AH2 Exam #2 PrepU

After undergoing a liver biopsy, a client should be placed in which position? Semi-Fowler's position Right lateral decubitus position Supine position Prone position

Right lateral decubitus position

A nurse is caring for a client with severe hemolytic jaundice. Laboratory tests show free bilirubin to be 24 mg/dL (408 mmol/L). For what complication is this client at risk? Chronic jaundice Pigment stones in portal circulation Central nervous system damage Hepatomegaly

Central nervous system damage

The nurse is administering 2 units of packed RBCs to an older adult patient who has a bleeding duodenal ulcer. The patient begins to experience difficulty breathing and the nurse assesses crackles in the lung bases, jugular vein distention, and an increase in blood pressure. What action by the nurse is necessary if the reaction is severe? (Select all that apply.) Continue the infusion but slow the rate down. Place the patient in an upright position with the feet dependent. Administer diuretics as prescribed. Discontinue the transfusion. Administer oxygen.

Administer oxygen. Administer diuretics as prescribed. Discontinue the transfusion. Place the patient in an upright position with the feet dependent.

The nurse expects which assessment finding when caring for a client with a decreased hemoglobin level? Bright red venous blood. Elevated temperature. Decreased oxygen level. Increased bruising.

Decreased oxygen level.

A client on the medical unit is receiving a unit of PRBCs. Difficult IV access has necessitated a slow infusion rate and the nurse notes that the infusion began 4 hours ago. What is the nurse's most appropriate action? Apply an icepack to the blood that remains to be infused. Discontinue the remainder of the PRBC transfusion and inform the health care provider. Disconnect the bag of PRBCs, cool for 30 minutes and then administer. Administer the remaining PRBCs by the IV direct (IV push) route.

Discontinue the remainder of the PRBC transfusion and inform the health care provider.

A client is given a diagnosis of hepatic cirrhosis. The client asks the nurse what findings led to this determination. Which of the following clinical manifestations would the nurse correctly identify? Select all that apply. Enlarged liver size Ascites Accelerated behaviors and mental processes Hemorrhoids Excess storage of vitamin C

Enlarged liver size Ascites Hemorrhoids

A client with severe anemia is admitted to the hospital. Because of religious beliefs, the client is refusing blood transfusions. The nurse anticipates pharmacologic therapy with which drug to stimulate the production of red blood cells? Filgrastim Sargramostim Epoetin alfa Eltrombopag

Epoetin alfa

A patient with chronic kidney disease has chronic anemia. What pharmacologic alternative to blood transfusion may be used for this patient? GM-CSF (Leukine) Erythropoietin (Epogen) Eltrombopag (Promacta) Thrombopoietin (TPO)

Erythropoietin (Epogen)

A client has ascites. Which of the following interventions would the nurse prepare to assist with implementing to help the client control this condition? Select all that apply. Instructing the client to remove salty and salted foods from the diet Administering prescribed spironolactone (Aldactone) Assisting with placement of a transjugular intrahepatic portosystemic shunt Mobilizing the client every 2 hours Taking the client's weight every 3 to 4 days

Instructing the client to remove salty and salted foods from the diet Administering prescribed spironolactone (Aldactone) Assisting with placement of a transjugular intrahepatic portosystemic shunt

Albumin is important for the maintenance of fluid balance within the vascular system. Albumin is produced by which of the following? Liver Pancreas Kidney Large intestine

Liver

Which is a symptom of severe thrombocytopenia? Petechiae Inflammation of the mouth Inflammation of the tongue Dyspnea

Petechiae

The nurse is preparing to check for tube placement in the client's stomach as well as measure the residual volume. What is the main purpose of these nursing actions? Prevent gastric ulcers Prevent aspiration Prevent abdominal distention Prevent diarrhea

Prevent aspiration

The nurse is caring for a client with cirrhosis. Which assessment findings indicate that the client has deficient vitamin K absorption caused by this hepatic disease? Dyspnea and fatigue Ascites and orthopnea Purpura and petechiae Gynecomastia and testicular atrophy

Purpura and petechiae

The nurse began transfusing the first unit of packed red blood cells (PRBCs) fifteen minutes ago. The client begins complaining of shortness of breath, nausea, and is restless. What is the nurse's priority action? Flush the blood tubing with normal saline. Discontinue the intravenous line. Stop the infusion. Notify the primary care provider.

