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NUR 210 Exam 4 — Nursing Care of Adult
Questions With Verified Solutions And
Rationales
1. A nurse is assessing a client with a suspected peptic ulcer. Which assessment
finding is most concerning and requires immediate follow-up?
A. Burning epigastric pain relieved by food
B. Nausea after eating
C. Sudden severe abdominal pain with a rigid abdomen
D. Bloating and belching
Correct Answer: C
Rationale: Sudden severe abdominal pain with a rigid, board-like abdomen
suggests perforation of the ulcer, a life-threatening emergency requiring
immediate intervention. The other findings are common but not immediately life-
threatening.
2. A client with gastroesophageal reflux disease (GERD) is being taught about
lifestyle modifications. Which statement indicates a need for further teaching?
A. "I will avoid eating within 2 to 3 hours of bedtime."
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B. "I will elevate the head of my bed on blocks."
C. "I will lie down immediately after meals to rest."
D. "I will avoid caffeine and spicy foods."
Correct Answer: C
Rationale: Lying down immediately after meals worsens GERD by allowing
stomach contents to reflux. Clients should remain upright for at least 2 hours
after eating.
3. A nurse is caring for a client with ulcerative colitis who reports 10 to 15 bloody
stools per day. Which complication should the nurse monitor for?
A. Toxic megacolon
B. Fistula formation
C. Steatorrhea
D. Gastric outlet obstruction
Correct Answer: A
Rationale: Ulcerative colitis with frequent bloody stools places the client at risk
for toxic megacolon, a life-threatening dilation of the colon. Fistula formation is
more common in Crohn's disease.
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4. A client with Crohn's disease has a new ileostomy. Which assessment finding
requires immediate notification of the provider?
A. Stoma is red and moist
B. Stoma is dark and dusky
C. Output is liquid
D. Output is 600 mL in 24 hours
Correct Answer: B
Rationale: A dark, dusky stoma indicates inadequate blood supply and possible
necrosis. This requires immediate provider notification. A healthy stoma is red
and moist.
5. A nurse is reviewing laboratory results for a client with cirrhosis. Which finding
indicates a complication of the disease?
A. Hemoglobin 14 g/dL
B. Platelet count 85,000/mm³
C. Serum potassium 4.0 mEq/L
D. Serum sodium 140 mEq/L
Correct Answer: B
Rationale: Thrombocytopenia (platelet count below 150,000/mm³) is a common
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complication of cirrhosis due to splenomegaly and decreased thrombopoietin
production. This increases the client's bleeding risk.
6. A client with cirrhosis is prescribed lactulose. The nurse should evaluate the
effectiveness of this medication by monitoring which finding?
A. Increased urine output
B. Decreased serum ammonia level
C. Decreased abdominal girth
D. Increased serum potassium
Correct Answer: B
Rationale: Lactulose is given to reduce serum ammonia levels in hepatic
encephalopathy. The therapeutic effect is indicated by decreased ammonia levels
and improved mental status.
7. A nurse is assessing a client with acute pancreatitis. Which finding is most
characteristic of this condition?
A. Left lower quadrant pain
B. Right upper quadrant pain radiating to the back
NUR 210 Exam 4 — Nursing Care of Adult
Questions With Verified Solutions And
Rationales
1. A nurse is assessing a client with a suspected peptic ulcer. Which assessment
finding is most concerning and requires immediate follow-up?
A. Burning epigastric pain relieved by food
B. Nausea after eating
C. Sudden severe abdominal pain with a rigid abdomen
D. Bloating and belching
Correct Answer: C
Rationale: Sudden severe abdominal pain with a rigid, board-like abdomen
suggests perforation of the ulcer, a life-threatening emergency requiring
immediate intervention. The other findings are common but not immediately life-
threatening.
2. A client with gastroesophageal reflux disease (GERD) is being taught about
lifestyle modifications. Which statement indicates a need for further teaching?
A. "I will avoid eating within 2 to 3 hours of bedtime."
,2|Page
B. "I will elevate the head of my bed on blocks."
C. "I will lie down immediately after meals to rest."
D. "I will avoid caffeine and spicy foods."
Correct Answer: C
Rationale: Lying down immediately after meals worsens GERD by allowing
stomach contents to reflux. Clients should remain upright for at least 2 hours
after eating.
3. A nurse is caring for a client with ulcerative colitis who reports 10 to 15 bloody
stools per day. Which complication should the nurse monitor for?
A. Toxic megacolon
B. Fistula formation
C. Steatorrhea
D. Gastric outlet obstruction
Correct Answer: A
Rationale: Ulcerative colitis with frequent bloody stools places the client at risk
for toxic megacolon, a life-threatening dilation of the colon. Fistula formation is
more common in Crohn's disease.
,3|Page
4. A client with Crohn's disease has a new ileostomy. Which assessment finding
requires immediate notification of the provider?
A. Stoma is red and moist
B. Stoma is dark and dusky
C. Output is liquid
D. Output is 600 mL in 24 hours
Correct Answer: B
Rationale: A dark, dusky stoma indicates inadequate blood supply and possible
necrosis. This requires immediate provider notification. A healthy stoma is red
and moist.
5. A nurse is reviewing laboratory results for a client with cirrhosis. Which finding
indicates a complication of the disease?
A. Hemoglobin 14 g/dL
B. Platelet count 85,000/mm³
C. Serum potassium 4.0 mEq/L
D. Serum sodium 140 mEq/L
Correct Answer: B
Rationale: Thrombocytopenia (platelet count below 150,000/mm³) is a common
, 4|Page
complication of cirrhosis due to splenomegaly and decreased thrombopoietin
production. This increases the client's bleeding risk.
6. A client with cirrhosis is prescribed lactulose. The nurse should evaluate the
effectiveness of this medication by monitoring which finding?
A. Increased urine output
B. Decreased serum ammonia level
C. Decreased abdominal girth
D. Increased serum potassium
Correct Answer: B
Rationale: Lactulose is given to reduce serum ammonia levels in hepatic
encephalopathy. The therapeutic effect is indicated by decreased ammonia levels
and improved mental status.
7. A nurse is assessing a client with acute pancreatitis. Which finding is most
characteristic of this condition?
A. Left lower quadrant pain
B. Right upper quadrant pain radiating to the back
