NUR 265 Exam 3: Nur Med Surg - Galen College of Nursing
Updated and Latest Questions and Correct Answers with
Rationale
1. A patient with cirrhosis presents with increased confusion and a flapping tremor of the hands. Which
laboratory result should the nurse prioritize?
A. Serum Ammonia
B. Serum Potassium
C. Prothrombin Time
D. Serum Bilirubin
Correct Answer: A
Rationale: Increased confusion and asterixis are classic signs of hepatic encephalopathy caused by high
ammonia levels. The liver is unable to convert ammonia to urea, leading to neurotoxicity in the brain. The
nurse should monitor this level to evaluate the effectiveness of treatments like lactulose. Patient safety is
a major concern during this phase due to cognitive impairment. Reducing protein intake temporarily may
also be indicated to lower ammonia production.
2. Which clinical manifestation is most characteristic of a patient experiencing an acute episode of
Pancreatitis?
A. Right upper quadrant pain radiating to the shoulder
B. Painless jaundice and clay-colored stools
C. Lower abdominal cramping relieved by defecation
D. Severe epigastric pain radiating to the back
Correct Answer: D
,Rationale: Acute pancreatitis typically presents with steady, boring epigastric pain that radiates to the
back. This pain is often exacerbated by lying supine and may be relieved by leaning forward. The
underlying mechanism involves autodigestion of the pancreas by its own enzymes. Nursing care focuses
on keeping the patient NPO to rest the pancreas and providing aggressive pain management. Respiratory
status must be monitored closely due to the risk of pleural effusion or ARDS.
3. A patient in the oliguric phase of Acute Kidney Injury (AKI) is at greatest risk for which electrolyte
imbalance?
A. Hypokalemia
B. Hypercalcemia
C. Hyperkalemia
D. Hyponatremia
Correct Answer: C
Rationale: During the oliguric phase, the kidneys cannot effectively excrete potassium, leading to
dangerous serum elevations. Hyperkalemia is a medical emergency because it can lead to fatal cardiac
arrhythmias. The nurse should monitor the EKG for peaked T-waves or widened QRS complexes.
Immediate interventions may include insulin with dextrose or sodium polystyrene sulfonate. Patient
education should include avoiding high-potassium foods like bananas and potatoes.
4. Which assessment finding in a patient receiving Peritoneal Dialysis would require the nurse to notify the
healthcare provider immediately?
A. Effluent that is clear and light yellow
B. Cloudy or opaque dialysate drainage
C. Weight loss of 2 pounds after a cycle
, D. Cramping during the inflow of dialysate
Correct Answer: B
Rationale: Cloudy drainage is the earliest sign of peritonitis, a serious complication of peritoneal dialysis.
The nurse should also assess for abdominal pain, rebound tenderness, and fever. Treatment usually
involves intraperitoneal antibiotics to resolve the infection quickly. Sterile technique must be emphasized
during all bag changes to prevent this occurrence. Clear or straw-colored effluent is considered a normal
finding for these patients.
5. A patient is admitted with Diabetic Ketoacidosis (DKA). Which of the following is the nurse’s primary
priority in the initial hour of treatment?
A. Administering subcutaneous long-acting insulin
B. Correction of hypokalemia with oral supplements
C. Intravenous fluid resuscitation with Normal Saline
D. Monitoring for signs of metabolic alkalosis
Correct Answer: C
Rationale: The immediate priority in DKA is to restore circulatory volume and improve tissue perfusion
through fluid resuscitation. Dehydration in DKA is often severe due to osmotic diuresis caused by high
glucose levels. Once fluids are initiated, an intravenous insulin infusion is started to address
hyperglycemia and ketosis. Electrolytes, particularly potassium, must be monitored because insulin
causes potassium to move into the cells. The nurse should also assess for signs of fluid volume overload
during rapid replacement.
