Question

A nurse in an emergency department is caring for a client.

Answer 1

Correct Answers:

Administer oxygen via nasal cannula.
Assess for Chvostek's sign and Trousseau's sign.
Prepare to administer IV fluids.
Place a nasogastric tube.
Frequently monitor pulse oximetry.
Frequently monitor blood glucose.

Rationale :

✅ Administer oxygen via nasal cannula — Indicated

🌹 The client's oxygen saturation has decreased to 92% on room air, indicating impaired oxygenation.

🌹 Acute pancreatitis can produce a systemic inflammatory response that affects pulmonary function.

🌹 Respiratory complications can include atelectasis, pleural effusion, and acute respiratory distress syndrome (ARDS).

🌹 Supplemental oxygen helps maintain adequate tissue oxygenation during the acute inflammatory process.

🌹 The client's tachypnea of 26/min further supports respiratory compromise.

🌹 Oxygenation is particularly important because the client is also hypotensive and tachycardic, suggesting compromised tissue perfusion.

🌹 The nurse should administer oxygen as prescribed and evaluate the client's response.

🌹 Therefore, oxygen via nasal cannula is indicated.

✅ Assess for Chvostek's sign and Trousseau's sign — Indicated

✍️ The client's calcium is 8.5 mg/dL, indicating hypocalcemia.

✍️ Acute pancreatitis can cause hypocalcemia because calcium can become deposited in areas of fat necrosis.

✍️ Chvostek's sign involves facial muscle contraction after tapping the facial nerve.

✍️ Trousseau's sign involves carpal spasm when a blood pressure cuff is inflated above systolic pressure.

✍️ Positive findings indicate increased neuromuscular excitability associated with hypocalcemia.

✍️ More severe hypocalcemia can cause tetany, muscle spasms, seizures, and cardiac dysrhythmias.

✍️ The nurse should continue monitoring the client's serum calcium level and clinical manifestations.

✍️ Therefore, assessment for Chvostek's and Trousseau's signs is indicated.

✅ Prepare to administer IV fluids — Indicated

👉 The client's BP of 91/55 mm Hg, HR 109/min, vomiting, and poor oral intake indicate significant volume depletion and impaired circulation.

👉 Acute pancreatitis causes substantial third-spacing of fluid into the retroperitoneal and abdominal tissues.

👉 Fluid loss can lead to hypovolemia, hypotension, decreased organ perfusion, and shock.

👉 Aggressive isotonic IV fluid resuscitation is an important component of early management.

👉 IV fluids help restore intravascular volume and pancreatic/organ perfusion.

👉 The nurse should closely monitor blood pressure, heart rate, urine output, respiratory status, and fluid balance during replacement.

👉 Fluid administration requires careful reassessment because severe pancreatitis can also produce pulmonary complications.

👉 Therefore, preparing to administer IV fluids is indicated.

✅ Place a nasogastric tube — Indicated

♦️ The client has persistent nausea and vomiting with mild abdominal distention, which can indicate significant gastrointestinal dysfunction.

♦️ An NG tube may be prescribed for gastric decompression when acute pancreatitis is accompanied by persistent vomiting or ileus.

♦️ Gastric decompression can decrease abdominal distention and vomiting.

♦️ The tube can also reduce the risk of aspiration when vomiting is severe.

♦️ NG decompression is not routinely required for every client with pancreatitis.

♦️ This client's persistent vomiting and abdominal distention make NG decompression clinically appropriate among the available interventions.

♦️ The nurse should monitor the amount and characteristics of gastric drainage and maintain tube patency.

♦️ Therefore, NG tube placement is indicated in this clinical presentation.

✅ Frequently monitor pulse oximetry — Indicated

✏️ The client's oxygen saturation has fallen from 98% to 92%, accompanied by tachypnea.

✏️ Severe pancreatitis can cause rapidly developing respiratory complications.

✏️ Frequent pulse oximetry helps identify worsening hypoxemia early.

✏️ Respiratory deterioration can result from atelectasis, pleural effusion, pulmonary edema, or ARDS.

✏️ The nurse should also assess respiratory rate, effort, breath sounds, and mental status.

✏️ Worsening oxygen saturation may indicate the need for escalation of respiratory support.

✏️ Monitoring is especially important because the client's current findings suggest systemic inflammatory involvement.

✏️ Therefore, frequent pulse oximetry monitoring is indicated.

✅ Frequently monitor blood glucose — Indicated

🌻 Acute pancreatitis can interfere with the pancreatic cells responsible for insulin secretion and glucose regulation.

🌻 Pancreatic inflammation may therefore result in hyperglycemia.

