NUR 2502 Exam 3: Multidimensional Care III
(MDC 3) Verified and Updated Questions and
Answers
1. A nurse is caring for a client with acute pancreatitis. Which physical
assessment finding should the nurse report immediately as a sign of
retroperitoneal bleeding?
A. Pain radiating to the left shoulder
B. Increased serum amylase levels
C. Hyperactive bowel sounds in all four quadrants
D. Bluish discoloration around the umbilicus (Cullen’s sign)
Answer: D
Explanation: Cullen’s sign (bluish discoloration around the umbilicus) or Turner’s sign
(discoloration of the flanks) indicates retroperitoneal hemorrhage, which is a medical
emergency in acute pancreatitis.
2. A client with cirrhosis and hepatic encephalopathy is prescribed lactulose.
What is the primary therapeutic goal of this medication?
A. To reduce serum potassium levels
B. To promote the excretion of ammonia through the stool
C. To decrease the production of gastric acid
D. To increase the absorption of fat-soluble vitamins
Answer: B
Explanation: Lactulose works by trapping ammonia in the gut and promoting its excretion
via a laxative effect, thereby reducing blood ammonia levels and improving mental status in
hepatic encephalopathy.
,3. Which assessment finding should the nurse prioritize in a client diagnosed
with chronic kidney disease (CKD) who has a potassium level of 6.4 mEq/L?
A. Increased urine output
B. Hypoactive bowel sounds
C. Tall, peaked T waves on the EKG
D. Dry mucous membranes
Answer: C
Explanation: Hyperkalemia (K+ > 5.0 mEq/L) is life-threatening due to its effect on cardiac
conduction; tall, peaked T waves are an early sign of cardiotoxicity.
4. A client is admitted with Diabetic Ketoacidosis (DKA). Which of the following
acid-base imbalances does the nurse expect to see on the arterial blood gas
(ABG) report?
A. Respiratory Acidosis
B. Respiratory Alkalosis
C. Metabolic Acidosis
D. Metabolic Alkalosis
Answer: C
Explanation: In DKA, the breakdown of fats leads to the production of ketones (acids),
causing a drop in serum bicarbonate and a decrease in pH, resulting in metabolic acidosis.
5. When providing discharge teaching to a client with a new diagnosis of Crohn’s
disease, which dietary recommendation is most appropriate during an acute
flare-up?
A. High-fiber, raw vegetable salad
B. Low-residue, high-protein diet
C. Whole-grain breads and cereals
D. Increased intake of caffeinated beverages
Answer: B
, Explanation: During an acute flare of Crohn’s disease, a low-residue (low fiber) diet is
recommended to minimize bowel stimulation and irritation, while high protein aids
healing.
6. A nurse is monitoring a client after a liver biopsy. In which position should the
nurse place the client immediately following the procedure?
A. High-Fowler’s with the head of bed at 90 degrees
B. Right side-lying with a pillow under the biopsy site
C. Prone with a pillow under the abdomen
D. Left side-lying with the bed in Trendelenburg position
Answer: B
Explanation: The client is placed on the right side to apply pressure to the liver biopsy site,
which helps prevent post-procedure bleeding.
7. A client with Type 1 Diabetes is found unresponsive with a blood glucose of
28 mg/dL. What is the nurse’s priority action?
A. Administer Glucagon IM or SQ
B. Give 4 ounces of orange juice
C. Administer 15 grams of simple carbohydrates orally
D. Re-check the blood glucose in 15 minutes
Answer: A
Explanation: Because the client is unresponsive and cannot safely swallow, the nurse must
administer Glucagon or IV Dextrose to treat severe hypoglycemia.
(MDC 3) Verified and Updated Questions and
Answers
1. A nurse is caring for a client with acute pancreatitis. Which physical
assessment finding should the nurse report immediately as a sign of
retroperitoneal bleeding?
A. Pain radiating to the left shoulder
B. Increased serum amylase levels
C. Hyperactive bowel sounds in all four quadrants
D. Bluish discoloration around the umbilicus (Cullen’s sign)
Answer: D
Explanation: Cullen’s sign (bluish discoloration around the umbilicus) or Turner’s sign
(discoloration of the flanks) indicates retroperitoneal hemorrhage, which is a medical
emergency in acute pancreatitis.
2. A client with cirrhosis and hepatic encephalopathy is prescribed lactulose.
What is the primary therapeutic goal of this medication?
A. To reduce serum potassium levels
B. To promote the excretion of ammonia through the stool
C. To decrease the production of gastric acid
D. To increase the absorption of fat-soluble vitamins
Answer: B
Explanation: Lactulose works by trapping ammonia in the gut and promoting its excretion
via a laxative effect, thereby reducing blood ammonia levels and improving mental status in
hepatic encephalopathy.
,3. Which assessment finding should the nurse prioritize in a client diagnosed
with chronic kidney disease (CKD) who has a potassium level of 6.4 mEq/L?
A. Increased urine output
B. Hypoactive bowel sounds
C. Tall, peaked T waves on the EKG
D. Dry mucous membranes
Answer: C
Explanation: Hyperkalemia (K+ > 5.0 mEq/L) is life-threatening due to its effect on cardiac
conduction; tall, peaked T waves are an early sign of cardiotoxicity.
4. A client is admitted with Diabetic Ketoacidosis (DKA). Which of the following
acid-base imbalances does the nurse expect to see on the arterial blood gas
(ABG) report?
A. Respiratory Acidosis
B. Respiratory Alkalosis
C. Metabolic Acidosis
D. Metabolic Alkalosis
Answer: C
Explanation: In DKA, the breakdown of fats leads to the production of ketones (acids),
causing a drop in serum bicarbonate and a decrease in pH, resulting in metabolic acidosis.
5. When providing discharge teaching to a client with a new diagnosis of Crohn’s
disease, which dietary recommendation is most appropriate during an acute
flare-up?
A. High-fiber, raw vegetable salad
B. Low-residue, high-protein diet
C. Whole-grain breads and cereals
D. Increased intake of caffeinated beverages
Answer: B
, Explanation: During an acute flare of Crohn’s disease, a low-residue (low fiber) diet is
recommended to minimize bowel stimulation and irritation, while high protein aids
healing.
6. A nurse is monitoring a client after a liver biopsy. In which position should the
nurse place the client immediately following the procedure?
A. High-Fowler’s with the head of bed at 90 degrees
B. Right side-lying with a pillow under the biopsy site
C. Prone with a pillow under the abdomen
D. Left side-lying with the bed in Trendelenburg position
Answer: B
Explanation: The client is placed on the right side to apply pressure to the liver biopsy site,
which helps prevent post-procedure bleeding.
7. A client with Type 1 Diabetes is found unresponsive with a blood glucose of
28 mg/dL. What is the nurse’s priority action?
A. Administer Glucagon IM or SQ
B. Give 4 ounces of orange juice
C. Administer 15 grams of simple carbohydrates orally
D. Re-check the blood glucose in 15 minutes
Answer: A
Explanation: Because the client is unresponsive and cannot safely swallow, the nurse must
administer Glucagon or IV Dextrose to treat severe hypoglycemia.
