EAQ 5

A nurse is taking care of a client with cirrhosis of the liver. Which clinical manifestations should the nurse assess in the client? SATA. a. Ascites b. Hunger c. Pruritus d. Jaundice e. Headache

a. Ascites c. Pruritus d. Jaundice Ascites is a result of portal hypertension that occurs with cirrhosis. Pruritus is common because bile pigments seep into the skin from the bloodstream. Jaundice occurs because the bile duct becomes obstructed and bile enters the bloodstream. The appetite decreases because of the pressure on the abdominal organs from the ascites and the liver's decreased ability to metabolize food. Headache is not a common manifestation of cirrhosis of the liver.

A nurse is caring for a client with end-stage renal disease who has a mature arteriovenous (AV) fistula. Which nursing care should be included in the client's plan of care? SATA. a. Auscultate for a bruit b. Palpate the site to ID a thrill c. Irrigate with saline to maintain patency d. Avoid drawing blood from the affected extremity e. Keep the fistula clamped until ready to perform dialysis

a. Auscultate for a bruit b. Palpate the site to ID a thrill d. Avoid drawing blood from the affected extremity The presence of a bruit indicates patency of the AV fistula. The presence of a vibration or thrill indicates patency of the AV fistula. Drawing blood is avoided to prevent damage to the AV fistula. An AV fistula is internal and is not irrigated. The AV fistula is under the skin and is not clamped.

A client who is receiving peritoneal dialysis reports severe respiratory difficulty. What immediate action should the nurse implement? a. Auscultate the lungs b. Obtain arterial blood gases c. Notify the HCP d. Apply pressure to the abdomen

a. Auscultate the lungs Always assess the client first to determine if the lung sounds are indicative of fluid overload. When respiratory distress occurs, possibly from pressure of the dialysate on the diaphragm, respiratory status and vital signs should be assessed. The healthcare provider should be notified and arterial blood gases should be obtained after immediate action is taken. Never apply pressure to the abdomen, as that could worsen the respiratory status.

The nursing instructor determines that the student nurse understands the type(s) of hepatitis that most commonly are spread by consuming contaminated food and water or by fecal contamination if the student identifies which of these diseases? SATA. a. Hepatitis A b. Hepatitis B c. Hepatitis C d. Hepatitis D e. Hepatitis E

a. Hepatitis A e. Hepatitis E Hepatitis A and E most commonly are spread through the fecal-oral route. Hepatitis B most commonly is spread through the sharing of needles and through unprotected sex. Hepatitis C and D most commonly are spread through intravenous (IV) drug needle sharing.

A client with limited mobility is being discharged. To prevent urinary stasis and formation of renal calculi, what should the nurse instruct the client to do? a. Increase oral fluid intake to 2-3 L/day b. Maintain bed rest after discharge c. Limit fluid intake to 1 L/day d. Void at least every hour

a. Increase oral fluid intake to 2-3 L/day Increasing oral fluid intake to 2 to 3 L/day, if not contraindicated, will dilute urine and promote urine flow, thus preventing stasis and complications such as renal calculi. Bed rest and limited fluid intake may lead to urinary stasis and increase risk for the formation of renal calculi. Voiding at least every hour has no effect on urinary stasis and renal calculi.

A client is admitted to the hospital with a diagnosis of cirrhosis of the liver. For which assessment signs of hepatic encephalopathy should the nurse assess this client? SATA. a. Mental confusion b. Increased cholesterol c. Brown-colored stools d. Flapping hand tremors e. Musty, sweet breath odor

a. Mental confusion d. Flapping hand tremors e. Musty, sweet breath odor An accumulation of nitrogenous wastes affects the central nervous system, causing mental confusion. An accumulation of nitrogenous wastes in hepatic encephalopathy affects the nervous system. Flapping tremors and generalized twitching occur in the second and third stages, respectively. Fetor hepaticus is the musty, sweet odor of the client's breath. Increased cholesterol levels are not necessarily present. Stool is often clay-colored because of lack of bile caused by biliary obstruction.

