NUR104 | NUR104 Medsurg 2 Exam 2 Version 1
Questions with Correct Answers and Expert
Explanation for Each Question
1. A patient with cirrhosis and hepatic encephalopathy has an elevated serum
ammonia level. Which medication should the nurse expect to administer to reduce
this level?
A. Spironolactone
B. Furosemide
C. Lactulose
D. Propranolol
Correct Answer: C
Expert Explanation: Lactulose is the primary medication used to promote the
excretion of ammonia through the stool. It works by trapping ammonia in the gut
and facilitating its removal via an osmotic laxative effect. Diuretics like
spironolactone or furosemide are used for ascites but do not directly lower
ammonia levels. The nurse should monitor for the frequency of bowel movements to
evaluate the medication’s effectiveness. Maintaining lower ammonia levels is critical
for improving the patient’s neurological status and mental clarity.
,2. Which clinical manifestation would the nurse expect to find in a patient diagnosed
with acute pancreatitis?
A. Epigastric pain that radiates to the back
B. Right lower quadrant pain with rebound tenderness
C. Pain in the left lower quadrant relieved by defecation
D. Pain in the right upper quadrant radiating to the shoulder
Correct Answer: A
Expert Explanation: Acute pancreatitis typically presents as severe, steady
epigastric pain that often radiates through to the back. This pain is caused by the
autodigestion of the pancreas and local inflammatory response. Right lower
quadrant pain is more characteristic of appendicitis, while right upper quadrant
pain suggests cholecystitis. The nurse should assess the patient for other signs such
as nausea, vomiting, and abdominal guarding. Understanding the location and
nature of pain helps in differentiating between various gastrointestinal disorders.
3. A patient is admitted with a suspected upper gastrointestinal bleed. Which
assessment finding is most indicative of this condition?
A. Bright red blood in the stool
B. Steatorrhea
C. Hematemesis
,D. Clay-colored stools
Correct Answer: C
Expert Explanation: Hematemesis, or vomiting blood, is a hallmark sign of a bleed
occurring in the upper gastrointestinal tract. Bright red blood in the stool, or
hematochezia, usually suggests a lower GI source of bleeding. Steatorrhea refers to
fatty stools often seen in malabsorption syndromes or chronic pancreatitis. Clay-
colored stools are associated with biliary obstruction and liver disease rather than
active bleeding. Early identification of the bleeding source is vital for initiating
appropriate hemodynamic stabilization interventions.
4. The nurse is caring for a patient after a paracentesis. Which assessment is the
priority to monitor for complications?
A. Bowel sounds in all four quadrants
B. Urine output and color
C. Respiratory rate and depth
D. Blood pressure and heart rate
Correct Answer: D
Expert Explanation: Monitoring vital signs like blood pressure and heart rate is
essential to detect hypovolemic shock after a large-volume paracentesis. The rapid
removal of fluid can cause a shift from the vascular space, leading to decreased
, circulating volume. While bowel sounds and respiratory status are important,
hemodynamic stability is the immediate priority post-procedure. The nurse should
also check the puncture site for any leakage or signs of infection. Ensuring the
patient remains stable helps prevent further complications like syncope or organ
hypoperfusion.
5. Which diet modification should the nurse recommend for a patient with
symptomatic cholelithiasis?
A. High-protein, high-calorie diet
B. Fluid restriction with sodium limitation
C. Low-fiber, high-carbohydrate diet
D. Low-fat, small, frequent meals
Correct Answer: D
Expert Explanation: A low-fat diet is recommended for patients with cholelithiasis
to reduce gallbladder stimulation and prevent biliary colic. Small, frequent meals
help manage digestion and prevent the sudden release of bile that causes pain. High-
fat foods are known to trigger the gallbladder to contract, which can move stones
into the ducts. The nurse should educate the patient on identifying and avoiding
high-fat triggers like fried foods or heavy creams. Proper nutritional management is
a key component of chronic management for gallbladder disease.