Stop the infusion.

A nurse is creating a care plan for a client with a nasogastric tube. How should the nurse direct other members of the care team to check correct placement of the tube? Auscultate the client's abdomen after injecting air through the tube. Assess the color and pH of aspirate. Locate the marking made after the initial x-ray confirming placement. Use a combination of at least two accepted methods for confirming placement.

Use a combination of at least two accepted methods for confirming placement.

The client is receiving 50% dextrose parenteral nutrition with fat emulsion therapy through a peripherally inserted central catheter (PICC). The nurse has developed a care plan for the nursing diagnosis "Risk for infection related to contamination of the central catheter site or infusion line." The nurse includes the intervention Change the transparent dressing every 3 days. Wear a face mask during dressing changes. Assess the PICC insertion site daily. Use clean gloves when providing site care.

Wear a face mask during dressing changes.

A client verbalizes fear of infection from a blood transfusion. What is the nurse's best response? "The risk of transmission of HIV is so low, there's no need to worry." "Blood typing is more important than testing for infection." "There is no need for testing unless you have a history of a transfusion reaction." "Every unit of donated blood is typed and tested for antibodies to infections."

"Every unit of donated blood is typed and tested for antibodies to infections."

A nurse is inserting a nasogastric tube for feeding a client. Place in order the steps from 1 to 6 for correctly inserting the tube.

1. Sit the client in an upright position 2. Apply gloves to the nurse's hands 3. Measure the length of the tube that will be inserted 4. Apply water-soluble lubricant to the tip of the tube 5. Tilt the client's nose upward 6. Instruct the client to lower the head and swallow

A nurse has participated in organizing a blood donation drive at a local community center. Which of the following individuals would most likely be disallowed from donating blood? A man who is 81 years of age A woman whose blood pressure is 88/51 mm Hg A man who donated blood 4 months ago A woman who has type 1 diabetes

A woman whose blood pressure is 88/51 mm Hg

A nurse is aware of the high incidence of catheter-related bloodstream infections in clients receiving parenteral nutrition. What nursing action has the greatest potential to reduce catheter-related bloodstream infections? Use clean technique and wear a mask during dressing changes. Change the dressing no more than weekly. Apply antibiotic ointment around the site with each dressing change. Irrigate the insertion site with sterile water during each dressing change.

Change the dressing no more than weekly.

A patient develops a hemolytic reaction to a blood transfusion. What actions should the nurse take after this occurs? (Select all that apply.) Administer diphenhydramine (Benadryl). Begin iron chelation therapy. Obtain appropriate blood specimens. Collect a urine sample to detect hemoglobin. Document the reaction according to policy.

Collect a urine sample to detect hemoglobin. Document the reaction according to policy. Obtain appropriate blood specimens.

Post transfusion, the donor stands up immediately after the needle is withdrawn. The nurse should be alert for which vital sign change? Decreased blood pressure. Decreased pulse. Decreased respiratory rate. Elevated temperature.

Decreased blood pressure.

A client tells the nurse that he would like to donate blood before his abdominal surgery next week. What should be the nurse's first action? Provide the client with a list of the nearest donation centers. Explain the time frame needed for autologous donation. Remind the client to take supplemental iron before donation. Tell the client that 2 units of blood will be needed.

Explain the time frame needed for autologous donation.

A client who can't tolerate oral feedings begins receiving intermittent enteral feedings. When monitoring for evidence of intolerance to these feedings, the nurse must remain alert for: a. diaphoresis, vomiting, and diarrhea. b. manifestations of electrolyte disturbances. c. manifestations of hypoglycemia. d. constipation, dehydration, and hypercapnia.

a. diaphoresis, vomiting, and diarrhea.

