ICU exam 3

A patient with chronic kidney disease is admitted with muscle weakness and an irregular heart rhythm. Which electrolyte imbalance is the nurse most concerned about?

A. Hypokalemia
B. Hyperkalemia
C. Hyponatremia
D. Hypocalcemia

✅ Correct Answer: B. Hyperkalemia 🧠 Rationale:

From your electrolyte PDF:

• Renal failure → cannot excrete potassium

• Leads to hyperkalemia

Clinical manifestations listed:

• Skeletal muscle weakness

• Cardiac dysrhythmias

👉 The question gives:

• Weakness + irregular rhythm
  ➡ Classic hyperkalemia

❌ Why others are wrong:

• A (Hypokalemia): causes weakness but NOT typically due to renal failure

• C (Hyponatremia): causes confusion/seizures (not primary here)

• D (Hypocalcemia): not supported by your slides in this context

The nurse is teaching a patient about peritoneal dialysis (PD). Which statements are correct? Select all that apply.

A. The peritoneal membrane acts as a filter
B. Dialysis occurs through a machine filtering blood outside the body
C. CAPD involves manual exchanges during the day
D. APD is usually performed overnight using a machine
E. It requires vascular access such as an AV fistula

✅ Correct Answers: A, C, D

🧠 Rationale:

From your PDF:

• PD uses peritoneal membrane as filter

• Types:

  • CAPD = manual exchanges

  • APD = machine overnight

✔ Correct:

• A → correct mechanism

• C → CAPD = manual

• D → APD = machine

❌ Incorrect:

• B → describes hemodialysis

• E → vascular access is for HD, not PD

A patient with CKD is being assessed for complications. Which findings are consistent with worsening kidney function? Select all that apply.

A. Increased urine output
B. Weight gain
C. Edema
D. Cardiac dysrhythmias
E. Decreased urine output

✅ Correct Answers: B, C, D, E

🧠 Rationale:

From your PDFs:

• Fluid overload:

  • Weight gain

  • Edema

  • ↓ urine output

• Electrolyte imbalance:

  • Hyperkalemia → dysrhythmias

A patient with CKD reports muscle weakness. Which electrolyte imbalance is the nurse most concerned about?

A. Hyponatremia
B. Hypokalemia
C. Hyperkalemia
D. Hypercalcemia

✅ Correct Answer: C. Hyperkalemia

🧠 Rationale:

From your electrolyte PDF:

• CKD → hyperkalemia

• Causes:

  • Muscle weakness

  • Dysrhythmias

A patient with hyponatremia is being assessed. Which finding requires immediate intervention?

A. Nausea
B. Headache
C. Confusion
D. Seizure activity

✅ Correct Answer: D. Seizure activity

🧠 Rationale:

From your PDF:

• Hyponatremia causes:

  • Confusion

  • Lethargy

  • Seizures

👉 Seizures indicate severe neurologic involvement → highest priority

The nurse is assessing a patient with hyponatremia. Which findings are expected? Select all that apply.

A. Confusion
B. Seizures
C. Restlessness
D. Headache
E. Lethargy

✅ Correct Answers: A, B, D, E

🧠 Rationale:

From your PDF:

Hyponatremia causes:

• Confusion

• Headache

• Lethargy

• Seizure

A patient presents with confusion, lethargy, and headache. Lab results show sodium of 128 mEq/L. What is the nurse’s best interpretation?

A. The patient is dehydrated
B. The patient is experiencing hyponatremia with neurologic involvement
C. The patient has fluid overload without complications
D. The patient has normal sodium levels

✅ Correct Answer: B. The patient is experiencing hyponatremia with neurologic involvement

🧠 Rationale:

From your PDF:

• Sodium <135 = hyponatremia

• Symptoms include:

  • Confusion

  • Headache

  • Lethargy

👉 These are neurologic signs from brain swelling

A patient reports constipation, muscle weakness, and numbness. Which electrolyte imbalance is most likely?

A. Hyperkalemia
B. Hypokalemia
C. Hypernatremia
D. Hypocalcemia

✅ Correct Answer: B. Hypokalemia

🧠 Rationale:

From your PDF:

• Hypokalemia causes:

  • Constipation

  • Muscle weakness

  • Numbness

👉 Constipation is a key clue

The nurse is assessing a patient with hyperkalemia. Which findings are expected? Select all that apply.

A. Muscle weakness
B. Cardiac dysrhythmias
C. U waves on ECG
D. T wave changes on ECG
E. Constipation

✅ Correct Answers: A, B, D

🧠 Rationale:

From your PDF:

• Hyperkalemia:

  • Muscle weakness

  • Cardiac dysrhythmias

  • T wave changes

A patient with hypocalcemia is being assessed. Which finding requires immediate intervention?