🌻 Severe illness also produces a physiologic stress response that can further elevate blood glucose.

🌻 Frequent glucose monitoring allows early identification of abnormal glucose regulation.

🌻 Persistent hyperglycemia may require treatment according to the client's prescribed management plan.

🌻 Glucose abnormalities can also provide information regarding the severity of pancreatic dysfunction.

🌻 Monitoring becomes particularly important in severe or complicated pancreatitis.

🌻 Therefore, frequent blood glucose monitoring is indicated.

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Answer 2

Correct Answers:

The client reports tingling and a burning sensation in one foot.

Rationale :

🖍️ A herniated lumbar disc can compress or irritate a spinal nerve root, producing radiculopathy.

🖍️ Nerve-root compression commonly causes pain, burning, tingling, or numbness along the distribution of the affected nerve.

🖍️ These sensory symptoms can radiate from the lower back into the buttock, leg, and foot.

🖍️ Lumbar disc herniation commonly involves the L4-L5 or L5-S1 levels.

🖍️ Depending on the affected nerve root, the client may also develop muscle weakness and decreased reflexes.

🖍️ Symptoms affecting the sciatic nerve distribution are commonly referred to as sciatica.

🖍️ The nurse should assess for worsening neurologic findings, including motor weakness, sensory loss, and changes in bowel or bladder function.

🖍️ Therefore, tingling and burning in one foot are expected manifestations of lumbar nerve-root compression.

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Answer 3

Correct Answers

Aspartate aminotransferase (AST) [ Increased ]
Serum albumin [ Decreased ]
Prothrombin time [ Increased ]
Haemoglobin [ Decreased ]
Alanine aminotransferase (ALT) [ Increased ]
Risk of liver cancer [ Increased ]

Rationale :

✅ Aspartate aminotransferase (AST) — Increased

📘 AST is an intracellular enzyme released into the bloodstream when hepatocytes are damaged.

📘 Chronic hepatitis B can produce ongoing hepatocellular inflammation and injury.

📘 Progressive liver damage therefore commonly results in elevations of serum AST.

📘 The client's jaundice, ascites, and hepatomegaly indicate clinically significant hepatic dysfunction.

📘 AST can also be found in other tissues, so it is not completely specific to the liver.

📘 AST and ALT are commonly evaluated together when assessing hepatocellular injury.

📘 Advanced chronic liver disease may eventually produce variable aminotransferase values as functional hepatocyte mass declines.

📘 Based on the client's current manifestations, increased AST is the expected selection.

✅ Serum albumin — Decreased

📗 Albumin is synthesized by the liver, making its concentration an important indicator of hepatic synthetic function.

📗 Chronic liver damage reduces the liver's ability to produce adequate albumin.

📗 Hypoalbuminemia decreases plasma oncotic pressure, allowing fluid to move from the vascular space into surrounding tissues.

📗 This process contributes to ascites and peripheral edema in advanced liver disease.

📗 The client's current ascites supports impaired hepatic synthetic function.

📗 Reduced albumin production is particularly associated with chronic or advanced liver disease rather than brief acute injury.

📗 Serum albumin can therefore help evaluate the severity and progression of hepatic dysfunction.

📗 The expected finding is decreased serum albumin.

✅ Prothrombin time — Increased

🌹 The liver synthesizes many important clotting factors, including factors II, VII, IX, and X.

🌹 Progressive hepatic dysfunction decreases production of these coagulation proteins.

🌹 Reduced clotting-factor production causes the blood to take longer to clot, resulting in a prolonged PT.

🌹 A prolonged PT therefore indicates impaired hepatic synthetic function.

🌹 Vitamin K deficiency associated with liver and biliary disease can further contribute to impaired coagulation.

🌹 Clients with advanced liver dysfunction consequently have an increased risk for bleeding.

🌹 PT/INR is commonly monitored to evaluate coagulation status and severity of hepatic dysfunction.

🌹 Therefore, prothrombin time is expected to increase.

✅ Hemoglobin — Decreased

✍️ The client has end-stage kidney disease, which significantly increases the likelihood of anemia.

✍️ Diseased kidneys produce inadequate erythropoietin, resulting in decreased stimulation of red blood cell production.

✍️ Clients receiving chronic hemodialysis can also experience blood loss associated with repeated treatments and laboratory testing.

✍️ Chronic liver disease can further contribute to anemia through nutritional deficiencies, hypersplenism, and gastrointestinal bleeding.

✍️ Reduced red blood cell production ultimately lowers the client's circulating hemoglobin concentration.

