Practice Questions

A nurse administers a medication to a client and the client is harmed due to a documented allergy. The provider who ordered the medication did not see that the client was allergic to the drug. Which statement is true regarding liability for the administration of the wrong medication? -The nurse is not responsible because the nurse was following the provider orders. -Only the nurse is responsible, because the nurse administered the medication -Only the physician is responsible, because they ordered the drug -Both the nurse and the physician are responsible for their respective actions

-Both the nurse and the physician are responsible for their respective actions

A nursing student asks the charge nurse about legal liability when performing clinical practice. Which statement regarding liability is true? -Students are not responsible for their acts of negligence resulting in patient injury. -Student nurses are held to the same standard of care that would be used to evaluate the actions of a registered nurse. -Hospitals are exempt from liability for student negligence if the student nurse is properly supervised by an instructor. -Most nursing programs carry group professional liability making student personal professional liability insurance unnecessary.

-Student nurses are held to the same standard of care that would be used to evaluate the actions of a registered nurse

As a newly hired nurse, you are required to read the state Nursing Practice Act as part of your training. Which topics are covered by this act? Select all that apply -Violations that may result in disciplinary action -Clinical procedures -Medication administration -Scope of practice -Delegation policies -Medicare reimbursement

-a, d

A nurse answers a client's call light and finds the patient on the floor by the bathroom door. After calling for assistance and examining the patient for injury, the nurse helps the patient back to bed, notifies the MD and then fills out an incident report. Which statements accurately describe incident reports? SELECT ALL THAT APPLY -An incident report is not filed because it may be used as disciplinary action against staff members. -An incident report is filed because it is a means of identifying risks. -An incident report is used for quality control. -The facility manager completes the incident report. -An incident report makes facts available if a case litigation occurs. -Filing of an incident report should be documented in the patient record.

-b, c, e

The client on a vent is being turned and is disconnected. What alarm will sound and why? A. Low pressure alarm B. Apnea C. High pressure alarm

A. Low pressure alarm

The client on a vent wakes up and bites down on the tube. What alarm do you expect hear and why? A. Low pressure alarm B. Apnea C. High pressure alarm

C. High pressure alarm

A client is admitted with viral hepatitis. What clinical manifestations may be present with viral hepatitis? (SATA) a. Fever b. Yellow sclera c. Dark urine d. Pruritus e. Abdominal pain

a, b, c, d, e,

A nurse cares for a client with ascites. Which assessment findings indicate the ascites is improving? (SATA) a. Decreased abdominal girth b. A change in ankle edema from 3+ pitting to 1+ pitting c. A decrease in weight d. An increase in heart rate over time e. Client reports breathing easier

a, b, c, e

A nurse instructs a client before an upper endoscopy. The nurse includes which instruction/s? (SATA) a. "A sedative is administered before the procedure" b. "You must not eat for at least 6 hours before" c. "Eating is allowed immediately after the procedure" d. "Do not take aspirin several days before" e. "A bowel preparation will be administered"

a, b, d

Which assessments made by the nurse could indicate the development of portal hypertension in a client with cirrhosis? (SATA) a. Hemorrhoids b. Bleeding gums c. Muscle wasting d. Splenomegaly e. Ascites

a, d, e

The nurse should evaluate the results of which laboratory tests while caring for a client who has cirrhosis? (SATA) a. Prothrombin time b. Urinalysis c. Serum lipase d. Serum troponin e. Serum albumin

a, e

1. Which is the priority nursing action while caring for a client with esophageal varices? a. Assessing for hemorrhage b. Controlling blood pressure c. Encouraging nutritional intake d. Teaching the client about varices

a. Assessing for hemorrhage

A nurse does an assessment on a client after an endoscopic retrograde cholangiopancreatography (ERCP). The nurse should report which finding to the health care provider? a. Distended firm abdomen b. Absence of a gag reflex c. Left-sided hip soreness d. Colicky abdominal pain

a. Distended firm abdomen

What is the nurse's priority while caring for a client with spontaneous bacterial peritonitis? a. Fluid and electrolyte b. Gastric irrigation c. Pain management d. Psychosocial issues

a. Fluid and electrolyte

The physician has determined that the client with hepatitis has contracted the infection from contaminated food. The nurse understands that this client is most likely experiencing what type of hepatitis? a. Hepatitis A b. Hepatitis B c. Hepatitis C d. Hepatitis D

a. Hepatitis A

The nurse is reviewing the laboratory results in a client with cirrhosis and notes the ammonia level is elevated. Which diet does the nurse anticipate to be prescribed? a. Low-protein diet b. High-protein diet c. Moderate-fat diet d. High-carbohydrate diet

a. Low-protein diet

A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which of the following? a. Malaise b. Dark stools c. Weight gain d. LUQ pain

a. Malaise

A 57 year old male with diagnosis of hepatitis A is admitted to the unit. He is also recovering from vascular surgery and has an open wound on his left lower leg. Which type of isolation is likely to be requested for this client? a. Universal standard precautions b. Droplet precautions c. Airborne precautions d. Contact precautions

a. Universal standard precautions

1. A 23-year-old client is admitted after being found unresponsive by paramedics. After starting an intravenous drip, you accidentally stick yourself with the same needle used for venipuncture. a. Based on the preceding information, what type of hepatitis would you most likely be exposed? i. Hepatitis A ii. Hepatitis B and C iii. Hepatitis D iv. No risk of hepatitis acquisition b. Initial post exposure prophylaxis treatment for you, assuming no prior exposure to hepatitis exists, would include administration of which of the following? i. Hepatitis B immune globulin (HBIG) and vaccine if not HbsAb-positive ii. Hepatitis A immune globulin (HAIG) iii. Interferon iv. Hepatitis A vaccine