Questions with Correct Answers and Expert
Explanation for Each Question
1. A patient with cirrhosis and hepatic encephalopathy has an elevated serum
ammonia level. Which medication should the nurse expect to administer to reduce
this level?
A. Spironolactone
B. Furosemide
C. Lactulose
D. Propranolol
Correct Answer: C
Expert Explanation: Lactulose is the primary medication used to promote the
excretion of ammonia through the stool. It works by trapping ammonia in the gut
and facilitating its removal via an osmotic laxative effect. Diuretics like
spironolactone or furosemide are used for ascites but do not directly lower
ammonia levels. The nurse should monitor for the frequency of bowel movements to
evaluate the medication’s effectiveness. Maintaining lower ammonia levels is critical
for improving the patient’s neurological status and mental clarity.
,2. Which clinical manifestation would the nurse expect to find in a patient diagnosed
with acute pancreatitis?
A. Epigastric pain that radiates to the back
B. Right lower quadrant pain with rebound tenderness
C. Pain in the left lower quadrant relieved by defecation
D. Pain in the right upper quadrant radiating to the shoulder
Correct Answer: A
Expert Explanation: Acute pancreatitis typically presents as severe, steady
epigastric pain that often radiates through to the back. This pain is caused by the
autodigestion of the pancreas and local inflammatory response. Right lower
quadrant pain is more characteristic of appendicitis, while right upper quadrant
pain suggests cholecystitis. The nurse should assess the patient for other signs such
as nausea, vomiting, and abdominal guarding. Understanding the location and
nature of pain helps in differentiating between various gastrointestinal disorders.
3. A patient is admitted with a suspected upper gastrointestinal bleed. Which
assessment finding is most indicative of this condition?
A. Bright red blood in the stool
B. Steatorrhea
C. Hematemesis
,D. Clay-colored stools
Correct Answer: C
Expert Explanation: Hematemesis, or vomiting blood, is a hallmark sign of a bleed
occurring in the upper gastrointestinal tract. Bright red blood in the stool, or
hematochezia, usually suggests a lower GI source of bleeding. Steatorrhea refers to
fatty stools often seen in malabsorption syndromes or chronic pancreatitis. Clay-
colored stools are associated with biliary obstruction and liver disease rather than
active bleeding. Early identification of the bleeding source is vital for initiating
appropriate hemodynamic stabilization interventions.
4. The nurse is caring for a patient after a paracentesis. Which assessment is the
priority to monitor for complications?
A. Bowel sounds in all four quadrants
B. Urine output and color
C. Respiratory rate and depth
D. Blood pressure and heart rate
Correct Answer: D
Expert Explanation: Monitoring vital signs like blood pressure and heart rate is
essential to detect hypovolemic shock after a large-volume paracentesis. The rapid
removal of fluid can cause a shift from the vascular space, leading to decreased
, circulating volume. While bowel sounds and respiratory status are important,
hemodynamic stability is the immediate priority post-procedure. The nurse should
also check the puncture site for any leakage or signs of infection. Ensuring the
patient remains stable helps prevent further complications like syncope or organ
hypoperfusion.
5. Which diet modification should the nurse recommend for a patient with
symptomatic cholelithiasis?
A. High-protein, high-calorie diet
B. Fluid restriction with sodium limitation
C. Low-fiber, high-carbohydrate diet
D. Low-fat, small, frequent meals
Correct Answer: D
Expert Explanation: A low-fat diet is recommended for patients with cholelithiasis
to reduce gallbladder stimulation and prevent biliary colic. Small, frequent meals
help manage digestion and prevent the sudden release of bile that causes pain. High-
fat foods are known to trigger the gallbladder to contract, which can move stones
into the ducts. The nurse should educate the patient on identifying and avoiding
high-fat triggers like fried foods or heavy creams. Proper nutritional management is
a key component of chronic management for gallbladder disease.