A. Muscle weakness
B. Positive Chvostek’s sign
C. Prolonged QT interval
D. Mild fatigue

✅ Correct Answer: C. Prolonged QT interval

🧠 Rationale:

From your PDF/course content:

• Hypocalcemia causes:

  • Tetany

  • Chvostek’s sign

  • Prolonged QT interval

👉 ECG changes = risk for dangerous dysrhythmias → highest priority

A patient’s lab results show calcium of 11.2 mg/dL. Which assessment finding would the nurse expect?

A. Tetany
B. Positive Chvostek’s sign
C. Muscle weakness
D. Seizures

✅ Correct Answer: C. Muscle weakness

🧠 Rationale:

From your PDF:

• High calcium → decreased neuromuscular excitability
  ➡ Leads to:

• Weakness

The nurse is assessing a patient with hypercalcemia. Which findings are expected? Select all that apply.

A. Muscle weakness
B. Decreased neuromuscular activity
C. Positive Chvostek’s sign
D. Reduced muscle excitability
E. Tetany

✅ Correct Answers: A, B, D

🧠 Rationale:

From your PDF:

• Hypercalcemia:

  • ↓ neuromuscular activity

  • Weakness

A nurse is caring for a patient with hypermagnesemia. Which finding requires immediate intervention?

A. Muscle weakness
B. Decreased deep tendon reflexes
C. Bradycardia
D. Fatigue

✅ Correct Answer: C. Bradycardia

---

🧠 Rationale:

From your PDF:

• Hypermagnesemia causes:

  • Bradycardia

  • Hypotension

  • ↓ DTRs

👉 Bradycardia = cardiac instability → priority

A patient presents with muscle twitching, increased reflexes, and tachycardia. Which electrolyte imbalance is most likely?

A. Hypermagnesemia
B. Hypomagnesemia
C. Hypercalcemia
D. Hyponatremia

Correct Answer: B. Hypomagnesemia

🧠 Rationale:

From your PDF:

• Hypomagnesemia causes:

  • Increased DTRs

  • Twitching

  • Tachycardia

👉 Overactive neuromuscular system = low magnesium

The nurse is assessing a patient with hypermagnesemia. Which findings are expected? Select all that apply.

A. Decreased deep tendon reflexes
B. Hypotension
C. Tachycardia
D. Bradycardia
E. Muscle twitching

Correct Answers: A, B, D

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🧠 Rationale:

From your PDF:

• Hypermagnesemia:

  • ↓ DTRs

  • Hypotension

  • Bradycardia

The nurse is comparing two patients:

• Patient A: Increased reflexes, muscle twitching

• Patient B: Decreased reflexes, bradycardia

Which interpretation is correct?

A. Both patients have hypomagnesemia
B. Patient A has hypermagnesemia, Patient B has hypomagnesemia
C. Patient A has hypomagnesemia, Patient B has hypermagnesemia
D. Both patients have hypermagnesemia

✅ Correct Answer: C. Patient A has hypomagnesemia, Patient B has hypermagnesemia

---

🧠 Rationale:

From your PDF:

• Low Mg:

  • ↑ DTRs

  • Twitching

• High Mg:

  • ↓ DTRs

  • Bradycardia

A patient with hypophosphatemia is being assessed. Which finding requires immediate intervention?

A. Muscle weakness
B. Decreased cardiac contractility
C. Decreased respiratory drive
D. Slurred speech

✅ Correct Answer: C. Decreased respiratory drive

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🧠 Rationale:

From your PDF:

• Hypophosphatemia causes:

  • Decreased respiratory drive

  • Muscle weakness

  • Decreased cardiac contractility

👉 Respiratory compromise = highest priority

A patient with chronic kidney disease is most likely to develop which electrolyte imbalance related to phosphorus?

A. Hypophosphatemia
B. Hyperphosphatemia
C. Normal phosphorus levels
D. Fluctuating phosphorus levels

✅ Correct Answer: B. Hyperphosphatemia

🧠 Rationale:

From your PDF:

• CKD → kidneys cannot excrete phosphorus
  ➡ Hyperphosphatemia develops

The nurse is assessing a patient with hyperphosphatemia. Which findings are expected? Select all that apply.

A. Increased deep tendon reflexes
B. Muscle weakness
C. Signs of hypocalcemia
D. Decreased respiratory drive
E. Neuromuscular excitability

✅ Correct Answers: A, C, E

🧠 Rationale:

From your PDF:

• Hyperphosphatemia:

  • Increased DTRs

  • Hypocalcemia

From calcium connection:

• Hypocalcemia → neuromuscular excitability

A patient has the following lab values:

• Phosphorus: 6.2 mg/dL

• Calcium: low

Which assessment finding would the nurse expect?