The nurse provides discharge instructions to a male client who had an ureterolithotomy. The client has a history of recurrent urinary tract infections (UTIs). For which indicators of a UTI should the nurse instruct the client? a. Urgency or frequency of urination b. An increase of ketones in the urine c. The inability to maintain an erection d. Pain radiating to the external genitalia

a. Urgency or frequency of urination Urgency or frequency of urination occur with a urinary tract infection[1][2] because of bladder irritability; burning on urination and fever are additional signs of a UTI. Increase of ketones is associated with diabetes mellitus, starvation, or dehydration. The inability to maintain an erection is not related to a UTI. Pain radiating to the external genitalia is a symptom of a urinary calculus, not infection.

A client is admitted with renal calculi. Which clinical manifestations does a nurse expect the client to report? SATA. a. blood in the urine b. Irritability & twitching c. Dry, itchy skin and pyuria d. Frequency and urgency of urination e. Pain radiating from the kidney to a shoulder

a. blood in the urine d. Frequency and urgency of urination Hematuria is a common clinical manifestation of renal calculi. Frequency and a sense of urgency may occur because of irritation caused by the calculi; the most common expectation is sharp, severe pain. Irritability may occur because of discomfort; twitching does not occur. Pyuria may occur when infection is present; skin problems do not occur. Pain radiates from the flank to the groin area.

A client is admitted with a diagnosis of acute pancreatitis. The medical and nursing measures for this client are aimed toward maintaining nutrition, promoting rest, maintaining fluid and electrolytes, and decreasing anxiety. Which interventions should the nurse implement? SATA. a. Provide a low-fat diet b. Administer analgesics c. Teach relaxation exercises d. Encourage walking in the hall e. Monitor cardiac rate and rhythm f. Observe for signs of hypercalcemia

b. Administer analgesics c. Teach relaxation exercises e. Monitor cardiac rate and rhythm Analgesics, histamine-receptor antagonists, and proton pump inhibitors may be administered to decrease gastrointestinal activity and the secretion of pancreatic enzymes. Relaxation will decrease the metabolic rate, which will decrease gastrointestinal activity, including the secretion of pancreatic enzymes. Monitoring cardiac rate and rhythm is necessary to assess for hypokalemia and fluid volume changes. The client would be kept nothing by mouth to decrease gastrointestinal activity and the secretion of pancreatic enzymes. Walking increases the metabolic rate, which will increase gastrointestinal activity, including the secretion of pancreatic enzymes. Hypocalcemia, not hypercalcemia, occurs because of calcium and fatty acids combining during fat necrosis.

A nurse is providing discharge instructions to a client diagnosed with cirrhosis and varices. Which information should the nurse include in the teaching session? SATA. a. Adhering to a low-carbohydrate diet b. Avoiding aspirin and aspirin-containing products c. Limiting alcohol consumption to two drinks weekly d. Avoiding acetaminophen and productions containing acetaminophen e. Avoiding coughing, sneezing, and straining to have a bowel movement

b. Avoiding aspirin and aspirin-containing products d. Avoiding acetaminophen and productions containing acetaminophen e. Avoiding coughing, sneezing, and straining to have a bowel movement Aspirin can damage the gastric mucosa and precipitate hemorrhage when esophageal or gastric varices are present. Acetaminophen is hepatotoxic and should not be used by the client with cirrhosis. The client with cirrhosis should avoid coughing, sneezing, and straining to have a bowel movement. These activities increase pressure in the portal venous system and increase the client's risk of variceal hemorrhage. A high-carbohydrate diet is encouraged as the diseased liver's ability to synthesize and store glucose is diminished. To decrease the risk of complications, the client must abstain from alcohol.