6. Which set of laboratory results is most consistent with a diagnosis of SIADH?
A. High serum sodium and low urine specific gravity
Updated and Latest Questions and Correct Answers with
Rationale
1. A patient with cirrhosis presents with increased confusion and a flapping tremor of the hands. Which
laboratory result should the nurse prioritize?
A. Serum Ammonia
B. Serum Potassium
C. Prothrombin Time
D. Serum Bilirubin
Correct Answer: A
Rationale: Increased confusion and asterixis are classic signs of hepatic encephalopathy caused by high
ammonia levels. The liver is unable to convert ammonia to urea, leading to neurotoxicity in the brain. The
nurse should monitor this level to evaluate the effectiveness of treatments like lactulose. Patient safety is
a major concern during this phase due to cognitive impairment. Reducing protein intake temporarily may
also be indicated to lower ammonia production.
2. Which clinical manifestation is most characteristic of a patient experiencing an acute episode of
Pancreatitis?
A. Right upper quadrant pain radiating to the shoulder
B. Painless jaundice and clay-colored stools
C. Lower abdominal cramping relieved by defecation
D. Severe epigastric pain radiating to the back
Correct Answer: D
,Rationale: Acute pancreatitis typically presents with steady, boring epigastric pain that radiates to the
back. This pain is often exacerbated by lying supine and may be relieved by leaning forward. The
underlying mechanism involves autodigestion of the pancreas by its own enzymes. Nursing care focuses
on keeping the patient NPO to rest the pancreas and providing aggressive pain management. Respiratory
status must be monitored closely due to the risk of pleural effusion or ARDS.
3. A patient in the oliguric phase of Acute Kidney Injury (AKI) is at greatest risk for which electrolyte
imbalance?
A. Hypokalemia
B. Hypercalcemia
C. Hyperkalemia
D. Hyponatremia
Correct Answer: C
Rationale: During the oliguric phase, the kidneys cannot effectively excrete potassium, leading to
dangerous serum elevations. Hyperkalemia is a medical emergency because it can lead to fatal cardiac
arrhythmias. The nurse should monitor the EKG for peaked T-waves or widened QRS complexes.
Immediate interventions may include insulin with dextrose or sodium polystyrene sulfonate. Patient
education should include avoiding high-potassium foods like bananas and potatoes.
4. Which assessment finding in a patient receiving Peritoneal Dialysis would require the nurse to notify the
healthcare provider immediately?
A. Effluent that is clear and light yellow
B. Cloudy or opaque dialysate drainage
C. Weight loss of 2 pounds after a cycle
, D. Cramping during the inflow of dialysate
Correct Answer: B
Rationale: Cloudy drainage is the earliest sign of peritonitis, a serious complication of peritoneal dialysis.
The nurse should also assess for abdominal pain, rebound tenderness, and fever. Treatment usually
involves intraperitoneal antibiotics to resolve the infection quickly. Sterile technique must be emphasized
during all bag changes to prevent this occurrence. Clear or straw-colored effluent is considered a normal
finding for these patients.
5. A patient is admitted with Diabetic Ketoacidosis (DKA). Which of the following is the nurse’s primary
priority in the initial hour of treatment?
A. Administering subcutaneous long-acting insulin
B. Correction of hypokalemia with oral supplements
C. Intravenous fluid resuscitation with Normal Saline
D. Monitoring for signs of metabolic alkalosis
Correct Answer: C
Rationale: The immediate priority in DKA is to restore circulatory volume and improve tissue perfusion
through fluid resuscitation. Dehydration in DKA is often severe due to osmotic diuresis caused by high
glucose levels. Once fluids are initiated, an intravenous insulin infusion is started to address
hyperglycemia and ketosis. Electrolytes, particularly potassium, must be monitored because insulin
causes potassium to move into the cells. The nurse should also assess for signs of fluid volume overload
during rapid replacement.
6. Which set of laboratory results is most consistent with a diagnosis of SIADH?
A. High serum sodium and low urine specific gravity