The nurse confirms placement of a client's nasogastric (NG) tube using a combination of visual and pH assessment of the aspirate. The nurse determines that the NG tube remains properly placed when the pH of the aspirate is alkaline acidic neutral unmeasurable

acidic

The primary source of microorganisms for catheter-related infections are the skin and the catheter tubing. catheter hub. IV fluid bag. IV tubing.

catheter hub.

What type of feedings should be administered to a client who is at risk of diarrhea due to hypertonic feeding solutions? continuous feedings intermittent feeding bolus feeding cyclic feeding

continuous feedings

A client with acute pancreatitis has jaundice with diminished bowel sounds and a tender distended abdomen. Additionally, lab results indicate hypovolemia. What will the physician order to treat the large amount of protein-rich fluid that has been released into the client's tissues and peritoneal cavity? Select all that apply. diuretics albumin sodium dextrose solution

diuretics albumin

The nurse prepares to administer all of a client's medications via feeding tube. The nurse consults the pharmacist and/or physician when the nurse notes which type of oral medication on the client's medication administration record? simple compressed tablets buccal or sublingual tablets enteric-coated tablets soft, gelatin capsules filled with liquid

enteric-coated tablets

A client who has just been diagnosed with hepatitis A asks, "How did I get this disease?" What is the nurse's best response? "You could have gotten it by using I.V. drugs." "You must have received an infected blood transfusion." "You probably got it by engaging in unprotected sex." "You may have eaten contaminated restaurant food."

"You may have eaten contaminated restaurant food."

The nurse is administering total parenteral nutrition (TPN) to a client who underwent surgery for gastric cancer. Which of the nurse's assessments most directly addresses a major complication of TPN? Checking the client's capillary blood glucose levels regularly Having the client frequently rate his or her hunger on a 10-point scale Measuring the client's heart rhythm at least every 6 hours Monitoring the client's level of consciousness each shift

Checking the client's capillary blood glucose levels regularly

The nurse is caring for a client who is postoperative from having a gastrostomy tube placed. What should the nurse do on a daily basis to prevent skin breakdown? Verify tube placement. Loop adhesive tape around the tube and connect it securely to the abdomen. Gently rotate the tube. Change the wet-to-dry dressing.

Gently rotate the tube.

A client is admitted with increased ascites related to cirrhosis. Which nursing diagnosis should receive top priority? Fatigue Excess fluid volume Ineffective breathing pattern Imbalanced nutrition: less than body requirements

Ineffective breathing pattern

A mother brings her teenage son to the clinic, where tests show that he has hepatitis A virus (HAV). They ask the nurse how this could have happened. Which of the following explanations would the nurse correctly identify as possible causes? Select all that apply. Infection at school Suboptimal sanitary habits Consumption of sewage-contaminated water or shellfish Sexual activity Ingestion of undercooked beef

Infection at school Consumption of sewage-contaminated water or shellfish Sexual activity Suboptimal sanitary habits

When caring for a client with hepatitis B, the nurse should monitor closely for the development of which finding associated with a decrease in hepatic function? Jaundice Pruritus of the arms and legs Fatigue during ambulation Irritability and drowsiness

Irritability and drowsiness

The nurse should notify the healthcare provider before administering fresh frozen plasma (FFP) based on which assessment finding? White sclera Jugular venous distention Strong pedal pulses Absence of tenting skin turgor

Jugular venous distention

A physician orders spironolactone (Aldactone), 50 mg by mouth four times daily, for a client with fluid retention caused by cirrhosis. Which finding indicates that the drug is producing a therapeutic effect? Serum potassium level of 3.5 mEq/L Loss of 2.2 lb (1 kg) in 24 hours Serum sodium level of 135 mEq/L Blood pH of 7.25

Loss of 2.2 lb (1 kg) in 24 hours

The nurse is caring for a patient who has ascites as a result of hepatic dysfunction. What intervention can the nurse provide to determine if the ascites is increasing? (Select all that apply.) Measure urine output every 8 hours. Assess and document vital signs every 4 hours. Measure abdominal girth daily. Perform daily weights. Monitor number of bowel movements per day.

