NUR 265 Exam 3: Nur Med Surg - Galen College of Nursing
Updated and Latest Questions and Correct Answers with
Rationale
1. A patient with hepatic encephalopathy is prescribed lactulose. The nurse knows the medication is
effective when which clinical finding is observed?
A. The patient has four soft bowel movements in 24 hours.
B. The patient’s sclera appears less icteric.
C. The patient’s abdominal girth decreases by two centimeters.
D. The patient’s serum ammonia level decreases toward normal.
Correct Answer: D
Rationale: The primary goal of lactulose therapy is to reduce serum ammonia levels by trapping it in the
gut for excretion. As ammonia levels drop, the patient’s neurological status and mental clarity typically
improve. The nurse must monitor laboratory values to evaluate the direct metabolic impact of the drug.
While frequent bowel movements are a side effect, they do not confirm therapeutic success regarding
brain function. Continued assessment of orientation is vital to ensure the prevention of further
encephalopathy complications.
2. During the oliguric phase of Acute Kidney Injury (AKI), which electrolyte imbalance is the nurse most
likely to observe?
A. Hyperkalemia
B. Hypercalcemia
C. Hypokalemia
D. Hypophosphatemia
,Correct Answer: A
Rationale: In the oliguric phase of AKI, the kidneys fail to excrete potassium, leading to dangerous
systemic accumulation. Hyperkalemia is a life-threatening condition that requires immediate monitoring
for cardiac arrhythmias. The nurse should assess the EKG for peaked T waves which indicate high
potassium levels. Other imbalances like hypocalcemia and hyperphosphatemia are also common but
hyperkalemia is the most critical priority. Patient safety depends on restricting dietary potassium intake
during this acute phase of renal failure.
3. A patient is admitted with Diabetic Ketoacidosis (DKA). Which physician order should the nurse
implement first?
A. Administer 10 units of regular insulin IV bolus.
B. Start an infusion of 0.9% normal saline at 1000 mL/hr.
C. Obtain a baseline arterial blood gas (ABG) result.
D. Administer potassium chloride 20 mEq IV piggyback.
Correct Answer: B
Rationale: Fluid resuscitation is the highest priority in DKA to restore circulatory volume and stabilize
blood pressure. Dehydration in DKA can lead to hypovolemic shock, so isotonic fluids are initiated before
insulin. While insulin is necessary to stop ketone production, it can cause fluid shifts that worsen
hypotension if the patient is not hydrated. The nurse must also monitor for fluid overload during rapid
administration to ensure patient safety. Potassium is typically replaced later once urine output is
confirmed and levels start to drop from insulin therapy.
4. Which assessment finding in a patient with acute pancreatitis requires immediate notification of the
healthcare provider?
A. Serum amylase level three times the normal limit.
, B. Patient reporting pain that radiates to the back.
C. Absence of bowel sounds in all four quadrants.
D. Ecchymosis around the periumbilical area (Cullen’s sign).
Correct Answer: D
Rationale: Cullen’s sign indicates retroperitoneal hemorrhage and is a sign of severe, necrotizing
pancreatitis. This finding suggests a high risk of hemorrhagic shock and requires immediate medical
intervention. While elevated amylase and radiating pain are expected findings in pancreatitis, they are
not immediately life-threatening. The nurse should prepare the patient for potential surgical consults or
intensive care monitoring. Monitoring vital signs for signs of shock is the next critical nursing action.
5. The nurse is caring for a patient with Chronic Kidney Disease (CKD) who is receiving hemodialysis. Which
intervention is most important for maintaining the integrity of the AV fistula?
A. Ensure the patient keeps the arm elevated at heart level.
B. Apply a warm compress to the site if it feels cool.
C. Check the site for a bruit and a thrill every shift.
D. Clean the site with alcohol wipes before every assessment.
Correct Answer: C
Rationale: A palpable thrill and an audible bruit confirm that the AV fistula is patent and has adequate
blood flow. Loss of these signs indicates clotting or stenosis, which is a medical emergency for a dialysis
patient. The nurse must avoid taking blood pressure or performing venipunctures on the affected arm to
prevent damage. Education should include teaching the patient to avoid wearing tight clothing or jewelry
on that limb. Consistent monitoring ensures the access remains viable for life-sustaining hemodialysis
treatments.