b & a

A 61 year old male is admitted with diagnosis of upper GI bleeding. History is alcohol abuse and prior GI bleeding. His abdomen is distended and his liver is enlarged. He has no complaint of pain. The vomitus is bright red. a. Based on the preceding information, which condition is most likely to be present? i. Diverticuli ii. Esophageal varices iii. Duodenal ulcers iv. Colonic varices a. The physician elects to place an esophageal balloon (sengstaken-blakemore tube) to aid bleeding control. Which of the following is a potential complication of the esophageal balloon treatment? SATA) i. Tracheal occlusion ii. Esophageal necrosis iii. Esophageal rupture iv. Reversal of portal blood flow

b & a, b, c

What is the most important information for the nurse to teach a client who has been diagnosed with hepatitis C? (SATA) a. "this disease is spread by airborne transmission" b. "you should not drink alcohol if you have this diagnosis" c. "constipation is a common manifestation of this disorder" d. "rest, vitamins and diet will prompt remission" e. "hepatitis C can cause liver failure"

b, e

The client diagnosed with end-stage liver failure has an elevated ammonia level. The HCP prescribes lactulose. Which intervention should the nurse implement to determine the effectiveness of the medication? a. Monitor the client' intake and output. b. Assess the client's neurological status c. Measure the client's abdominal girth. d. Document the number of bowel movements

b. Assess the client's neurological status

A client is suspected of having hepatitis. Which diagnostic test result will assist in confirming this diagnosis? a. Elevated hemoglobin b. Elevated serum bilirubin c. Elevated blood urea nitrogen d. Decreased erythrocyte sedimentation rate

b. Elevated serum bilirubin

The client is admitted to the hospital with viral hepatitis, reporting of "no appetite" and "losing my taste for food." What instruction should the nurse give the client to provide adequate nutrition? a. Select foods high in fat b. Increase intake of fluids, including juices c. Eat a good dinner when anorexia is not severe d. Eat less often, preferably only three large meals a day

b. Increase intake of fluids, including juices

A nurse monitors a client with a bowel perforation for the presence of spontaneous bacterial peritonitis. The nurse watches for which manifestations? (SATA) a. Bradycardia b. Hypertension c. Abdominal pain d. Rigid abdomen e. Fever

c, d, e

The nurse is caring for a client who has ascites, and the healthcare provider prescribes spironolactone. When the client asks why this drug is being used, what is the best response by the nurse? a. "This drug will help increase the level of protein in your blood" b. "This drug will cause an increase in the amount of the hormone aldosterone your body produces" c. "This medication is a diuretic but does not make your kidneys excrete potassium" d. "This will help you excrete larger amounts of ammonia"

c. "This medication is a diuretic but does not make your kidneys excrete potassium"

The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence? a. Dorsiflex the client's foot b. Measure the abdominal girth c. Ask the client to extend their arms d. Instruct the client to learn forward

c. Ask the client to extend their arms

Asterixis is regarded as a sign of the development of which condition? a. Left ventricular failure b. Acute calcium disturbance c. Hepatic encephalopathy d. Seizures

c. Hepatic encephalopathy

Which diagnostic test will confirm a diagnosis of cirrhosis? a. Albumin level b. Bromsulphthalein dye excretion c. Liver biopsy d. Liver enzyme tests

c. Liver biopsy

A client is experiencing respiratory distress related to ascites. What treatment will help to relieve the distress? a. Placing the client in a supine position b. Endoscopy c. Protein restriction in the diet d. Administration of diuretics and sodium restriction

d. Administration of diuretics and sodium restriction

The client has undergone esophagogastroduodenescopy (EGD). The nurse places highest priority on which item as part of the client's plan of care? a. Monitor the temperature b. Monitoring for complaints of heartburn c. Giving warm gargles for a sore throat d. Assessing for the return of the gag reflex

d. Assessing for the return of the gag reflex

A nurse cares for a client with cirrhosis. While making menu selections, which does the nurse suggest the client should choose? a. Hamburger and garlic fries b. Ham sandwich and cottage cheese c. Canned soup and a cheese sandwich d. Chicken and plain potatoes

d. Chicken and plain potatoes

Transjugular intrahepatic portosystemic shunt (TIPS) works to decrease bleeding from esophageal varices by which mechanism? a. Improving vena caval blood flow b. Improving production of clotting factors c. Decreasing blood return to the liver d. Decreasing portal venous pressure

d. Decreasing portal venous pressure

A client prepares to undergo an upper endoscopy for the diagnosis of esophageal varices. What does the nurse tell the client about the diagnosis? a. The risk of heart failure is increased b. Esophageal varices are untreatable c. Esophageal varices rarely cause complications d. Esophageal varices occur with cirrhosis

d. Esophageal varices occur with cirrhosis

A client with cirrhosis reports that their skin always feels itchy. Which abnormality, associated with cirrhosis, results in itching? a. Prolonged prothrombin time b. Decreased protein level c. Increased aspartate aminotransferase (AST) d. Increased bilirubin level

d. Increased bilirubin level

The nurse prepares a client for an endoscopic retrograde cholangiopancreatography (ERCP) and provides education for the procedure. Which does the nurse teach the client? a. Deep sedation is not typically provided during the procedure b. The procedure is done externally using an ultrasound probe c. Fasting must be done for two hours before the procedure d. The client will not be able to drink anything right after the procedure

d. The client will not be able to drink anything right after the procedure