The nurse is creating a discharge teaching plan for a client who had a subtotal gastrectomy. The nurse should include what instructions about minimizing dumping syndrome? SATA. a. Drink fluids with meals b. Eat small, frequent meals c. Lie down for 1 hour after eating d. Chew food five times before swallowing e. Select foods that are low in fiber

b. Eat small, frequent meals c. Lie down for 1 hour after eating Small, frequent meals keep the volume within the stomach to a minimum at any one time, limiting dumping syndrome. Lying down delays emptying of the stomach contents, which will limit dumping syndrome. Fluids should be taken between meals to decrease the volume within the stomach at one time. Dumping syndrome occurs after eating because of the rapid movement of food into the jejunum without the usual digestive mixing in the stomach and processing in the duodenum. Chewing a set number of times before swallowing is not pertinent to solving this problem. High fiber, complex carbohydrates, moderate fats, and high protein in small, frequent meals are recommended to prevent dumping syndrome.

A client with a history of alcoholism and cirrhosis is admitted with severe dyspnea as a result of ascites. Which process that most likely caused the ascites should the nurse consider when planning care? a. Increased secretion of bile salts b. Increased pressure in the portal vein c. Increased interstitial osmotic pressure d. Increased production of serum albumin

b. Increased pressure in the portal vein The enlarged cirrhotic liver impinges on the portal system, causing increased hydrostatic pressure from increased pressure in the portal vein, resulting in ascites. Bile salts are not responsible for fluid shifts; increased serum bile results from biliary obstruction, not increased secretion of bile. Interstitial osmotic pressure is unchanged; decreased intravascular osmotic pressure accounts for fluid movement into interstitial spaces. The liver's production of serum albumin is decreased with cirrhosis of the liver.

A nurse is caring for a client with hepatic encephalopathy and ascites. Which elements are important to include in this client's diet? SATA. a. High fat b. Low sodium c. High vitamins d. Moderate protein e. Low carbohydrates

b. Low sodium c. High vitamins d. Moderate protein A low sodium intake controls fluid retention and edema and, consequently, ascites. Vitamins help to repair long-standing nutritional deficits associated with cirrhosis of the liver. A moderate-protein diet reduces formation of ammonia, which must be degraded by the liver. High fat intake is avoided because of related cardiovascular risks and the demand for bile that the liver may not be capable of meeting. High, not low, carbohydrate intake is necessary to meet energy requirements for tissue regeneration.

The nurse is providing care to a client with ascites secondary to liver failure. What is appropriate to include in this client's care? SATA. a. High protein diet b. Low sodium diet c. Daily abdominal girth measurements d. Encourage increased by mouth fluid intake e. Daily weights

b. Low sodium diet c. Daily abdominal girth measurements e. Daily weights In the client with liver failure and ascites, the liver has lost its ability to synthesize proteins. This leads to hypoalbuminemia and decreased oncotic pressure in the vessels. This decrease in oncotic pressure leads to fluids leaking out of the vessels and into the interstitial spaces and peritoneum, causing edema and ascites. A low sodium and low protein diet is recommended. A high protein diet will worsen the symptoms, and often these clients are on a fluid restriction. Taking daily weights is the most reliable indicator of fluid retention.

A client is admitted to the hospital with a diagnosis of Crohn disease. What is most important for the nurse to include in the teaching plan for this client? a. Controlling constipation b. Meeting nutritional needs c. Preventing increased weakness d. Anticipating a sexual alteration

b. Meeting nutritional needs To avoid gastrointestinal pain and diarrhea, these clients often refuse to eat and become malnourished. The consumption of a high-calorie, high-protein diet is advised. Diarrhea, not constipation, is a problem with Crohn disease. Preventing an increase in weakness is a secondary concern that results from malnutrition; correcting the malnutrition will increase strength. Anticipating a sexual alteration generally is not a problem with Crohn disease.

