NUR 425 Exam 3: Acute & Chronic Health Disruptions In
Adults II V2 - Arizona College Updated and Latest
Questions and Correct Answers with Rationale
1. A patient is admitted with Acute Kidney Injury (AKI) and is currently in the oliguric phase. Which clinical
manifestation should the nurse prioritize for assessment?
A. Decreased BUN and creatinine levels
B. Hypotension and dehydration
C. Weight loss and increased appetite
D. Hyperkalemia and ECG changes
Ans: D
Explanation: During the oliguric phase of AKI, potassium excretion is significantly reduced leading to
dangerous levels of hyperkalemia. The nurse must monitor for peaked T waves or widened QRS
complexes on the ECG. Other options like hypotension are more common in the preceding pre-renal
phase or later stages. BUN and creatinine typically rise during this period rather than fall. Assessing for
cardiac stability is the highest priority nursing intervention.
2. The nurse is caring for a patient with Chronic Kidney Disease (CKD) who is receiving hemodialysis. What is
the most important assessment before the treatment?
A. Checking the patient’s temperature
B. Reviewing the patient’s dietary intake
C. Measuring the patient’s height
D. Assessing the patency of the AV fistula
Ans: D
,Explanation: Evaluating the patency of the arteriovenous (AV) fistula is critical before initiating
hemodialysis. The nurse should palpate for a thrill and auscultate for a bruit to ensure vascular access is
functional. Temperature and diet are relevant but do not directly impact the mechanical ability to
perform the procedure. Height is usually only needed upon admission and does not change between
treatments. Ensuring access patency prevents delays in life-sustaining therapy.
3. A patient with cirrhosis of the liver presents with increased abdominal girth and a fluid wave on
percussion. Which intervention is most appropriate?
A. Encourage a high-sodium diet
B. Position the patient flat on their back
C. Increase fluid intake to 3 liters daily
D. Prepare the patient for a paracentesis
Ans: D
Explanation: Paracentesis is often indicated to remove excess fluid and relieve the pressure caused by
ascites in cirrhosis. A high-sodium diet would exacerbate fluid retention and is therefore contraindicated.
Placing the patient flat can increase respiratory distress due to the pressure on the diaphragm. Increasing
fluid intake is generally restricted in patients with significant volume overload and edema. This
procedure provides immediate symptomatic relief for the patient’s discomfort.
4. Which lab result is the most sensitive indicator of acute pancreatitis?
A. Serum Amylase
B. Serum Lipase
C. Blood Urea Nitrogen (BUN)
D. Serum Calcium
, Ans: B
Explanation: Serum lipase levels are considered more specific and sensitive for acute pancreatitis as
they stay elevated longer than amylase. While amylase rises early, it often returns to normal within 24 to
72 hours. BUN reflects renal function and hydration but not direct pancreatic damage. Calcium levels may
drop in severe cases but are not used for primary diagnosis. Monitoring lipase helps confirm the
diagnosis and track the severity of the inflammatory process.
5. A patient presents with deep partial-thickness burns to the entire left arm and chest. Using the Rule of
Nines, calculate the approximate total body surface area (TBSA) burned.
A. 18%
B. 27%
C. 36%
D. 45%
Ans: B
Explanation: According to the Rule of Nines, the entire arm accounts for 9% and the entire anterior
trunk (chest and abdomen) accounts for 18%. Since the question specifies the entire left arm (9%) and
the chest (9%), the total is 18% if only the upper trunk is meant, but if the full anterior chest/abdomen is
implied, it varies. However, standard testing often considers the chest as 9% and the arm as 9%, totaling
18% or 27% if including the abdomen. In this context, the entire arm (9) plus the anterior trunk (18)
equals 27%. Accurate TBSA calculation is vital for determining fluid resuscitation needs.
6. Which medication is typically administered to lower ammonia levels in patients with hepatic
encephalopathy?
A. Lactulose
Adults II V2 - Arizona College Updated and Latest
Questions and Correct Answers with Rationale
1. A patient is admitted with Acute Kidney Injury (AKI) and is currently in the oliguric phase. Which clinical
manifestation should the nurse prioritize for assessment?
A. Decreased BUN and creatinine levels
B. Hypotension and dehydration
C. Weight loss and increased appetite
D. Hyperkalemia and ECG changes
Ans: D
Explanation: During the oliguric phase of AKI, potassium excretion is significantly reduced leading to
dangerous levels of hyperkalemia. The nurse must monitor for peaked T waves or widened QRS
complexes on the ECG. Other options like hypotension are more common in the preceding pre-renal
phase or later stages. BUN and creatinine typically rise during this period rather than fall. Assessing for
cardiac stability is the highest priority nursing intervention.
2. The nurse is caring for a patient with Chronic Kidney Disease (CKD) who is receiving hemodialysis. What is
the most important assessment before the treatment?
A. Checking the patient’s temperature
B. Reviewing the patient’s dietary intake
C. Measuring the patient’s height
D. Assessing the patency of the AV fistula
Ans: D
,Explanation: Evaluating the patency of the arteriovenous (AV) fistula is critical before initiating
hemodialysis. The nurse should palpate for a thrill and auscultate for a bruit to ensure vascular access is
functional. Temperature and diet are relevant but do not directly impact the mechanical ability to
perform the procedure. Height is usually only needed upon admission and does not change between
treatments. Ensuring access patency prevents delays in life-sustaining therapy.
3. A patient with cirrhosis of the liver presents with increased abdominal girth and a fluid wave on
percussion. Which intervention is most appropriate?
A. Encourage a high-sodium diet
B. Position the patient flat on their back
C. Increase fluid intake to 3 liters daily
D. Prepare the patient for a paracentesis
Ans: D
Explanation: Paracentesis is often indicated to remove excess fluid and relieve the pressure caused by
ascites in cirrhosis. A high-sodium diet would exacerbate fluid retention and is therefore contraindicated.
Placing the patient flat can increase respiratory distress due to the pressure on the diaphragm. Increasing
fluid intake is generally restricted in patients with significant volume overload and edema. This
procedure provides immediate symptomatic relief for the patient’s discomfort.
4. Which lab result is the most sensitive indicator of acute pancreatitis?
A. Serum Amylase
B. Serum Lipase
C. Blood Urea Nitrogen (BUN)
D. Serum Calcium
, Ans: B
Explanation: Serum lipase levels are considered more specific and sensitive for acute pancreatitis as
they stay elevated longer than amylase. While amylase rises early, it often returns to normal within 24 to
72 hours. BUN reflects renal function and hydration but not direct pancreatic damage. Calcium levels may
drop in severe cases but are not used for primary diagnosis. Monitoring lipase helps confirm the
diagnosis and track the severity of the inflammatory process.
5. A patient presents with deep partial-thickness burns to the entire left arm and chest. Using the Rule of
Nines, calculate the approximate total body surface area (TBSA) burned.
A. 18%
B. 27%
C. 36%
D. 45%
Ans: B
Explanation: According to the Rule of Nines, the entire arm accounts for 9% and the entire anterior
trunk (chest and abdomen) accounts for 18%. Since the question specifies the entire left arm (9%) and
the chest (9%), the total is 18% if only the upper trunk is meant, but if the full anterior chest/abdomen is
implied, it varies. However, standard testing often considers the chest as 9% and the arm as 9%, totaling
18% or 27% if including the abdomen. In this context, the entire arm (9) plus the anterior trunk (18)
equals 27%. Accurate TBSA calculation is vital for determining fluid resuscitation needs.
6. Which medication is typically administered to lower ammonia levels in patients with hepatic
encephalopathy?
A. Lactulose