✍️ Anemia can contribute to symptoms such as fatigue, weakness, and shortness of breath.

✍️ Hemoglobin levels are routinely monitored in clients receiving chronic dialysis.

✍️ Therefore, decreased hemoglobin is expected.

✅ Alanine aminotransferase (ALT) — Increased

👉 ALT is primarily concentrated in hepatocytes and is an important marker of hepatocellular injury.

👉 Damage to liver cells causes ALT to leak into the circulation.

👉 Chronic viral hepatitis can therefore cause elevated ALT levels during active hepatocellular injury.

👉 ALT is generally considered more liver-specific than AST.

👉 The client's current physical findings indicate progression from the previously asymptomatic infection to significant chronic hepatic disease.

👉 ALT and AST levels are evaluated together to assess patterns of liver injury.

👉 Aminotransferase levels can fluctuate during chronic hepatitis and may not directly reflect the exact severity of cirrhosis.

👉 For this classification question, ALT is expected to be increased.

✅ Risk of liver cancer — Increased

♦️ Chronic hepatitis B is an important risk factor for hepatocellular carcinoma (HCC).

♦️ Persistent hepatic inflammation and repeated cellular injury can promote fibrosis and cirrhosis.

♦️ Cirrhosis itself substantially increases the likelihood of malignant transformation of hepatocytes.

♦️ Hepatitis B can also contribute directly to carcinogenesis through integration of viral genetic material into hepatocyte DNA.

♦️ The client's firm enlarged liver, jaundice, and ascites warrant careful evaluation for advanced liver disease and its complications.

♦️ Individuals with chronic HBV infection may require ongoing surveillance for hepatocellular carcinoma according to their risk profile.

♦️ Surveillance commonly involves appropriate liver imaging, particularly ultrasonography, at recommended intervals for qualifying high-risk clients.

♦️ Therefore, the client's risk of liver cancer is increased.

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Answer 4

Correct Answers:

Provide assistance with ambulation.

Rationale :

🌹 The cerebellum is responsible for coordinating voluntary movement, posture, equilibrium, and balance.

🌹 A cerebellar tumor can cause ataxia, unsteady gait, poor coordination, and impaired balance.

🌹 These neurologic deficits place the client at significant risk for falls and injury during ambulation.

🌹 Using the priority principle of safety, the nurse should provide assistance whenever the client ambulates.

🌹 Additional precautions can include keeping the environment free of obstacles and ensuring needed items are within easy reach.

🌹 The nurse should assess for ataxia, dysmetria, intention tremor, and changes in gait or coordination.

🌹 Ambulation assistance allows the client to maintain as much mobility as possible while reducing the likelihood of injury.

🌹 Therefore, providing assistance with ambulation is the priority nursing action.

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Answer 5

Correct Answers:

Monitor blood glucose levels.
Maintain NPO status until pain-free.
Manage acute pain.

Rationale :

✅ Monitor blood glucose levels

👉 Acute pancreatitis causes inflammation and injury of pancreatic tissue, which can interfere with normal endocrine function.

👉 Damage to pancreatic beta cells can reduce insulin secretion and contribute to hyperglycemia.

👉 The physiologic stress response associated with acute illness can further increase blood glucose levels.

👉 Regular glucose monitoring allows the nurse to recognize abnormal glucose regulation promptly.

👉 Significant hyperglycemia may require insulin therapy based on glucose measurements and provider prescriptions.

👉 Glucose monitoring also helps evaluate the severity of pancreatic dysfunction during the acute illness.

👉 Both hyperglycemia and hypoglycemia can complicate treatment and require prompt intervention.

👉 Therefore, monitoring blood glucose levels should be included in the client's plan of care.

✅ Maintain NPO status until pain-free

👉 During significant acute pancreatitis with severe pain, nausea, or vomiting, oral intake may initially be withheld to reduce gastrointestinal stimulation and manage intolerance.

👉 Eating can stimulate digestive activity and may exacerbate symptoms during the acute phase.

👉 Temporary NPO status can be appropriate when the client cannot tolerate oral intake.

👉 The nurse should provide prescribed IV fluids to maintain hydration and circulation during this period.

👉 The client's abdominal pain, nausea, vomiting, bowel function, and hydration status should be monitored closely.

👉 Nutritional support should be resumed according to the client's clinical status and provider-directed treatment plan.

👉 Current management generally favors early enteral nutrition when tolerated rather than prolonged fasting solely to “rest” the pancreas.

👉 For this exam item, NPO status during the painful acute phase is the intended intervention.

✅ Manage acute pain

👉 Severe epigastric abdominal pain is a hallmark manifestation of acute pancreatitis.