Measure abdominal girth daily. Perform daily weights.

A client is receiving continuous tube feedings at 75 mL/hr. The nurse has checked the residual volume 4 hours ago as 250 mL. The nurse now assesses the residual volume as 325 mL. The first action of the nurse is to Discard the residual volume Stop the continuous feeding Decrease the rate to 40 mL/hr Notify the physician

Notify the physician

A client involved in a motor vehicle accident arrives at the emergency department unconscious and severely hypotensive. The nurse suspects he has several fractures in the pelvis and legs. Which parenteral fluid is the best choice for the client's current condition? Fresh frozen plasma Normal saline solution Lactated Ringer's solution Packed red blood cells (RBCs)

Packed red blood cells (RBCs)

A nurse reviews a client's laboratory results and notes the client has a decreased lymphocyte count. What nursing diagnosis will the nurse use when planning the client's care? Risk for bleeding Risk for infection Impaired oxygenation Impaired tissue integrity

Risk for infection

A nurse is preparing to perform a dressing change to the site of a patient's central venous catheter used for parenteral nutrition. Which equipment and supplies would the nurse need to gather? Select all that apply. Masks Clean gloves Skin antiseptic Alcohol wipes Sterile gauze pads Extension set tubing

Sterile gauze pads Masks Alcohol wipes Skin antiseptic

A 18-year-old client presents to the emergency department with a severe open fracture of the lower extremity. The health care provider tells the client that the client will need a blood transfusion. The client refuses, despite the advise of the health care provider. What does the nurse understand is the legal implication of the scenario? The client has a right to refuse the transfusion. The health care provider may first call the client's parents if the client refuses. The client can only refuse the transfusion if the consent form has not been signed. The health care provider may ask for a court order if the client refuses.

The client has a right to refuse the transfusion.

A nurse practitioner treating a patient who is diagnosed with hepatitis A should provide health care information. Which of the following statements are correct for this disorder? Select all that apply. The incubation period for this virus is up to 4 months. There is a 70% chance that jaundice will occur. Transmission of the virus is possible with oral-anal contact during sex. Typically there is a spontaneous recovery. There is a 50% risk that cirrhosis will develop.

There is a 70% chance that jaundice will occur. Transmission of the virus is possible with oral-anal contact during sex. Typically there is a spontaneous recovery.

A client receives tube feedings after an oral surgery. The nurse manages tube feedings to minimize the risk of aspiration. Which measure should the nurse include in the care plan to reduce the risk of aspiration? Change the tube feeding container, tubing, and adjust patient head of bed . Avoid cessation of feedings and adjust patient head of bed. Use semi-Fowler position during, and 60 minutes after, an intermittent feeding. Administer 15 to 30 mL of water before and after medications and feedings.

Use semi-Fowler position during, and 60 minutes after, an intermittent feeding.

The client is to receive a unit of packed red blood cells. The first intervention of the nurse is to Check the label on the unit of blood with another registered nurse. Ensure that the intravenous site has a 20-gauge or larger needle. Observe for gas bubbles in the unit of packed red blood cells. Verify that the client has signed a written consent form.

Verify that the client has signed a written consent form.

A client with acute liver failure exhibits confusion, a declining level of consciousness, and slowed respirations. The nurse finds him very difficult to arouse. The diagnostic information which best explains the client's behavior is: elevated liver enzymes and low serum protein level. subnormal serum glucose and elevated serum ammonia levels. subnormal clotting factors and platelet count. elevated blood urea nitrogen and creatinine levels and hyperglycemia.

subnormal serum glucose and elevated serum ammonia levels.

A nurse is responsible for monitoring the diet of a client with hepatic encephalopathy. Which daily protein intake should this 185-pound (84-kilogram) male consume? 16 to 49 grams 50 to 75 grams 76 to 99 grams 100 to 126 grams

100 to 126 grams

A nurse is reviewing laboratory test results from a client. The report indicates that the client has jaundice. What serum bilirubin level must the client's finding exceed? Enter the correct number only.

