PNR 206/PNR206 Exam 4 V2 | Medical-
Surgical Nursing II Q&A with Rationale |
Fortis College
1. A patient is admitted with a diagnosis of Diabetic Ketoacidosis (DKA). Which clinical
manifestation should the nurse expect to find during the physical assessment?
A. Cheyne-Stokes breathing and pinpoint pupils
B. Bradycardia and increased blood pressure
C. Moist, clammy skin and tremors
D. Kussmaul respirations and fruity breath odor
Correct Answer: D
Expert Explanation: Kussmaul respirations are deep, rapid breaths that the body uses to
blow off excess carbon dioxide to compensate for metabolic acidosis. The fruity breath
odor is caused by the presence of ketones in the system, which are metabolic byproducts of
fat breakdown. These findings are classic signs of DKA and require immediate medical
intervention to stabilize the patient’s pH and electrolyte balance.
2. Which laboratory value is the most critical for the nurse to monitor in a patient diagnosed
with Acute Pancreatitis?
A. Serum Amylase and Lipase
B. Serum Creatinine
,C. White Blood Cell Count
D. Prothrombin Time (PT)
Correct Answer: A
Expert Explanation: Serum amylase and lipase are the primary enzymes released into the
bloodstream when pancreatic cells are damaged or inflamed. Lipase is generally more
specific to the pancreas and stays elevated longer than amylase. Monitoring these levels
helps the clinical team confirm the diagnosis and track the progression or resolution of the
inflammatory process.
3. A patient with cirrhosis of the liver is prescribed Lactulose. What is the primary purpose of
this medication in this specific patient population?
A. To reduce serum ammonia levels and prevent encephalopathy
B. To treat chronic constipation and prevent hemorrhoids
C. To lower blood glucose levels in diabetic patients
D. To promote the excretion of excess bilirubin via the kidneys
Correct Answer: A
Expert Explanation: Lactulose works by acidifying the colon, which converts ammonia
into ammonium, a form that cannot be easily reabsorbed into the blood. This allows the
ammonia to be excreted through the stool, thereby lowering systemic levels. High ammonia
levels are toxic to the brain and can lead to hepatic encephalopathy, making this
medication vital for liver failure management.
,4. A nurse is caring for a patient post-cholecystectomy. The patient reports severe pain in the
right shoulder. What is the best interpretation of this finding?
A. This is a sign of internal hemorrhage and requires a rapid response.
B. The patient is experiencing an early sign of myocardial infarction.
C. This is referred pain caused by CO2 insufflation during surgery.
D. The patient is developing a pulmonary embolism post-operatively.
Correct Answer: C
Expert Explanation: During laparoscopic surgery, carbon dioxide is used to inflate the
abdomen for better visualization, which can irritate the phrenic nerve. This irritation often
manifests as referred pain in the right shoulder. The nurse should encourage early
ambulation to help the body absorb the gas and alleviate the discomfort.
5. Which dietary instruction is most appropriate for a patient newly diagnosed with
Diverticulitis during the acute inflammatory phase?
A. Consume a high-fiber diet with whole grains and nuts.
B. Follow a high-protein, high-fat diet to promote healing.
C. Increase intake of raw vegetables and fruits with seeds.
D. Maintain a clear liquid diet or NPO status to rest the bowel.
Correct Answer: D
, Expert Explanation: During an acute flare-up of diverticulitis, the bowel needs time to
heal from inflammation and infection. A clear liquid diet or NPO (nothing by mouth) status
reduces peristalsis and prevents further irritation of the diverticula. Once the acute
symptoms subside, the patient is slowly transitioned back to a high-fiber diet for long-term
management.
6. A patient is diagnosed with Pernicious Anemia. The nurse understands this is caused by a
deficiency in which substance?
A. Iron
B. Folic Acid
C. Intrinsic Factor
D. Erythropoietin
Correct Answer: C
Expert Explanation: Pernicious anemia occurs when the gastric mucosa fails to produce
intrinsic factor, which is necessary for the absorption of Vitamin B12 in the small intestine.
Without Vitamin B12, red blood cells cannot mature properly, leading to macrocytic
anemia. Patients with this condition usually require lifelong Vitamin B12 injections because
oral supplements are not absorbed effectively.
7. Which assessment finding would lead the nurse to suspect a patient has a Bowel
Obstruction?