A. Muscle weakness
B. Decreased reflexes
C. Muscle spasms and twitching
D. Bradycardia

✅ Correct Answer: C. Muscle spasms and twitching

🧠 Rationale:

From your PDFs:

• High phosphorus → low calcium

• Low calcium →:

  • Tetany

  • Muscle spasms

👉 This is a classic inverse relationship questio\

a patient has a bicarbonate level of 18 mEq/L. Which finding requires immediate intervention?

A. Hypoventilation
B. Kussmaul respirations
C. Mild fatigue
D. Decreased appetite

✅ Correct Answer: B. Kussmaul respirations

---

🧠 Rationale:

From your PDF:

• Low bicarbonate (<22) → metabolic acidosis

• Symptoms include:

  • Kussmaul respirations

  • Arrhythmias

  • Confusion

👉 Deep, rapid breathing = compensating for acidosis → serious condition

Question 5 (Hard – differentiation)

The nurse is comparing two patients:

• Patient A: Bicarbonate 20, rapid deep breathing

• Patient B: Bicarbonate 28, slow respirations

Which interpretation is correct?

A. Both patients have metabolic acidosis
B. Patient A has alkalosis, Patient B has acidosis
C. Patient A has acidosis, Patient B has alkalosis
D. Both patients have metabolic alkalosis

✅ Correct Answer: C. Patient A has acidosis, Patient B has alkalosis

---

🧠 Rationale:

From your PDF:

• Low bicarb → acidosis → Kussmaul breathing

• High bicarb → alkalosis → hypoventilation

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👉 If you want to level up:

• Say “mixed exam” → I’ll give a full exam (dialysis + CKD + electrolytes combined like your real test)

• Or say “weak areas” and I’ll target what you’re missing based on your answers

Question 4 (Clinical Scenario – chloride integration)

A patient has the following lab values:

• Chloride: 110 mEq/L

• Bicarbonate: low

What condition should the nurse suspect?

A. Metabolic alkalosis
B. Metabolic acidosis
C. Respiratory alkalosis
D. Normal acid-base balance

✅ Correct Answer: B. Metabolic acidosis

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🧠 Rationale:

From your PDF:

• High chloride → associated with:

  • Metabolic acidosis

• Low bicarbonate → acidosis

👉 Both labs point to the same condition → acidosis

Question 3 (SATA – harder)

The nurse is assessing a patient with metabolic acidosis. Which findings are expected? Select all that apply.

A. Kussmaul respirations
B. Arrhythmias
C. Confusion
D. Hypoventilation
E. Poor perfusion

✅ Correct Answers: A, B, C, E

🧠 Rationale:

From your PDF:

• Metabolic acidosis (low bicarb):

  • Kussmaul respirations

  • Arrhythmias

  • Confusion

  • Poor perfusion

Question 2 (Multiple Choice)

A patient presents with slow, shallow respirations and a bicarbonate level of 30 mEq/L. What is the nurse’s best interpretation?

A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Normal acid-base balance

✅ Correct Answer: B. Metabolic alkalosis

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🧠 Rationale:

From your PDF:

• High bicarbonate (>26) → metabolic alkalosis

• Symptoms:

  • Hypoventilation

  • Confusion

  • Tetany

👉 Slow breathing = alkalosis pattern

A nurse is caring for a patient with cirrhosis. Which finding requires immediate intervention?

A. Abdominal distention
B. Mild fatigue
C. Confusion and altered mental status
D. Decreased appetite

✅ Correct Answer: C. Confusion and altered mental status

🧠 Rationale:

From your PDF:

• Liver failure → impaired detoxification
  ➡ leads to hepatic encephalopathy

• Symptoms:

  • Confusion

  • Altered mental status

👉 This indicates toxic buildup affecting the brain → highest priority

Which pathophysiologic change is responsible for ascites in a patient with cirrhosis?

A. Increased sodium intake
B. Decreased albumin and increased portal pressure
C. Increased kidney function
D. Decreased blood pressure

✅ Correct Answer: B. Decreased albumin and increased portal pressure

🧠 Rationale:

From your PDF:

• Cirrhosis causes:

  • Decreased protein (albumin)

  • Portal hypertension

👉 This leads to fluid shifting into the abdomen → ascites

The nurse is assessing a patient with cirrhosis. Which findings are expected? Select all that apply.

A. Ascites
B. Portal hypertension
C. Confusion
D. Increased detoxification
E. Abdominal distention

✅ Correct Answers: A, B, C, E

🧠 Rationale:

From your PDF:

Cirrhosis leads to:

• Portal hypertension

• Ascites

• Hepatic encephalopathy (confusion)

A patient with cirrhosis develops confusion and decreased level of consciousness. What is the underlying cause?

A. Hypokalemia
B. Dehydration
C. Toxin buildup due to impaired liver detoxification
D. Increased albumin levels

✅ Correct Answer: C. Toxin buildup due to impaired liver detoxification

---

🧠 Rationale:

From your PDF:

• Liver failure → impaired detoxification
  ➡ toxins accumulate
  ➡ leads to hepatic encephalopathy

A critically ill patient with acute kidney injury is receiving continuous renal replacement therapy (CRRT). Which findings indicate a complication of therapy? Select all that apply.

