NURS 460 HESI Practice Questions and Correct Answers A client is admitted to the emergency department after vomiting bright red blood. After the vomiting ceases and the vital signs are stabilized, the client is transferred to a medical -surgical unit. To assess for bleeding, what should the nurse on the medic al-
surgical unit monitor the client for? A. Lethargy B. Tachycardia C. Deep Breathing D. Abdominal pain ✅B. Tachycardia Rationale: Tachycardia is a cardiovascular compensatory mechanism as the effort to circulate the decreasing blood volume intensifies. Lethargy is not an initial response to blood loss. The client is more apt to be restless; lethargy may occur later. Breath ing may be rapid, not deep, with blood loss. Abdominal pain is not a response to blood loss. A nurse is caring for a client with acute pancreatitis. Which elevated laboratory test result is most indicative of acute pancreatitis? A. blood glucose B. serum lipase C. serum bilirubin level D. white blood cell count ✅B. Serum Lipase Rationale: Lipase concentration is increased in the pancreas and is elevated in the serum when the pancreas becomes acutely inflamed; this distinguishes pancreatitis from other acute abdominal problems. An elevated blood glucose level is not indicative of pancreatitis but rather diabetes mellitus; however, hyperglycemia and glycosuria may occur in some people with acute pancreatitis if the islets of Langerhans are affected. Serum bilirubin level occurs in other disease processes, such as cholecystitis. Whit e blood cell count is not specific to pancreatitis; white blood cells are elevated in other disease processes. A nurse is caring for a client with a diagnosis of acute pancreatitis and alcoholism. The client asks, "what does my drinking have to do with my diagnosis?" What effect of alcohol should the nurse include when responding? A. promotes the formation of calculi in the cystic duct B. Stimulates the pancreas to secrete more insulin than it can immediately produce C. Alters the composition of enzymes so they are capable of damaging the pancreas
surgical unit monitor the client for? A. Lethargy B. Tachycardia C. Deep Breathing D. Abdominal pain ✅B. Tachycardia Rationale: Tachycardia is a cardiovascular compensatory mechanism as the effort to circulate the decreasing blood volume intensifies. Lethargy is not an initial response to blood loss. The client is more apt to be restless; lethargy may occur later. Breath ing may be rapid, not deep, with blood loss. Abdominal pain is not a response to blood loss. A nurse is caring for a client with acute pancreatitis. Which elevated laboratory test result is most indicative of acute pancreatitis? A. blood glucose B. serum lipase C. serum bilirubin level D. white blood cell count ✅B. Serum Lipase Rationale: Lipase concentration is increased in the pancreas and is elevated in the serum when the pancreas becomes acutely inflamed; this distinguishes pancreatitis from other acute abdominal problems. An elevated blood glucose level is not indicative of pancreatitis but rather diabetes mellitus; however, hyperglycemia and glycosuria may occur in some people with acute pancreatitis if the islets of Langerhans are affected. Serum bilirubin level occurs in other disease processes, such as cholecystitis. Whit e blood cell count is not specific to pancreatitis; white blood cells are elevated in other disease processes. A nurse is caring for a client with a diagnosis of acute pancreatitis and alcoholism. The client asks, "what does my drinking have to do with my diagnosis?" What effect of alcohol should the nurse include when responding? A. promotes the formation of calculi in the cystic duct B. Stimulates the pancreas to secrete more insulin than it can immediately produce C. Alters the composition of enzymes so they are capable of damaging the pancreas