A. Decreased abdominal girth and increased appetite
Surgical Nursing II Q&A with Rationale |
Fortis College
1. A patient is admitted with a diagnosis of Diabetic Ketoacidosis (DKA). Which clinical
manifestation should the nurse expect to find during the physical assessment?
A. Cheyne-Stokes breathing and pinpoint pupils
B. Bradycardia and increased blood pressure
C. Moist, clammy skin and tremors
D. Kussmaul respirations and fruity breath odor
Correct Answer: D
Expert Explanation: Kussmaul respirations are deep, rapid breaths that the body uses to
blow off excess carbon dioxide to compensate for metabolic acidosis. The fruity breath
odor is caused by the presence of ketones in the system, which are metabolic byproducts of
fat breakdown. These findings are classic signs of DKA and require immediate medical
intervention to stabilize the patient’s pH and electrolyte balance.
2. Which laboratory value is the most critical for the nurse to monitor in a patient diagnosed
with Acute Pancreatitis?
A. Serum Amylase and Lipase
B. Serum Creatinine
,C. White Blood Cell Count
D. Prothrombin Time (PT)
Correct Answer: A
Expert Explanation: Serum amylase and lipase are the primary enzymes released into the
bloodstream when pancreatic cells are damaged or inflamed. Lipase is generally more
specific to the pancreas and stays elevated longer than amylase. Monitoring these levels
helps the clinical team confirm the diagnosis and track the progression or resolution of the
inflammatory process.
3. A patient with cirrhosis of the liver is prescribed Lactulose. What is the primary purpose of
this medication in this specific patient population?
A. To reduce serum ammonia levels and prevent encephalopathy
B. To treat chronic constipation and prevent hemorrhoids
C. To lower blood glucose levels in diabetic patients
D. To promote the excretion of excess bilirubin via the kidneys
Correct Answer: A
Expert Explanation: Lactulose works by acidifying the colon, which converts ammonia
into ammonium, a form that cannot be easily reabsorbed into the blood. This allows the
ammonia to be excreted through the stool, thereby lowering systemic levels. High ammonia
levels are toxic to the brain and can lead to hepatic encephalopathy, making this
medication vital for liver failure management.
,4. A nurse is caring for a patient post-cholecystectomy. The patient reports severe pain in the
right shoulder. What is the best interpretation of this finding?
A. This is a sign of internal hemorrhage and requires a rapid response.
B. The patient is experiencing an early sign of myocardial infarction.
C. This is referred pain caused by CO2 insufflation during surgery.
D. The patient is developing a pulmonary embolism post-operatively.
Correct Answer: C
Expert Explanation: During laparoscopic surgery, carbon dioxide is used to inflate the
abdomen for better visualization, which can irritate the phrenic nerve. This irritation often
manifests as referred pain in the right shoulder. The nurse should encourage early
ambulation to help the body absorb the gas and alleviate the discomfort.
5. Which dietary instruction is most appropriate for a patient newly diagnosed with
Diverticulitis during the acute inflammatory phase?
A. Consume a high-fiber diet with whole grains and nuts.
B. Follow a high-protein, high-fat diet to promote healing.
C. Increase intake of raw vegetables and fruits with seeds.
D. Maintain a clear liquid diet or NPO status to rest the bowel.
Correct Answer: D
, Expert Explanation: During an acute flare-up of diverticulitis, the bowel needs time to
heal from inflammation and infection. A clear liquid diet or NPO (nothing by mouth) status
reduces peristalsis and prevents further irritation of the diverticula. Once the acute
symptoms subside, the patient is slowly transitioned back to a high-fiber diet for long-term
management.
6. A patient is diagnosed with Pernicious Anemia. The nurse understands this is caused by a
deficiency in which substance?
A. Iron
B. Folic Acid
C. Intrinsic Factor
D. Erythropoietin
Correct Answer: C
Expert Explanation: Pernicious anemia occurs when the gastric mucosa fails to produce
intrinsic factor, which is necessary for the absorption of Vitamin B12 in the small intestine.
Without Vitamin B12, red blood cells cannot mature properly, leading to macrocytic
anemia. Patients with this condition usually require lifelong Vitamin B12 injections because
oral supplements are not absorbed effectively.
7. Which assessment finding would lead the nurse to suspect a patient has a Bowel
Obstruction?
A. Decreased abdominal girth and increased appetite