A. Potassium 3.0 mEq/L
B. Blood pressure 82/48 mmHg
C. Phosphate 2.0 mg/dL
D. Clear dialysate drainage
E. Oozing blood at central line site
F. Stable MAP with vasopressor support

✅ Answer:

A, B, C, E

💡 Rationale:

• A (K⁺ 3.0) → Hypokalemia → CRRT complication (electrolyte imbalance) ✔

• B (BP 82/48) → Hemodynamic instability → complication ✔

• C (Low phosphate) → Hypophosphatemia → CRRT complication ✔

• E (Bleeding) → due to anticoagulation → complication ✔

• D (clear drainage) → normal finding ❌

• F (stable MAP) → expected/desired ❌

👉 CRRT complications in PPT:

• Hypotension

• Electrolyte imbalances

• Bleeding

A patient is receiving intermittent hemodialysis. Thirty minutes into the treatment, the patient reports dizziness and nausea. Blood pressure is 88/54 mmHg. What is the nurse’s priority action?

A. Continue dialysis and reassess in 15 minutes
B. Lower the head of the bed and administer IV fluids as ordered
C. Stop dialysis immediately and prepare for intubation
D. Encourage oral fluid intake

✅ Answer:

B

💡 Rationale:

• Hypotension is the MOST COMMON complication of hemodialysis ✔

• Priority intervention:

  • Lower HOB

  • Give IV fluids

  • Notify provider if needed

Why others are wrong:

• A → delays care ❌

• C → too aggressive (not first step) ❌

• D → oral fluids not appropriate during dialysis ❌

A patient receiving peritoneal dialysis reports abdominal pain and has a temperature of 38.9°C (102°F). The nurse notes the dialysate drainage is cloudy. What is the priority nursing action?

A. Document findings and continue dialysis
B. Increase dwell time to improve clearance
C. Notify the provider and anticipate treatment for infection
D. Reposition the patient to improve drainage

✅ Answer:

C

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💡 Rationale:

• Findings = PERITONITIS

  • Cloudy effluent

  • Fever

  • Abdominal pain

👉 This is a MEDICAL EMERGENCY

Priority:

• Notify provider immediately

• Expect antibiotics (often intraperitoneal)

The nurse is preparing a patient for scheduled hemodialysis. Which actions are appropriate before initiating dialysis? Select all that apply.

A. Assess for bruit and thrill at AV fistula
B. Administer scheduled antihypertensive medication
C. Obtain current weight and vital signs
D. Review potassium, BUN, and creatinine levels
E. Insert IV catheter into fistula arm for access
F. Assess central line for infection if present

✅ Answer:

A, C, D, F

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💡 Rationale:

• A → MUST assess fistula (bruit & thrill) ✔

• C → weight + vitals = baseline ✔

• D → labs guide dialysis safety ✔

• F → central line must be assessed ✔

• B → antihypertensives are HELD before dialysis ❌

• E → NEVER use fistula arm ❌

👉 All directly from pre-dialysis responsibilities

A patient on CRRT has the following hourly documentation:

• Ordered ultrafiltration goal: 200 mL/hr

• After 4 hours: net fluid balance = –1200 mL

What is the nurse’s best action?

A. Continue therapy as prescribed
B. Increase fluid removal rate
C. Notify the provider of excessive fluid removal
D. Stop CRRT permanently

✅ Answer: C

💡 Rationale:

• Expected removal after 4 hrs:

  • 200 × 4 = 800 mL

• Actual = 1200 mL removed → TOO MUCH

👉 This exceeds prescribed limit → risk for:

• Hypotension

• Instability

✔ Nurse must notify provider

Why others are wrong:

• A → unsafe ❌

• B → worsens problem ❌

• D → too extreme ❌

A patient undergoing hemodialysis suddenly develops headache, nausea, and restlessness. Which condition should the nurse suspect and what is the priority action?

A. Hypotension; raise HOB
B. Dialysis disequilibrium syndrome; slow dialysis rate
C. Infection; obtain blood cultures
D. Hyperkalemia; administer calcium gluconate

✅ Answer:

B

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💡 Rationale:

• Symptoms = Dialysis Disequilibrium Syndrome

  • Headache

  • Nausea

  • Neuro changes

👉 Priority:

• Slow dialysis rate

• Monitor neurological status

Why others are wrong:

• A → hypotension = dizziness, not neuro symptoms ❌

• C → no infection signs ❌

• D → no hyperkalemia signs given ❌

A patient is admitted with acute liver failure. Which findings should the nurse expect? Select all that apply.