A client with Crohn disease is admitted to the hospital with a history of chronic, bloody diarrhea, weight loss, and signs of general malnutrition. The client has anemia, a low serum albumin level, and signs of negative nitrogen balance. The nurse concludes that the client's health status is related to what major deficiency? a. Ferrous sulfate b. Protein c. Ascorbic acid d. Linoleic acid

b. Protein Protein deficiency causes a low serum albumin level, which permits fluid shifts from the intravascular to the interstitial compartment, resulting in edema. Decreased protein also causes anemia; protein intake must be increased. Although a deficiency of ferrous sulfate will result in anemia, it will not cause the other adaptations. Ascorbic acid is unrelated to these adaptations. Linoleic acid is unrelated to these adaptations.

A client is diagnosed with calcium oxalate renal calculi. Which foods should the nurse teach the client to avoid? SATA. a. Milk b. Tea c. Liver d. Spinach e. Rhubarb

b. Tea d. Spinach e. Rhubarb Tea, rhubarb, and spinach are high in calcium oxalate. Limiting oxalate-rich foods limits oxalate absorption and the formation of calcium oxalate calculi. Milk is an acceptable calcium-rich protein and is avoided in calcium stones but not with oxalate stones. Liver is a purine-rich food that may be eaten.

A nurse is performing peritoneal dialysis for a client. Which action should the nurse take? a. Place the client in a side-lying position b. Warm the dialysate solution slightly before instillation c. Infuse the dialysate solution quickly over 5-10 minutes d. Withhold the routine medications until after the procedure.

b. Warm the dialysate solution slightly before instillation The infusion should be warmed to body temperature to decrease abdominal discomfort and promote dilation of peritoneal vessels. The side-lying position may restrict fluid inflow and prevent maximum urea clearance; the client should be placed in the semi-Fowler position. The infusion of dialysate solution should take approximately 10 to 20 minutes. Routine medications should not interfere with the infusion of dialysate solution.

A client is to have hemodialysis. What must the nurse do before this treatment? a. Obtain a urine specimen to evaluate kidney function b. Weigh the client to establish a baseline for later comparison c. Administer medications that are scheduled to be given within the next hour d. Explain that the peritoneum serves as a semipermeable membrane to remove wastes

b. Weigh the client to establish a baseline for later comparison A baseline weight must be obtained to be able to determine the net fluid loss from dialysis. Obtaining a urine specimen to evaluate kidney function is not necessary; clients with advanced kidney disease may not produce urine. Medications often are delayed until after dialysis to prevent them from being filtered into the dialysate. Explaining that the peritoneum serves as a semipermeable membrane to remove wastes applies to peritoneal dialysis, not hemodialysis.

The nurse reviews a medical record and is concerned that the client may develop hyperkalemia. Which disease increases the risk of hyperkalemia? a. Crohn Disease b. Cushing Disease c. End-Stage Renal Disease d. GERD

c. End-Stage Renal Disease One of the kidneys' functions is to eliminate potassium from the body; diseases of the kidneys often interfere with this function, and hyperkalemia may develop, necessitating dialysis. Clients with Crohn disease have diarrhea, resulting in potassium loss. Clients with Cushing disease will retain sodium and excrete potassium. Clients with gastroesophageal reflux disease are prone to vomiting that may lead to sodium and chloride loss with minimal loss of potassium

When preparing a client for a liver biopsy, what should the nurse instruct the client to do? a. Turn onto the left side after the procedure b. Breathe normally throughout the procedure c. Hold breath at the moment of the actual biopsy d. Bear down during the insertion of the biopsy needle

c. Hold breath at the moment of the actual biopsy Holding the breath at the moment of the actual biopsy ensures that the liver does not move as it normally does with regular respiratory excursions; minimizing movement reduces potential injury to the liver. Lying on the right side after the procedure applies pressure at the insertion site, preventing hemorrhage. Movement or breathing increases the danger of damage to the liver. Bearing down (Valsalva maneuver) during the insertion of the biopsy needle is unnecessary; holding the breath at the moment of the actual biopsy is all that is necessary to help minimize injury to the liver.

