Liver cirrhosis. Esophageal varices
6. A patient with acute hepatitis B asks the nurse if treatment is available for the condition. The nurse explains to the patient that a. because no medication is available to treat acute viral hepatitis, adequate nutrition and rest are the most important treatments. b. lamivudine (Epivir) can decrease viral load and liver damage in patients with acute hepatitis B, but it must be taken for at least 1 year. c. patients with acute hepatitis B can be given HBIG to help reduce the symptoms. d. various antiviral drugs are available to treat acute hepatitis B, but serious side effects limit their use.
A Rationale: There are no drug therapies to treat acute hepatitis, although -interferon and nucleoside analogs (i.e., lamivudine) may be used to treat chronic hepatitis B. Immune globulin may be given within 24 hours after exposure to prevent hepatitis B, but it is not used to decrease symptoms for patients with acute hepatitis. Cognitive Level: Application Text Reference: p. 1093 Nursing Process: Implementation NCLEX: Physiological Integrity
20. The nurse identifies a nursing diagnosis of risk for impaired skin integrity for a patient with cirrhosis who has ascites and 4+ pitting edema of the feet and legs. An appropriate nursing intervention for this problem is to a. restrict dietary protein intake. b. arrange for a pressure-relieving mattress. c. perform passive range of motion QID. d. turn the patient every 4 hours.
B Rationale: The pressure-relieving mattress will decrease the risk for skin breakdown for this patient. Dietary protein intake may be increased in patients with ascites to improve oncotic pressure. Turning the patient every 4 hours will not be adequate to maintain skin integrity. Passive range of motion will not take pressure off areas like the sacrum that are vulnerable to breakdown. Cognitive Level: Application Text Reference: p. 1111 Nursing Process: Implementation NCLEX: Safe and Effective Care Environment
21. A portocaval shunt is considered for a patient with cirrhosis following an episode of bleeding esophageal varices. The nurse plans to teach the patient that this procedure a. is likely to improve the patient's life expectancy. b. will increase the risk of hepatic encephalopathy. c. will help to decrease the incidence of peritonitis. d. is a first-line therapy for portal hypertension.
B Rationale: The risk for hepatic encephalopathy increases after shunt procedures because blood bypasses the portal system and ammonia is diverted past the liver and into the systemic circulation. Life expectancy is not improved. The risk for peritonitis is not decreased by a surgical procedure, which will increase infection risk. First-line procedures for portal hypertension are medications such as diuretics and albumin. Cognitive Level: Application Text Reference: p. 1108 Nursing Process: Planning NCLEX: Physiological Integrity
37. A patient who was admitted with acute bleeding from esophageal varices asks the nurse the purpose for the ordered ranitidine (Zantac). Which response by the nurse is most appropriate? a. The medication will inhibit the development of gastric ulcers. b. The medication will prevent irritation to the esophageal varices. c. The medication will decrease nausea and anorexia. d. The medication will reduce the risk for aspiration.
B Rationale: The therapeutic action of H2 receptor blockers in patients with esophageal varices is to prevent irritation and bleeding from the varices caused by reflux of acid gastric contents. Although ranitidine does decrease the risk for peptic ulcers, reduce nausea, and help prevent aspiration pneumonia, these are not the primary purpose for H2 receptor blockade in this patient. Cognitive Level: Application Text Reference: p. 1108 Nursing Process: Implementation NCLEX: Physiological Integrity
13. A patient with cirrhosis who is being treated with spironolactone (Aldactone) and furosemide (Lasix) has a serum sodium level of 135 mEq/L (135 mmol/L) and serum potassium 3.2 mEq/L (3.2 mmol/L). Before notifying the health care provider, the nurse should a. administer the furosemide and withhold the spironolactone. b. give both drugs as scheduled. c. administer the spironolactone. d. withhold both drugs until talking with the health care provider.
C Rationale: Spironolactone is a potassium-sparing diuretic and will help to increase the patient's potassium level. The nurse does not need to talk with the doctor before giving the spironolactone, although the health care provider should be notified about the low potassium value. The furosemide will further decrease the patient's potassium level and should be held until the nurse talks with the health care provider. Cognitive Level: Application Text Reference: p. 1107 Nursing Process: Implementation NCLEX: Physiological Integrity
19. A patient with severe cirrhosis has an episode of bleeding esophageal varices. To detect possible complications of the bleeding episode, it is most important for the nurse to monitor a. prothrombin time. b. bilirubin levels. c. ammonia levels. d. potassium levels.