A. Asterixis
B. Hypoglycemia
C. Increased ammonia levels
D. Bradycardia and hypertension
E. Elevated PT/INR
F. Clear mental status

✅ Answer:

A, B, C, E

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💡 Rationale:

• A (Asterixis) → sign of encephalopathy ✔

• B (Hypoglycemia) → ↓ glucose regulation ✔

• C (Ammonia ↑) → key cause of neuro changes ✔

• E (↑ PT/INR) → impaired clotting ✔

• D → incorrect (you’d expect instability, not this combo) ❌

• F → mental status is altered in liver failure ❌

👉 Acute liver failure = encephalopathy + coagulopathy + metabolic issue

A patient with cirrhosis becomes increasingly confused and develops slurred speech. Which intervention is the nurse’s priority?

A. Administer lactulose as prescribed
B. Restrict fluid intake
C. Administer vitamin K
D. Prepare for paracentesis

✅ Answer:

A

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💡 Rationale:

• Symptoms = hepatic encephalopathy (ammonia ↑)

• Lactulose = FIRST-LINE treatment → removes ammonia ✔

Why others are wrong:

• B → not priority ❌

• C → treats bleeding, not neuro issue ❌

• D → for ascites, not immediate concern ❌

👉 NCLEX rule:
Neuro change = treat ammonia FIRST

A patient with cirrhosis presents with increasing abdominal distention, shortness of breath, and weight gain. What complication should the nurse suspect?

A. Hepatic encephalopathy
B. Portal hypertension leading to ascites
C. Hepatorenal syndrome
D. Acute liver failure

✅ Answer: B

💡 Rationale:

• Symptoms =

  • Abdominal distention

  • Fluid buildup

  • SOB

👉 Classic ASCITES from portal hypertension ✔

Why others are wrong:

• A → neuro symptoms ❌

• C → kidney failure signs (oliguria) ❌

• D → rapid failure, different presentation

A nurse is caring for a patient with advanced cirrhosis. Which findings indicate worsening liver failure? Select all that apply.

A. Increasing ammonia level
B. Decreased albumin level
C. Elevated bilirubin
D. Increased PT/INR
E. Improved mental clarity
F. Decreased abdominal girth

✅ Answer:

A, B, C, D

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💡 Rationale:

• A (Ammonia ↑) → worsening encephalopathy ✔

• B (Albumin ↓) → poor liver synthesis ✔

• C (Bilirubin ↑) → worsening liver damage ✔

• D (PT/INR ↑) → impaired clotting ✔

• E → improvement, not worsening ❌

• F → improvement in ascites ❌

👉 Labs are key indicators of progression

A patient with acute liver failure suddenly becomes difficult to arouse and develops irregular respirations. What is the nurse’s priority action?

A. Administer lactulose
B. Initiate seizure precautions
C. Prepare for airway management
D. Obtain ammonia level

✅ Answer: C

💡 Rationale:

• Patient shows:

  • ↓ LOC

  • Respiratory changes

👉 Indicates possible cerebral edema → airway compromise

✔ Airway = priority (ABCs)

Why others are wrong:

• A → important but not first ❌

• B → safety but not priority ❌

• D → assessment delays intervention ❌

👉 Acute liver failure can progress to coma and respiratory failure

the nurse is caring for a patient receiving lactulose for hepatic encephalopathy. Which findings indicate the medication is effective? Select all that apply.

A. Decreased ammonia levels
B. Increased number of bowel movements
C. Improved mental status
D. Decreased PT/INR
E. Reduced confusion

✅ Answer:

A, B, C, E

💡 Rationale:

• A → goal = ↓ ammonia ✔

• B → lactulose works by causing bowel movements ✔

• C/E → improved neuro status = effective ✔

• D → lactulose does NOT affect clotting ❌

👉 Goal = 2–3 bowel movements/day + improved cognition

A nurse is assessing a patient with chronic kidney disease. Which findings are expected? Select all that apply.

A. Peripheral edema
B. Hypertension
C. Hyperactivity and restlessness
D. Pruritus
E. Anemia
F. Increased urine output

✅ Answer:

A, B, D, E

💡 Rationale:

• A (Edema) → fluid overload ✔

• B (HTN) → common in CKD ✔

• D (Pruritus) → due to uremia ✔

• E (Anemia) → ↓ erythropoietin ✔

• C → not expected (more confusion, not hyperactivity) ❌

• F → CKD usually has ↓ urine output ❌

👉 CKD = fluid overload + uremia + anemia

Which statement by a patient with CKD indicates correct understanding of dietary restrictions?

A. “I should increase my protein intake to gain strength.”
B. “I will eat foods high in potassium like bananas.”
C. “I need to limit sodium, potassium, and phosphorus in my diet.”
D. “I can drink as much fluid as I want as long as I urinate.”

