NUR 205 | NUR 205 Med Surg Exam 3 Version 1 |
Questions with Correct Answers and Expert
Explanation for Each Question | Saint Paul’s School
of Nursing
1. A nurse is caring for a client with cirrhosis who has developed hepatic
encephalopathy. Which laboratory value should the nurse prioritize when evaluating
the client’s condition?
A. Serum Creatinine
B. Serum Ammonia
C. Serum Potassium
D. Serum Amylase
Correct Answer: B
Expert Explanation: Hepatic encephalopathy is primarily caused by the
accumulation of neurotoxins such as ammonia in the blood. When the liver cannot
convert ammonia to urea, it crosses the blood-brain barrier and causes cognitive
impairment. Monitoring serum ammonia levels helps the nurse assess the severity
of the condition and the effectiveness of treatments like lactulose. While other labs
are important, ammonia is the specific marker for encephalopathy. Reducing levels
is the primary goal to improve the client’s neurological status.
,2. A client with type 1 diabetes is found unresponsive and clammy. What should be
the nurse’s first action?
A. Administer Glucagon IM or SQ
B. Administer 15g of oral glucose gel
C. Call the healthcare provider
D. Check the client’s HbA1c
Correct Answer: A
Expert Explanation: The client is showing signs of severe hypoglycemia and is
unable to swallow safely due to being unresponsive. Administering glucagon
stimulates the liver to release stored glucose into the bloodstream quickly. Oral
glucose is contraindicated in an unconscious patient due to the high risk of
aspiration. Calling the provider is necessary but should happen after or during the
life-saving intervention. Immediate reversal of hypoglycemia is the nursing priority
to prevent brain damage.
3. Which insulin type should the nurse expect to administer intravenously to a client in
Diabetic Ketoacidosis (DKA)?
A. NPH Insulin
B. Insulin Glargine
C. Insulin Lispro
,D. Regular Insulin
Correct Answer: D
Expert Explanation: Regular insulin is the only type of insulin that can be safely
administered via the intravenous route for acute management. In cases of DKA, a
continuous infusion is used to gradually lower blood glucose and reverse ketosis.
Other insulins like NPH or Glargine are designed for subcutaneous use and have
longer durations of action. Using the IV route allows for rapid titration based on
hourly blood glucose checks. The nurse must monitor for hypokalemia as insulin
shifts potassium into the cells.
4. A nurse is providing dietary teaching to a client with chronic cholecystitis. Which
food choice indicates the client understands the education?
A. Baked fish with steamed broccoli
B. Fried chicken with mashed potatoes
C. Whole milk and cheese omelet
D. Avocado toast with bacon
Correct Answer: A
Expert Explanation: Chronic cholecystitis requires a low-fat diet to prevent
gallbladder contraction and subsequent biliary colic. Baked fish and steamed
vegetables are excellent low-fat options that provide nutrition without triggering
, symptoms. High-fat foods like fried chicken, whole milk, and bacon cause the release
of cholecystokinin, which worsens the pain. Dietary management is a cornerstone of
preventing acute exacerbations in chronic gallbladder disease. The client should
also be encouraged to eat smaller, more frequent meals.
5. A client is scheduled for a liver biopsy. In which position should the nurse place the
client immediately following the procedure?
A. High-Fowler’s position
B. Left side-lying with a pillow under the side
C. Right side-lying with a pillow under the puncture site
D. Supine with the head of the bed flat
Correct Answer: C
Expert Explanation: After a liver biopsy, the primary risk is hemorrhage due to the
liver’s high vascularity. Placing the client on the right side applies pressure to the
puncture site against the chest wall to promote hemostasis. This position should be
maintained for several hours to minimize the risk of internal bleeding. The nurse
must also monitor vital signs frequently for signs of shock. Other positions do not
provide the necessary mechanical pressure to the operative site.
Questions with Correct Answers and Expert
Explanation for Each Question | Saint Paul’s School
of Nursing
1. A nurse is caring for a client with cirrhosis who has developed hepatic
encephalopathy. Which laboratory value should the nurse prioritize when evaluating
the client’s condition?
A. Serum Creatinine
B. Serum Ammonia
C. Serum Potassium
D. Serum Amylase
Correct Answer: B
Expert Explanation: Hepatic encephalopathy is primarily caused by the
accumulation of neurotoxins such as ammonia in the blood. When the liver cannot
convert ammonia to urea, it crosses the blood-brain barrier and causes cognitive
impairment. Monitoring serum ammonia levels helps the nurse assess the severity
of the condition and the effectiveness of treatments like lactulose. While other labs
are important, ammonia is the specific marker for encephalopathy. Reducing levels
is the primary goal to improve the client’s neurological status.
,2. A client with type 1 diabetes is found unresponsive and clammy. What should be
the nurse’s first action?
A. Administer Glucagon IM or SQ
B. Administer 15g of oral glucose gel
C. Call the healthcare provider
D. Check the client’s HbA1c
Correct Answer: A
Expert Explanation: The client is showing signs of severe hypoglycemia and is
unable to swallow safely due to being unresponsive. Administering glucagon
stimulates the liver to release stored glucose into the bloodstream quickly. Oral
glucose is contraindicated in an unconscious patient due to the high risk of
aspiration. Calling the provider is necessary but should happen after or during the
life-saving intervention. Immediate reversal of hypoglycemia is the nursing priority
to prevent brain damage.
3. Which insulin type should the nurse expect to administer intravenously to a client in
Diabetic Ketoacidosis (DKA)?
A. NPH Insulin
B. Insulin Glargine
C. Insulin Lispro
,D. Regular Insulin
Correct Answer: D
Expert Explanation: Regular insulin is the only type of insulin that can be safely
administered via the intravenous route for acute management. In cases of DKA, a
continuous infusion is used to gradually lower blood glucose and reverse ketosis.
Other insulins like NPH or Glargine are designed for subcutaneous use and have
longer durations of action. Using the IV route allows for rapid titration based on
hourly blood glucose checks. The nurse must monitor for hypokalemia as insulin
shifts potassium into the cells.
4. A nurse is providing dietary teaching to a client with chronic cholecystitis. Which
food choice indicates the client understands the education?
A. Baked fish with steamed broccoli
B. Fried chicken with mashed potatoes
C. Whole milk and cheese omelet
D. Avocado toast with bacon
Correct Answer: A
Expert Explanation: Chronic cholecystitis requires a low-fat diet to prevent
gallbladder contraction and subsequent biliary colic. Baked fish and steamed
vegetables are excellent low-fat options that provide nutrition without triggering
, symptoms. High-fat foods like fried chicken, whole milk, and bacon cause the release
of cholecystokinin, which worsens the pain. Dietary management is a cornerstone of
preventing acute exacerbations in chronic gallbladder disease. The client should
also be encouraged to eat smaller, more frequent meals.
5. A client is scheduled for a liver biopsy. In which position should the nurse place the
client immediately following the procedure?
A. High-Fowler’s position
B. Left side-lying with a pillow under the side
C. Right side-lying with a pillow under the puncture site
D. Supine with the head of the bed flat
Correct Answer: C
Expert Explanation: After a liver biopsy, the primary risk is hemorrhage due to the
liver’s high vascularity. Placing the client on the right side applies pressure to the
puncture site against the chest wall to promote hemostasis. This position should be
maintained for several hours to minimize the risk of internal bleeding. The nurse
must also monitor vital signs frequently for signs of shock. Other positions do not
provide the necessary mechanical pressure to the operative site.