Updated and Latest Questions and Correct Answers with
Rationale
1. A patient with hepatic encephalopathy is prescribed lactulose. The nurse knows the medication is
effective when which clinical finding is observed?
A. The patient has four soft bowel movements in 24 hours.
B. The patient’s sclera appears less icteric.
C. The patient’s abdominal girth decreases by two centimeters.
D. The patient’s serum ammonia level decreases toward normal.
Correct Answer: D
Rationale: The primary goal of lactulose therapy is to reduce serum ammonia levels by trapping it in the
gut for excretion. As ammonia levels drop, the patient’s neurological status and mental clarity typically
improve. The nurse must monitor laboratory values to evaluate the direct metabolic impact of the drug.
While frequent bowel movements are a side effect, they do not confirm therapeutic success regarding
brain function. Continued assessment of orientation is vital to ensure the prevention of further
encephalopathy complications.
2. During the oliguric phase of Acute Kidney Injury (AKI), which electrolyte imbalance is the nurse most
likely to observe?
A. Hyperkalemia
B. Hypercalcemia
C. Hypokalemia
D. Hypophosphatemia
,Correct Answer: A
Rationale: In the oliguric phase of AKI, the kidneys fail to excrete potassium, leading to dangerous
systemic accumulation. Hyperkalemia is a life-threatening condition that requires immediate monitoring
for cardiac arrhythmias. The nurse should assess the EKG for peaked T waves which indicate high
potassium levels. Other imbalances like hypocalcemia and hyperphosphatemia are also common but
hyperkalemia is the most critical priority. Patient safety depends on restricting dietary potassium intake
during this acute phase of renal failure.
3. A patient is admitted with Diabetic Ketoacidosis (DKA). Which physician order should the nurse
implement first?
A. Administer 10 units of regular insulin IV bolus.
B. Start an infusion of 0.9% normal saline at 1000 mL/hr.
C. Obtain a baseline arterial blood gas (ABG) result.
D. Administer potassium chloride 20 mEq IV piggyback.
Correct Answer: B
Rationale: Fluid resuscitation is the highest priority in DKA to restore circulatory volume and stabilize
blood pressure. Dehydration in DKA can lead to hypovolemic shock, so isotonic fluids are initiated before
insulin. While insulin is necessary to stop ketone production, it can cause fluid shifts that worsen
hypotension if the patient is not hydrated. The nurse must also monitor for fluid overload during rapid
administration to ensure patient safety. Potassium is typically replaced later once urine output is
confirmed and levels start to drop from insulin therapy.
4. Which assessment finding in a patient with acute pancreatitis requires immediate notification of the
healthcare provider?
A. Serum amylase level three times the normal limit.
, B. Patient reporting pain that radiates to the back.
C. Absence of bowel sounds in all four quadrants.
D. Ecchymosis around the periumbilical area (Cullen’s sign).
Correct Answer: D
Rationale: Cullen’s sign indicates retroperitoneal hemorrhage and is a sign of severe, necrotizing
pancreatitis. This finding suggests a high risk of hemorrhagic shock and requires immediate medical
intervention. While elevated amylase and radiating pain are expected findings in pancreatitis, they are
not immediately life-threatening. The nurse should prepare the patient for potential surgical consults or
intensive care monitoring. Monitoring vital signs for signs of shock is the next critical nursing action.
5. The nurse is caring for a patient with Chronic Kidney Disease (CKD) who is receiving hemodialysis. Which
intervention is most important for maintaining the integrity of the AV fistula?
A. Ensure the patient keeps the arm elevated at heart level.
B. Apply a warm compress to the site if it feels cool.
C. Check the site for a bruit and a thrill every shift.
D. Clean the site with alcohol wipes before every assessment.
Correct Answer: C
Rationale: A palpable thrill and an audible bruit confirm that the AV fistula is patent and has adequate
blood flow. Loss of these signs indicates clotting or stenosis, which is a medical emergency for a dialysis
patient. The nurse must avoid taking blood pressure or performing venipunctures on the affected arm to
prevent damage. Education should include teaching the patient to avoid wearing tight clothing or jewelry
on that limb. Consistent monitoring ensures the access remains viable for life-sustaining hemodialysis
treatments.