✅ Answer: C

💡 Rationale:

• CKD diet =
  ✔ Low sodium
  ✔ Low potassium
  ✔ Low phosphorus
  ✔ Low protein
  ✔ Fluid restriction

Why others are wrong:

• A → protein is restricted ❌

• B → potassium restricted ❌

• D → fluid restriction required

A nurse is reviewing a patient’s history to determine the cause of acute kidney injury (AKI). Which conditions are considered prerenal causes? Select all that apply.

A. Severe dehydration
B. Acute tubular necrosis
C. Hypotension
D. Kidney stones
E. Blood loss
F. Shock

✅ Answer:

A, C, E, F

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💡 Rationale:

• A (Dehydration) → ↓ kidney perfusion ✔

• C (Hypotension) → ↓ blood flow ✔

• E (Blood loss) → ↓ perfusion ✔

• F (Shock) → ↓ perfusion ✔

• B → intrarenal (kidney damage) ❌

• D → postrenal (obstruction) ❌

👉 Prerenal = perfusion problem

A patient with AKI has the following labs:

• Potassium: 6.5 mEq/L

• BUN: elevated

• Creatinine: elevated

What is the nurse’s priority action?

A. Encourage oral fluids
B. Place the patient on cardiac monitoring and notify the provider
C. Restrict sodium intake
D. Recheck labs in the morning

✅ Answer: B

💡 Rationale:

• K⁺ 6.5 = SEVERE HYPERKALEMIA

• Risk:

  • Fatal arrhythmias

✔ Priority:

• Cardiac monitoring

• Immediate intervention

Why others are wrong:

• A → not priority ❌

• C → not urgent ❌

• D → unsafe delay ❌

A nurse is assessing a patient with a suspected bowel obstruction. Which findings are most consistent with a small bowel obstruction (SBO)? Select all that apply.

A. Early onset vomiting
B. Severe abdominal distention
C. High-pitched bowel sounds
D. Constant, dull abdominal pain
E. Cramping abdominal pain
F. Vomiting occurring late in the condition

✅ Answer:

A, C, E

💡 Rationale:

• A (Early vomiting) → hallmark of SBO ✔

• C (High-pitched sounds) → early SBO finding ✔

• E (Cramping pain) → typical SBO ✔

• B → more severe in LBO ❌

• D → LBO pain is more constant ❌

• F → late vomiting = LBO ❌

👉 SBO = early vomiting + high-pitched sounds

A patient presents with abdominal pain that started near the umbilicus and has now localized to the right lower quadrant. The patient reports nausea and has a low-grade fever. What is the nurse’s priority intervention?

A. Administer a laxative to relieve discomfort
B. Apply heat to the abdomen
C. Prepare the patient for surgery
D. Encourage oral fluids

✅ Answer: C

💡 Rationale:

• Classic appendicitis presentation:

  • Pain migration (umbilical → RLQ)

  • N/V

  • Fever

👉 Priority = appendectomy

Why others are wrong:

• A → risk of rupture ❌

• B → heat can cause rupture ❌

• D → patient should be NPO ❌

👉 Prevent rupture → prevents peritonitis

A patient with a history of appendicitis suddenly develops severe abdominal pain. The nurse notes a rigid, board-like abdomen, fever, and absent bowel sounds. What is the nurse’s priority action?

A. Encourage ambulation
B. Keep the patient NPO and notify the provider
C. Administer a high-fiber diet
D. Apply cold compresses to the abdomen

✅ Answer: B

💡 Rationale:

• Findings = PERITONITIS

  • Board-like abdomen

  • Severe pain

  • Absent bowel sounds

👉 MEDICAL EMERGENCY

✔ Priority:

• NPO

• Notify provider

• Prepare for surgery

Why others are wrong:

• A → unsafe ❌

• C → inappropriate ❌

• D → delays treatment ❌

A nurse is caring for a patient with acute diverticulitis. Which interventions are appropriate? Select all that apply.

A. Keep patient NPO
B. Administer IV antibiotics
C. Encourage high-fiber diet immediately
D. Provide IV fluids
E. Monitor for signs of perforation
F. Encourage laxative use

✅ Answer:

A, B, D, E

💡 Rationale:

• A (NPO) → bowel rest ✔

• B (Antibiotics) → treat infection ✔

• D (IV fluids) → support hydration ✔

• E (Monitor complications) → perforation risk ✔

• C → high fiber is for long-term, not acute ❌

• F → laxatives contraindicated ❌

A patient presents with abdominal distention, constipation, and vomiting that began several days after symptom onset. Bowel sounds are decreased. Which condition should the nurse suspect?

A. Small bowel obstruction
B. Large bowel obstruction
C. Appendicitis
D. Peritonitis

✅ Answer: B

💡 Rationale:

• Key clues:

  • Severe distention

  • Constipation

  • Vomiting LATE

  • Decreased bowel sounds

👉 Classic LBO

Why others are wrong:

• A → SBO = early vomiting + high-pitched sounds ❌

• C → RLQ pain pattern ❌

• D → rigid abdomen + emergency signs ❌

A nurse is assessing four patients. Which patient requires immediate intervention?