A client is admitted to the hospital with suspected liver disease, and a needle biopsy of the liver is performed. After the procedure, the nurse should maintain the client in what position? a. Supine b. Semi-fowler c. Right side-lying d. Dorsal recumbent

c. Right side-lying The liver is on the right side of the body; the right side-lying position provides pressure at the needle insertion site and promotes hemostasis. The supine position does not provide pressure over the liver or promote hemostasis. The semi-Fowler position does not provide pressure over the liver or promote hemostasis. The dorsal recumbent position keeps the liver uppermost, thus no pressure is exerted to promote hemostasis.

A client with end-stage kidney disease is receiving continuous ambulatory peritoneal dialysis. The nurse should monitor the client for which peritoneal dialysis complications? SATA. a. Pruritus b. Oliguria c. Tachycardia d. Cloudy outflow e. Abdominal pain

c. Tachycardia d. Cloudy outflow e. Abdominal pain Tachycardia can be caused by peritonitis[1][2], a complication of peritoneal dialysis; the heart rate increases to meet the metabolic demands associated with infection. Cloudy or opaque dialysate outflow (effluent) is the earliest sign of peritonitis; it is caused by the constituents associated with an infectious process. Abdominal pain is associated with peritonitis, a complication of peritoneal dialysis; pain results from peritoneal inflammation, abdominal distention, and involuntary muscle spasms. Severe itching (pruritus) is caused by metabolic waste products that are deposited in the skin; dialysis removes metabolic waste products, preventing this adaptation associated with kidney failure. The production of abnormally small amounts of urine (oliguria) is a sign of kidney failure, not a complication of peritoneal dialysis.

Before a transurethral resection of the prostate (TURP), a client asks about what to expect postoperatively. Which response by the nurse is most appropriate? a. "Your urine will be pink and free of clots." b. "You will have an abdominal incision and a dressing" c. "There will be an incision between your scrotum and rectum" d. "There will be an indwelling urinary catheter and a continuous bladder irrigation in place"

d. "There will be an indwelling urinary catheter and a continuous bladder irrigation in place" The presence of an indwelling urinary catheter and a continuous bladder irrigation are routine postoperative expectations after a TURP; they provide for hemostasis and urinary excretion. An abdominal incision and dressing are present with a suprapubic, not transurethral, prostatectomy. After a TURP, the client initially can expect hematuria and some blood clots; the continuous bladder irrigation keeps the bladder free of clots and the catheter patent. An incision between the scrotum and rectum is associated with a perineal prostatectomy, not a TURP.

A client complains of nocturia, bladder pain, urinary frequency, urgency, and dribbling at the end of urination. On physical examination, the nurse finds a smooth, firm, and enlarged prostate. The digital rectal examination report indicates enlargement of prostate tissue surrounding the urethra. Which condition does the nurse suspect in the client? a. Prostatitis b. Paraphimosis c. Prostate cancer d. Benign prostatic hyperplasia (BPH)

d. Benign prostatic hyperplasia (BPH) BPH is a benign enlargement of the prostate gland caused by excessive accumulation of dihydrotestosterone in the prostate cells, which can stimulate cell growth and overgrowth of prostate tissue surrounding the urethra. The clinical manifestations of BPH include nocturia, bladder pain, urinary frequency, urgency, and dribbling at the end of urination. Presence of fever, chills, back pain, and perineal pain, along with acute urinary symptoms such as dysuria, urinary frequency, urgency, and cloudy urine indicates prostatitis, which involves inflammation of the prostate gland. Tightness of the foreskin of the penis resulting in the inability to pull it forward from a retracted position and preventing normal return over the glans indicates paraphimosis. Symptoms of prostate cancer include dysuria, hesitancy, urinary urgency, and leaking or dribbling.

