucose level.
Answers (Verified Answers) Plus Rationales
2026 Q&A | Instant Download Pdf
1. A nurse is caring for a client with acute pancreatitis. Which
laboratory finding is most indicative of this condition?
A. Decreased serum lipase
B. Elevated serum bilirubin only
C. Elevated serum amylase and lipase
D. Decreased white blood cell count
Rationale: Acute pancreatitis commonly causes inflammation and
autodigestion of the pancreas, leading to the release of digestive
enzymes into the bloodstream. Serum amylase rises within hours of
onset, while serum lipase is more specific and remains elevated
longer. Elevated lipase and amylase together strongly support the
diagnosis. Bilirubin may be elevated if gallstones are involved but is
not the hallmark finding. White blood cell counts are typically
elevated due to inflammation.
, 2. A client with chronic kidney disease asks why protein intake may
be limited. What is the nurse's best response?
A. Protein increases blood glucose levels.
B. Excess protein increases nitrogenous waste the kidneys must filter.
C. Protein causes fluid retention.
D. Protein prevents calcium absorption.
Rationale: In chronic kidney disease, damaged kidneys have difficulty
removing nitrogenous waste products produced during protein
metabolism. Moderating protein intake helps reduce uremic
symptoms while maintaining adequate nutrition. Protein does not
directly increase blood glucose, prevent calcium absorption, or
independently cause fluid retention.
3. Which assessment finding requires immediate intervention in a
client receiving a blood transfusion?
A. Mild anxiety
B. Temperature increase of 0.3°F
C. Sudden dyspnea and chest tightness
D. Slight fatigue
Rationale: Sudden dyspnea, chest tightness, tachycardia, hypotension,
or chills during a transfusion may indicate an acute hemolytic or
severe allergic transfusion reaction. The transfusion should be stopped
,immediately while maintaining IV access with normal saline. Mild
fatigue and minimal temperature changes are less concerning.
4. Which electrolyte imbalance places a client at greatest risk for life-
threatening cardiac dysrhythmias?
A. Mild hyponatremia
B. Hyperkalemia
C. Hypocalcemia
D. Hypermagnesemia
Rationale: Potassium plays a critical role in cardiac electrical
conduction. Elevated potassium levels can cause peaked T waves,
widened QRS complexes, ventricular dysrhythmias, and cardiac arrest.
While other electrolyte disturbances may also affect cardiac function,
hyperkalemia presents one of the greatest immediate threats.
5. A nurse is teaching a client about deep vein thrombosis
prevention after surgery. Which intervention is most effective?
A. Restrict oral fluids.
B. Remain on bed rest.
C. Ambulate as early as possible.
D. Massage the calves daily.
, Rationale: Early ambulation improves venous return, decreases
venous stasis, and significantly lowers the risk of deep vein
thrombosis. Calf massage is contraindicated because it may dislodge
an existing clot. Bed rest increases clot risk, and adequate hydration—
not restriction—is recommended.
6. Which finding is expected in a client experiencing left-sided heart
failure?
A. Peripheral edema only
B. Ascites
C. Crackles in the lungs
D. Jugular vein distention only
Rationale: Left-sided heart failure results in pulmonary congestion due
to blood backing up into the lungs. Crackles, dyspnea, orthopnea, and
pulmonary edema are characteristic findings. Peripheral edema and
jugular venous distention are more associated with right-sided heart
failure.
7. A client with diabetes reports shaking, sweating, and confusion.
What should the nurse do first?
A. Administer insulin.
B. Check the client's blood glucose level.
