SCF Level 4 Exam One Concepts
Your client diagnosed with type 1 diabetes is found lying unconscious on the floor of the bathroom.
Which of the following interventions should the nurse implement first?
A. Administer 50% dextrose IVP.
B. Notify the healthcare provider.
C. Move the client to the ICU.
D. Check the serum glucose level. - Answer A is correct
You are caring for a 45-year-old male patient who is admitted with suspected acute pancreatitis. Your
patient reports having severe mid-epigastric pain that radiates to his back. The patient states the pain
started last night after eating fast food. You anticipate performing which of the following tasks to manage
this patient's current condition? Select all that apply.
A. Medicate for pain
B. Monitor fluid and electrolyte status
C. Keep the patient NPO
D. Initiate broad-spectrum antibiotic coverage - Answers A, B, C, D are correct
Choice E is incorrect as antimicrobial therapy should only be used when necrosis of the pancreas is
suspected. All other answers are correct.
Your patient with acute pancreatitis reports that they have voiding excessively and feel extremely thirsty
despite drinking water. They also report new onset blurred vision. As the nurse, you're your next step
would be to do which of the following:
A: Offer to insert a Foley catheter.
B. Check the patient's blood glucose level.
C. Educate the patient excessive thirst and urination is normal with pancreatitis.
D. Offer to bring them some orange juice or apple juice. - Answer: B is correct.
,Check the patient's blood glucose level as blurred vision, polyuria and polydipsia are signs of
hyperglycemia. Answer A is incorrect: An invasive Foley catheter is not indicated in this ambulatory
patient. Answer C is incorrect: Polydipsia and polyuria are signs of hyperglycemia that results from
damage to the pancreas. Answer D is incorrect: With acute pancreatitis, juice is prohibited as it contains
sugar that can further disrupt the body's sugar balance.
A nurse is preparing to discharge her patient who was admitted with and treated for acute pancreatitis.
Which of the following statements made by the patient requires further discharge education:
A. "I will concentrate on eating complex carbohydrates and whole grains."
B. "I will purchase foods that are high in protein."
C. It will be hard, but I will avoid alcoholic beverages."
D. "After being on a clear liquid diet for the past few days, I can't wait to pick up a burger and fries on the
way home." - Answer D is correct.
This statement needs further education as clients with pancreatitis should avoid fatty food, alcohol and
refined carbohydrates. Fried foods and high-fat foods, such as burgers and french fries, can be
problematic for people with pancreatitis. The pancreas helps with fat digestion, so foods with more fat
make the pancreas work harder. All other answers are correct.
A 62-year-old man presents with dizziness and lightheadedness. His medical history includes
hypertension, hyperlipidemia, cirrhosis and alcohol use disorder. He was recently started on
spironolactone for recurrent ascites. His vital signs show a temperature of 97.6, blood pressure 98/57
mmHg, heart rate 120 bpm, respiratory rate of 12 breaths/min, and O2 saturation of 96% on room air.
Which of the following is responsible for the decrease in the patient's blood pressure secondary to
vasodilation?
A. A fall in serum lactic acid.
B. A fall in blood carbon dioxide.
C. A rise in serum potassium.
D. A rise in serum sodium. - Answer C is correct.
Rationale: Hyperkalemia is a known adverse effect of spironolactone. This increase in serum potassium
could lead to vasodilation and a drop in blood pressure, which would explain the symptoms of dizziness
and lightheadedness.
, Which outcome should the nurse identify for the client diagnosed with fluid volume excess?
A. The client will void a minimum of 30 mL per hour.
B. The client will have no adventitious breath sounds.
C. The client will have skin turgor of less than 3 seconds.
D. The client will have a serum creatinine of 1.4 mg/dL. - Answer B is correct
The client diagnosed with FVE has too much fluid, which is reflected by adventitious breath sounds.
Therefore, an expected outcome is to have no excess fluid as evidenced by normal, clear breath sounds.
Voiding a minimum of 30 mL of urine each hour is appropriate for a client diagnosed with fluid volume
deficit. Elastic skin turgor indicates a client has adequate fluid volume status and is an expected outcome
for the client diagnosed with fluid volume deficit. The creatinine is elevated in a client diagnosed with
dehydration.
Which of the following statements is true of ulcerative colitis? Select all that apply.
A. Complications such as hemorrhage and nutritional deficiencies may occur.
B. It can occur anywhere in the gastrointestinal tract from mouth to anus.
C. Causes diarrhea, abdominal pain and loss of appetite.
D. Characterized by skip lesions and granulomas.
E. Stools are frequent and watery with blood and mucus. - Answers A, C and E are correct
Complications such as hemorrhage and nutritional deficiencies may occur; Causes diarrhea, abdominal
pain and loss of appetite; Stools are frequent and watery with blood and mucus. B and D are indicative
of Crohn's disease which can appear anywhere in the GI tract and is characterized by granulomas and
skip lesions.
Which client should the nurse consider at risk for developing acute renal failure?
A. The client diagnosed with essential hypertension.
B. The client diagnosed with type 2 diabetes.
C. The client diagnosed with an anaphylactic reaction.
D. The client after having an autologous blood transfusion. - Answer C is correct
Your client diagnosed with type 1 diabetes is found lying unconscious on the floor of the bathroom.