👉 Pain commonly radiates to the back and may worsen after eating.

👉 Prescribed analgesics should be administered and their effectiveness reassessed regularly.

👉 Adequate pain management decreases the client's stress response and discomfort.

👉 Positioning may also help, with some clients obtaining relief by leaning forward or flexing the knees toward the chest.

👉 The nurse should routinely assess pain using an appropriate pain-rating scale.

👉 Increasing or changing pain can indicate worsening inflammation or complications and requires further evaluation.

👉 Therefore, management of acute pain is an essential component of care.

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Answer 6

Correct Answers:

Dietary services

Rationale :

♦️ Clients with chronic kidney disease (CKD) require careful nutritional management to reduce complications and slow disease progression when possible.

♦️ A referral to dietary services or a renal dietitian provides individualized education based on the client's kidney function, laboratory results, medications, and treatment plan.

♦️ Sodium intake may need to be limited to help control hypertension, edema, and fluid retention.

♦️ Potassium may require restriction when kidney function is inadequate to maintain normal serum potassium levels.

♦️ Phosphorus restriction may be necessary because phosphorus retention contributes to CKD-related mineral and bone disorders.

♦️ Protein intake is individualized according to the stage of CKD, nutritional status, and whether the client receives dialysis.

♦️ Fluid intake may also require adjustment when the client develops oliguria, edema, or fluid overload.

♦️ Therefore, referral to dietary services is an important component of discharge planning for a newly diagnosed client with CKD.

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Answer 7

Correct Answers:

Respiratory rate 30/min

Rationale :

✏️ A respiratory rate of 30/min indicates significant tachypnea and requires immediate assessment and intervention in a client with a traumatic brain injury (TBI).

✏️ Changes in respiratory rate or pattern can indicate worsening neurologic status or increasing intracranial pressure (ICP).

✏️ Brain injury can affect the respiratory centers responsible for maintaining normal ventilation.

✏️ Inadequate ventilation can alter carbon dioxide levels, which directly influence cerebral blood flow and ICP.

✏️ Rising carbon dioxide causes cerebral vasodilation, potentially increasing intracranial pressure further.

✏️ The nurse should immediately assess the client's airway, breathing pattern, oxygen saturation, level of consciousness, and other neurologic findings.

✏️ Maintaining adequate oxygenation and ventilation is a priority because secondary cerebral hypoxia can worsen brain injury.

✏️ Therefore, the respiratory rate of 30/min is the finding requiring the most immediate intervention.

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Answer 8

Correct Answers:

"This medication can cause your urine to turn a dark colour."

Rationale :

🌻 Carbidopa/levodopa is commonly used to improve motor manifestations of Parkinson's disease, including bradykinesia, rigidity, and tremor.

🌻 Levodopa crosses the blood-brain barrier and is converted into dopamine within the central nervous system.

🌻 Carbidopa decreases the peripheral breakdown of levodopa, allowing more levodopa to reach the brain while reducing peripheral adverse effects.

🌻 The medication can cause harmless darkening of urine, sweat, or saliva, sometimes appearing reddish-brown or black.

🌻 Clients should be informed about this effect so they do not mistake the discoloration for bleeding or another medical problem.

🌻 Other important adverse effects include orthostatic hypotension, nausea, dyskinesias, hallucinations, and confusion.

🌻 The medication should be taken consistently and should not be abruptly discontinued, because sudden withdrawal can cause serious deterioration.

🌻 Therefore, teaching that carbidopa/levodopa can cause dark-colored urine is appropriate.

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Answer 9

Correct Answers:

"Lie on your right side."

Rationale :

🏵️ Following a percutaneous liver biopsy, the client should be positioned on the right side.

🏵️ The liver is primarily located in the right upper quadrant, making right-side positioning appropriate after the procedure.

🏵️ Lying on the right side applies direct pressure to the biopsy site against the abdominal wall.

🏵️ This pressure helps promote hemostasis and decreases the risk of postprocedure hemorrhage.

🏵️ Bleeding is one of the most important complications following a liver biopsy because the liver is highly vascular.

🏵️ The nurse should closely monitor blood pressure, pulse, respiratory status, and the biopsy site after the procedure.

🏵️ Findings such as hypotension, tachycardia, increasing abdominal pain, abdominal distention, or right shoulder pain can indicate complications and require prompt evaluation.

🏵️ Therefore, instructing the client to lie on the right side is the appropriate postprocedure intervention.

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Answer 10

Correct Answers:

Ask the client to describe the pain and rate it on a scale of 0 to 10.