A. Patient with diverticulitis reporting LLQ pain and low-grade fever
B. Patient with SBO reporting cramping pain and vomiting
C. Patient with peritonitis and a rigid, board-like abdomen
D. Patient with LBO reporting constipation and mild distention

✅ Answer:

C

💡 Rationale:

• Peritonitis = LIFE-THREATENING emergency

• Rigid, board-like abdomen = key sign

👉 Priority = treat immediately

Why others are wrong:

• A → expected diverticulitis

• B → expected SBO

• D → expected LBO

A patient is admitted with acute pancreatitis. Which finding requires immediate nursing intervention?

A. Epigastric pain radiating to the back
B. Lipase level elevated
C. Blood pressure 84/50 mmHg
D. Nausea and vomiting

✅ Answer:

C

💡 Rationale:

• Hypotension = shock → LIFE-THREATENING

• Acute pancreatitis can cause hypovolemia

✔ Priority = maintain perfusion

Why others are wrong:

• A → expected finding

• B → diagnostic finding

• D → common symptom

A nurse is caring for a patient with acute pancreatitis. Which interventions are appropriate? Select all that apply.

A. Keep the patient NPO
B. Administer IV fluids
C. Encourage oral intake as tolerated
D. Provide pain medication
E. Insert NG tube if severe vomiting occurs
F. Encourage alcohol consumption to improve appetite

✅ Answer:

A, B, D, E

💡 Rationale:

• A (NPO) → rest pancreas ✔

• B (IV fluids) → prevent shock ✔

• D (Pain control) → priority ✔

• E (NG tube) → reduce stimulation ✔

• C → pancreas must rest ❌

• F → alcohol is contraindicated ❌

A patient presents with weight loss, anorexia, and jaundice but denies abdominal pain. Which condition should the nurse suspect?

A. Acute pancreatitis
B. Chronic pancreatitis
C. Pancreatic cancer
D. Small bowel obstruction

✅ Answer:

C

💡 Rationale:

• Painless jaundice = hallmark of pancreatic cancer ✔

• Also:

  • Weight loss

  • Anorexia

Why others are wrong:

• A → severe pain present ❌

• B → chronic pain + malabsorption ❌

• D → obstruction symptoms ❌

A patient with acute pancreatitis reports severe epigastric pain. Which position would the nurse encourage to help reduce the pain?

A. Supine with legs extended
B. Sitting upright and leaning forward
C. Lying flat with arms at sides
D. Trendelenburg position

✅ Answer: B

💡 Rationale:

• Pancreatitis pain is:

  • Worse lying flat

  • Relieved by leaning forward ✔

Why others are wrong:

• A/C → worsen pain ❌

• D → inappropriate

A nurse is reviewing laboratory results for a patient with suspected pancreatitis. Which combination of findings supports this diagnosis? Select all that apply.

A. Elevated lipase
B. Elevated amylase
C. Decreased calcium
D. Decreased bilirubin
E. Elevated glucose

✅ Answer:

A, B, C, E

💡 Rationale:

• A (Lipase ↑) → most specific ✔

• B (Amylase ↑) → supports diagnosis ✔

• C (Calcium ↓) → occurs in pancreatitis ✔

• E (Glucose ↑) → impaired pancreatic function ✔

• D → not expected (bilirubin may increase if gallstones involved) ❌

A patient with chronic pancreatitis reports frequent greasy, foul-smelling stools and weight loss. What is the nurse’s best interpretation?

A. The patient is experiencing fluid overload
B. The patient has developed malabsorption
C. The patient is improving
D. The patient has developed a bowel obstruction

✅ Answer: B

💡 Rationale:

• Chronic pancreatitis → loss of enzymes
  → fat malabsorption (steatorrhea) ✔
  → weight loss

Why others are wrong:

• A → unrelated ❌

• C → symptoms show worsening ❌

• D → different presentation ❌

A patient with a history of cirrhosis presents with vomiting large amounts of bright red blood. Vital signs: BP 86/48 mmHg, HR 122 bpm. What is the nurse’s priority action?

A. Prepare the patient for endoscopy
B. Administer proton pump inhibitor
C. Initiate IV fluids and prepare for blood transfusion
D. Obtain a stool sample

✅ Answer: C

💡 Rationale:

• Patient is in hypovolemic shock:

  • Hypotension

  • Tachycardia

  • Active bleeding

👉 Circulation first (ABCs)

✔ Priority = fluid resuscitation + blood

Why others are wrong:

• A → needed but after stabilization ❌

• B → not immediate priority ❌

• D → irrelevant ❌

A nurse is assessing a patient with a suspected upper GI bleed. Which findings support this diagnosis? Select all that apply.