Which of the following interventions should the nurse implement first?
A. Administer 50% dextrose IVP.
B. Notify the healthcare provider.
C. Move the client to the ICU.
D. Check the serum glucose level. - Answer A is correct
You are caring for a 45-year-old male patient who is admitted with suspected acute pancreatitis. Your
patient reports having severe mid-epigastric pain that radiates to his back. The patient states the pain
started last night after eating fast food. You anticipate performing which of the following tasks to manage
this patient's current condition? Select all that apply.
A. Medicate for pain
B. Monitor fluid and electrolyte status
C. Keep the patient NPO
D. Initiate broad-spectrum antibiotic coverage - Answers A, B, C, D are correct
Choice E is incorrect as antimicrobial therapy should only be used when necrosis of the pancreas is
suspected. All other answers are correct.
Your patient with acute pancreatitis reports that they have voiding excessively and feel extremely thirsty
despite drinking water. They also report new onset blurred vision. As the nurse, you're your next step
would be to do which of the following:
A: Offer to insert a Foley catheter.
B. Check the patient's blood glucose level.
C. Educate the patient excessive thirst and urination is normal with pancreatitis.
D. Offer to bring them some orange juice or apple juice. - Answer: B is correct.
,Check the patient's blood glucose level as blurred vision, polyuria and polydipsia are signs of
hyperglycemia. Answer A is incorrect: An invasive Foley catheter is not indicated in this ambulatory
patient. Answer C is incorrect: Polydipsia and polyuria are signs of hyperglycemia that results from
damage to the pancreas. Answer D is incorrect: With acute pancreatitis, juice is prohibited as it contains
sugar that can further disrupt the body's sugar balance.
A nurse is preparing to discharge her patient who was admitted with and treated for acute pancreatitis.
Which of the following statements made by the patient requires further discharge education:
A. "I will concentrate on eating complex carbohydrates and whole grains."
B. "I will purchase foods that are high in protein."
C. It will be hard, but I will avoid alcoholic beverages."
D. "After being on a clear liquid diet for the past few days, I can't wait to pick up a burger and fries on the
way home." - Answer D is correct.
This statement needs further education as clients with pancreatitis should avoid fatty food, alcohol and
refined carbohydrates. Fried foods and high-fat foods, such as burgers and french fries, can be
problematic for people with pancreatitis. The pancreas helps with fat digestion, so foods with more fat
make the pancreas work harder. All other answers are correct.
A 62-year-old man presents with dizziness and lightheadedness. His medical history includes
hypertension, hyperlipidemia, cirrhosis and alcohol use disorder. He was recently started on
spironolactone for recurrent ascites. His vital signs show a temperature of 97.6, blood pressure 98/57
mmHg, heart rate 120 bpm, respiratory rate of 12 breaths/min, and O2 saturation of 96% on room air.
Which of the following is responsible for the decrease in the patient's blood pressure secondary to
vasodilation?
A. A fall in serum lactic acid.
B. A fall in blood carbon dioxide.
C. A rise in serum potassium.
D. A rise in serum sodium. - Answer C is correct.
Rationale: Hyperkalemia is a known adverse effect of spironolactone. This increase in serum potassium
could lead to vasodilation and a drop in blood pressure, which would explain the symptoms of dizziness
and lightheadedness.
, Which outcome should the nurse identify for the client diagnosed with fluid volume excess?
A. The client will void a minimum of 30 mL per hour.
B. The client will have no adventitious breath sounds.
C. The client will have skin turgor of less than 3 seconds.
D. The client will have a serum creatinine of 1.4 mg/dL. - Answer B is correct
The client diagnosed with FVE has too much fluid, which is reflected by adventitious breath sounds.
Therefore, an expected outcome is to have no excess fluid as evidenced by normal, clear breath sounds.
Voiding a minimum of 30 mL of urine each hour is appropriate for a client diagnosed with fluid volume
deficit. Elastic skin turgor indicates a client has adequate fluid volume status and is an expected outcome
for the client diagnosed with fluid volume deficit. The creatinine is elevated in a client diagnosed with
dehydration.
Which of the following statements is true of ulcerative colitis? Select all that apply.
A. Complications such as hemorrhage and nutritional deficiencies may occur.
B. It can occur anywhere in the gastrointestinal tract from mouth to anus.
C. Causes diarrhea, abdominal pain and loss of appetite.
D. Characterized by skip lesions and granulomas.
E. Stools are frequent and watery with blood and mucus. - Answers A, C and E are correct
Complications such as hemorrhage and nutritional deficiencies may occur; Causes diarrhea, abdominal
pain and loss of appetite; Stools are frequent and watery with blood and mucus. B and D are indicative
of Crohn's disease which can appear anywhere in the GI tract and is characterized by granulomas and
skip lesions.
Which client should the nurse consider at risk for developing acute renal failure?
A. The client diagnosed with essential hypertension.
B. The client diagnosed with type 2 diabetes.
C. The client diagnosed with an anaphylactic reaction.
D. The client after having an autologous blood transfusion. - Answer C is correct