If a client on peritoneal dialysis develops symptoms of severe respiratory difficulty during the infusion of the dialysate solution, what should the nurse do? a. Increase the rate of infusion b. Auscultate the lungs for breath sounds c. Place the client in a low-Fowler position d. Drain the fluid from the peritoneal cavity

d. Drain the fluid from the peritoneal cavity Pressure from the fluid may cause upward displacement of the diaphragm; draining the solution reduces intraabdominal pressure, which allows the thoracic cavity to expand on inspiration. Additional fluid will aggravate the problem. Auscultation is important, but it does not alleviate the problem. The client should be placed in the semi-Fowler position for peritoneal dialysis; this allows inflow of fluid while not impinging on the thoracic cavity.

A nurse is caring for a client with a diagnosis of chronic kidney failure who has just been told by the primary healthcare provider that hemodialysis is necessary. Which clinical manifestation indicates the need for hemodialysis? a. Ascites b. Acidosis c. Hypertension d. Hyperkalemia

d. Hyperkalemia Protein breakdown liberates cellular potassium ions, leading to hyperkalemia, which can cause a cardiac dysrhythmia and standstill. The failure of the kidneys to maintain a balance of potassium is one of the main indications for dialysis. Ascites occurs in liver disease and is not an indication for dialysis. Dialysis is not the usual treatment for acidosis; usually this responds to administration of alkaline drugs. Dialysis is not a treatment for hypertension; this is usually controlled by antihypertensive medication and diet.

A nurse is assessing two clients. One client has ulcerative colitis, and the other client has Crohn disease. Which is more likely to be identified in the client with ulcerative colitis than in the client with Crohn disease? a. Inclusion of transmural involvement of the small bowel wall b. Higher occurrence of fistulas and abscesses from changes in the bowel wall c. Pathology beginning proximally with intermittent plaques found along the colon d. Involvement starting distally with rectal bleeding that spreads continuously up the colon

d. Involvement starting distally with rectal bleeding that spreads continuously up the colon Ulcerative colitis involvement starts distally with rectal bleeding that spreads continuously up the colon to the cecum. In ulcerative colitis, pathology usually is in the descending colon; in Crohn disease, it is primarily in the terminal ileum, cecum, and ascending colon. Ulcerative colitis, as the name implies, affects the colon, not the small intestine. Intermittent areas of pathology occur in Crohn. In ulcerative colitis, the pathology is in the inner layer and does not extend throughout the entire bowel wall; therefore, abscesses and fistulas are rare. Abscesses and fistulas occur more frequently in Crohn disease.

Which drug prescribed to a client with a urinary tract infection (UTI) turns urine reddish-orange in color? a. Amoxicillin b. Ciprofloxacin c. Nitrofurantoin d. Phenazopyridine

d. Phenazopyridine Phenazopyridine is a topical anesthetic that is used to treat pain or burning sensation associated with urination. It also imparts a characteristic orange or red color to urine. Amoxicillin is a penicillin form that could cause pseudomembranous colitis as a complication; it is not associated with reddish-orange colored urine. Ciprofloxacin is a quinolone antibiotic used for treating UTIs and can cause serious cardiac dysrhythmias and sunburns. It is not, however, responsible for reddish-orange colored urine. Nitrofurantoin is an antimicrobial medication prescribed for UTIs. This drug may affect the kidneys but is not associated with reddish-orange colored urine.

A client is a candidate for intubation as a result of bleeding esophageal varices. Which type of tube should the nurse anticipate will most likely be used to meet the needs of this client? a. Levin b. Salem sump c. Miller-Abbott d. Sengstaken-Blakemore

d. Sengstaken-Blakemore Sengstaken-Blakemore includes an esophageal balloon that exerts pressure on inflation, which retards hemorrhage. A Levin tube is used for gastric decompression, gavage, or lavage; it has one lumen. A Salem sump tube is used for gastric decompression; it has two lumens, one for decompression and one for an air vent. A Miller-Abbott tube is used for intestinal decompression.