A. Coffee-ground emesis
B. Hematemesis
C. Melena
D. Bright red blood per rectum
E. Decreased hemoglobin

✅ Answer:

A, B, C, E

---

💡 Rationale:

• A (coffee-ground) → upper GI ✔

• B (hematemesis) → upper GI ✔

• C (melena) → upper GI ✔

• E (↓ Hgb) → blood loss ✔

• D → lower GI bleed ❌

A patient with esophageal varices is being monitored on the unit. Which finding requires immediate intervention?

A. Mild fatigue
B. Black tarry stools
C. Sudden onset of hematemesis
D. Slight decrease in appetite

✅ Answer: C

💡 Rationale:

• Hematemesis = active bleeding → EMERGENCY

• Varices can rupture → massive hemorrhage

✔ Immediate intervention required

Why others are wrong:

• A/D → non-urgent ❌

• B → concerning but not as immediate as active bleeding ❌

A nurse is caring for a patient with esophageal varices. Which interventions are appropriate? Select all that apply.

A. Monitor for hematemesis
B. Maintain NPO status during active bleeding
C. Insert NG tube aggressively to check bleeding
D. Prepare for endoscopic banding
E. Monitor hemoglobin and hematocrit

✅ Answer:

A, B, D, E

💡 Rationale:

• A → monitor for bleeding ✔

• B → prevent aspiration ✔

• D → definitive treatment ✔

• E → monitor blood loss ✔

• C → NG tube can rupture varices ❌

A patient presents with black, tarry stools and a history of gastric ulcers. What is the nurse’s best interpretation?

A. Lower GI bleed
B. Upper GI bleed
C. Normal stool variation
D. Bowel obstruction

✅ Answer:

B

💡 Rationale:

• Melena (black tarry stool) = digested blood
  👉 Source = upper GI tract

Why others are wrong:

• A → bright red blood ❌

• C → abnormal finding ❌

• D → different symptoms ❌

A nurse is caring for a patient receiving total parenteral nutrition (TPN). Which findings require immediate intervention? Select all that apply.

A. Blood glucose of 260 mg/dL
B. Fever and redness at central line site
C. Gradual weight gain
D. Sudden discontinuation of TPN
E. Stable electrolyte levels

✅ Answer:

A, B, D

---

💡 Rationale:

• A (Hyperglycemia) → common complication ✔

• B (Infection signs) → central line infection ✔

• D (Stopped abruptly) → risk of hypoglycemia ✔

• C → expected with nutrition ❌

• E → normal finding ❌

A nurse is providing education about colorectal cancer screening. Which statement by the patient indicates correct understanding?

A. “I only need screening if I have symptoms.”
B. “Colonoscopy can detect and remove abnormal growths.”
C. “Screening is unnecessary if I feel healthy.”
D. “Only people with a family history need screening.”

✅ Answer:

B

💡 Rationale:

• Colonoscopy = gold standard
  👉 Detects + allows biopsy/removal ✔

Why others are wrong:

• A/C/D → screening is preventive, not symptom-based ❌

A nurse is reviewing lab results for a patient with suspected colorectal cancer. Which finding would the nurse expect?

A. Elevated hemoglobin
B. Decreased hematocrit
C. Hyperkalemia
D. Elevated calcium

✅ Answer:

B

💡 Rationale:

• Chronic GI bleeding → anemia
  👉 ↓ hematocrit ✔

Why others are wrong:

• A → opposite ❌

• C/D → not typical findings ❌

A nurse is collecting a 24-hour urine specimen for a patient. Which action indicates correct understanding of the procedure?

A. Save the first urine of the collection period
B. Discard the first urine, then collect all remaining urine for 24 hours
C. Collect only daytime urine samples
D. Stop collection if one specimen is missed

✅ Answer: B

💡 Rationale:

• Correct process:

  • Discard first void

  • Then collect ALL urine for 24 hours ✔

Why others are wrong:

• A → incorrect start ❌

• C → incomplete collection ❌

• D → collection must restart, not stop ❌

A patient has just undergone a renal biopsy. Which finding requires immediate intervention?

A. Mild discomfort at the biopsy site
B. Clear yellow urine
C. Hematuria and decreased blood pressure
D. Stable vital signs

✅ Answer:

C

💡 Rationale:

• Biopsy complication = bleeding

• Signs:

  • Hematuria

  • Hypotension

👉 Indicates possible hemorrhage → EMERGENCY ✔

Why others are wrong:

• A → expected ❌

• B → normal ❌

• D → stable ❌

A patient receiving total parenteral nutrition (TPN) has the infusion suddenly discontinued. Which complication is the nurse most concerned about?

A. Hypernatremia
B. Hypoglycemia
C. Hyperkalemia
D. Fluid overload

✅ Answer: B

💡 Rationale:

• TPN = high glucose solution

👉 Sudden stop → insulin still active → hypoglycemia

✔ This is a high-risk, immediate complication