Rationale :

🧿 The nursing process requires the nurse to assess before intervening when the client reports postoperative pain.

🧿 Asking the client to describe the pain provides information about its location, quality, intensity, onset, duration, and aggravating or relieving factors.

🧿 Using a 0-to-10 pain scale provides a measurable baseline for determining the severity of the client's discomfort.

🧿 A detailed assessment helps distinguish expected incisional pain from pain that could indicate a postoperative complication.

🧿 The client's pain report is the most reliable indicator because pain is subjective and is best described by the person experiencing it.

🧿 The baseline pain rating also allows the nurse to evaluate the effectiveness of subsequent interventions.

🧿 After completing the assessment, the nurse can determine whether pharmacologic or nonpharmacologic pain management is appropriate.

🧿 Therefore, assessing and rating the client's pain first follows the nursing process and guides appropriate treatment.

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Assessment Finding	Increased	Decreased
Aspartate aminotransferase (AST)
Serum albumin
Prothrombin time
Haemoglobin
Alanine aminotransferase (ALT)
Risk of liver cancer

Adult Medical Surgical Assessment (1)

No.

1 :
A nurse in an emergency department is caring for a client.

Answer Options

2 :
A nurse is assessing a client who has a herniated lumbar disc. Which of the following findings should the nurse expect?

3 :
A nurse is caring for a male client in the outpatient dialysis clinic.

Correct Answers

4 :
A nurse is caring for a client who has a cerebellar tumor. Which of the following actions is the nurse's priority?

5 :
A nurse is planning care for a client who has acute pancreatitis. Which of the following interventions should the nurse include in the client's plan? (Select all that apply.)

6 :
A nurse is preparing to discharge a client who has a new diagnosis of chronic kidney disease (CKD). Which of the following referrals should the nurse plan to initiate?

7 :
A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should indicate to the nurse the need for immediate intervention?

8 :
A nurse is providing discharge teaching to a client who is starting to take carbidopa/levodopa to treat Parkinson's disease. Which of the following instructions should the nurse include in the teaching?

9 :
A nurse is caring for a client who is to undergo a liver biopsy. Which of the following instructions should the nurse provide to the client following the procedure?

10 :
A nurse is caring for a client who had surgery 2 days ago and reports incisional pain. Which of the following actions should the nurse take first?

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Adult Medical Surgical Assessment (1)

No.

1 : A nurse in an emergency department is caring for a client.

Answer Options

2 : A nurse is assessing a client who has a herniated lumbar disc. Which of the following findings should the nurse expect?

3 : A nurse is caring for a male client in the outpatient dialysis clinic.

Correct Answers

4 : A nurse is caring for a client who has a cerebellar tumor. Which of the following actions is the nurse's priority?

5 : A nurse is planning care for a client who has acute pancreatitis. Which of the following interventions should the nurse include in the client's plan? (Select all that apply.)

6 : A nurse is preparing to discharge a client who has a new diagnosis of chronic kidney disease (CKD). Which of the following referrals should the nurse plan to initiate?

7 : A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should indicate to the nurse the need for immediate intervention?

8 : A nurse is providing discharge teaching to a client who is starting to take carbidopa/levodopa to treat Parkinson's disease. Which of the following instructions should the nurse include in the teaching?

9 : A nurse is caring for a client who is to undergo a liver biopsy. Which of the following instructions should the nurse provide to the client following the procedure?

10 : A nurse is caring for a client who had surgery 2 days ago and reports incisional pain. Which of the following actions should the nurse take first?

1 :
A nurse in an emergency department is caring for a client.

2 :
A nurse is assessing a client who has a herniated lumbar disc. Which of the following findings should the nurse expect?

3 :
A nurse is caring for a male client in the outpatient dialysis clinic.

4 :
A nurse is caring for a client who has a cerebellar tumor. Which of the following actions is the nurse's priority?

5 :
A nurse is planning care for a client who has acute pancreatitis. Which of the following interventions should the nurse include in the client's plan? (Select all that apply.)

6 :
A nurse is preparing to discharge a client who has a new diagnosis of chronic kidney disease (CKD). Which of the following referrals should the nurse plan to initiate?

7 :
A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should indicate to the nurse the need for immediate intervention?

8 :
A nurse is providing discharge teaching to a client who is starting to take carbidopa/levodopa to treat Parkinson's disease. Which of the following instructions should the nurse include in the teaching?

9 :
A nurse is caring for a client who is to undergo a liver biopsy. Which of the following instructions should the nurse provide to the client following the procedure?

10 :
A nurse is caring for a client who had surgery 2 days ago and reports incisional pain. Which of the following actions should the nurse take first?