2.5

A client is admitted to the hospital with acute hemorrhage from esophageal varices. What medication should the nurse anticipate administering that will reduce pressure in the portal venous system and control esophageal bleeding? Vitamin K Octreotide Vasopressin Epinephrine

Octreotide

A nurse is caring for a client with a nasogastric tube for feeding. During shift assessment, the nurse auscultates a new onset of bilateral lung crackles and notes a respiratory rate of 30 breaths per minute. The client's oxygen saturation is 89% by pulse oximetry. After ensuring the client's immediate safety, what is the nurse's most appropriate action? Perform chest physiotherapy. Reduce the height of the client's bed and remove the NG tube. Liaise with the dietitian to obtain a feeding solution with lower osmolarity. Report possible signs of aspiration pneumonia to the primary provider.

Report possible signs of aspiration pneumonia to the primary provider.

A nurse is caring for a client with a subclavian central line who is receiving parenteral nutrition (PN). In preparing a care plan for this client, what nursing diagnosis should the nurse prioritize? Risk for Activity Intolerance Related to the Presence of a Subclavian Catheter Risk for Infection Related to the Presence of a Subclavian Catheter Risk for Functional Urinary Incontinence Related to the Presence of a Subclavian Catheter Risk for Sleep Deprivation Related to the presence of a Subclavian Catheter

Risk for Infection Related to the Presence of a Subclavian Catheter

Before inserting a gastric or enteric tube, the nurse determines the length of tubing that will be needed to reach the stomach or small intestine. The Levin tube, a commonly used nasogastric tube, has circular markings at specific points. This tube should be inserted to 6 to 10 cm beyond what length? A length of 50 cm (20 in) A point that equals the distance from the nose to the xiphoid process The distance measured from the tip of the nose (N) to the earlobe (E) and from the earlobe to the xiphoid (X) process The distance determined by measuring from the tragus of the ear to the xiphoid process

The distance measured from the tip of the nose (N) to the earlobe (E) and from the earlobe to the xiphoid (X) process

When teaching about the advantages of autologous blood transfusion to a client, the nurse should include which information? Select all that apply. The primary advantage is prevention of viral infections. It is safer for clients with a history of transfusion reactions. It resolves anemia for clients with a hemoglobin less than 11g/dL. Blood can be transfused to family members and close relatives. If not needed immediately, the blood can be frozen for future use.

The primary advantage is prevention of viral infections. It is safer for clients with a history of transfusion reactions. If not needed immediately, the blood can be frozen for future use.

A client is in the hospital with a bleeding gastric ulcer and requires a blood transfusion. He has been typed and crossmatched for 2 units of packed red blood cells and found to have type O blood. What type of blood will the nurse administer to this client? Type A Type B Type AB Type O

Type O

A client with hepatitis C develops liver failure and GI hemorrhage. The blood products that most likely bring about hemostasis in the client are: whole blood and albumin. platelets and packed red blood cells. fresh frozen plasma and whole blood. cryoprecipitate and fresh frozen plasma.

cryoprecipitate and fresh frozen plasma.

A physician orders lactulose (Cephulac), 30 ml three times daily, when a client with cirrhosis develops an increased serum ammonia level. To evaluate the effectiveness of lactulose, the nurse should monitor: urine output. abdominal girth. stool frequency. level of consciousness (LOC).

level of consciousness (LOC).

A client with advanced cirrhosis has a prothrombin time (PT) of 15 seconds, compared with a control time of 11 seconds. The nurse expects to administer: spironolactone (Aldactone). phytonadione (Mephyton). furosemide (Lasix). warfarin (Coumadin).

phytonadione (Mephyton).

The most significant complication related to continuous tube feedings is the interruption of GI integrity. a disturbance of intestinal and hepatic metabolism. the increased potential for aspiration. an interruption in fat metabolism and lipoprotein synthesis.

the increased potential for aspiration.