C Rationale: The blood in the GI tract will be absorbed as protein and may result in an increase in ammonia level since the liver cannot metabolize protein well. The prothrombin time, bilirubin, and potassium levels should also be monitored, but these will not be affected by the bleeding episode. Cognitive Level: Application Text Reference: p. 1113 Nursing Process: Assessment NCLEX: Physiological Integrity
41. When the nurse is caring for a patient with acute pancreatitis, which of these assessment data should be of most concern? a. Absent bowel sounds b. Abdominal tenderness c. Left upper quadrant pain d. Palpable abdominal mass
D Rationale: A palpable abdominal mass may indicate the presence of a pancreatic abscess, which will require rapid surgical drainage to prevent sepsis. Absent bowel sounds, abdominal tenderness, and left upper quadrant pain are common in acute pancreatitis and do not require rapid action to prevent further complications. Cognitive Level: Application Text Reference: p. 1119 Nursing Process: Assessment NCLEX: Physiological Integrity
2. A patient contracts hepatitis from contaminated food. During the acute (icteric) phase of the patient's illness, the nurse would expect serologic testing to reveal a. hepatitis B surface antigen (HBsAg). b. anti-hepatitis B core immunoglobulin M (anti-HBc IgM). c. anti-hepatitis A virus immunoglobulin G (anti-HAV IgG). d. anti-hepatitis A virus immunoglobulin M (anti-HAV IgM).
D Rationale: Hepatitis A is transmitted through the oral-fecal route, and antibody to HAV IgM appears during the acute phase of hepatitis A. The patient would not have antigen or antibodies for hepatitis B. Anti-HAV IgG would indicate past infection and lifelong immunity. Cognitive Level: Application Text Reference: p. 1089 Nursing Process: Assessment NCLEX: Physiological Integrity
38. Which of these nursing actions included in the plan of care for a patient with cirrhosis can the nurse delegate to a nursing assistant? a. Assessing the patient for jaundice b. Assisting the patient in choosing the diet c. Palpating the abdomen for distention d. Providing oral hygiene before meals
D Rationale: Providing oral hygiene is included in the education and scope of practice of nursing assistants. Assessments and assisting patients to choose therapeutic diets are nursing actions that require higher-level nursing education and scope of practice and would be delegated to LPNs/LVNs or RNs. Cognitive Level: Application Text Reference: pp. 1110-1115 Nursing Process: Planning NCLEX: Safe and Effective Care Environment
35. Which data obtained by the nurse during the assessment of a patient with cirrhosis will be of most concern? a. The patient's skin has multiple spider-shaped blood vessels on the abdomen. b. The patient has ascites and a 2-kg weight gain from the previous day. c. The patient complains of right upper-quadrant pain with abdominal palpation. d. The patient's hands flap back and forth when the arms are extended.
D Rationale: The asterixis indicates that the patient has hepatic encephalopathy, and hepatic coma may occur. The spider angiomas and right upper-quadrant abdominal pain are not unusual for the patient with cirrhosis and do not require a change in treatment. The ascites and weight gain do indicate the need for treatment but not as urgently as the changes in neurologic status. Cognitive Level: Application Text Reference: p. 1106 Nursing Process: Assessment NCLEX: Physiological Integrity
15. When lactulose (Cephulac) 30 ml QID is ordered for a patient with advanced cirrhosis, the patient complains that it causes diarrhea. The nurse explains to the patient that it is still important to take the drug because the lactulose will a. promote fluid loss. b. prevent constipation. c. prevent gastrointestinal (GI) bleeding. d. improve nervous system function.
D Rationale: The purpose for lactulose in the patient with cirrhosis is to lower ammonia levels and prevent encephalopathy. Although the medication may promote fluid loss through the stool, prevent constipation, and prevent bearing down during bowel movements (which could lead to esophageal bleeding), the medication is not ordered for these purposes for this patient. Cognitive Level: Application Text Reference: p. 1109 Nursing Process: Implementation NCLEX: Physiological Integrity
1. A health care provider who has not been immunized for hepatitis B is exposed to the hepatitis B virus (HBV) through a needle stick from an infected patient. The infection control nurse informs the individual that treatment for the exposure should include a. baseline hepatitis B antibody testing now and in 2 months. b. active immunization with hepatitis B vaccine. c. hepatitis B immune globulin (HBIG) injection. d. both the hepatitis B vaccine and HBIG injection.
D Rationale: The recommended treatment for exposure to hepatitis B in unvaccinated individuals is to receive both HBIG and the hepatitis B vaccine, which would provide temporary passive immunity and promote active immunity. Antibody testing may also be done, but this would not provide protection from the exposure. Cognitive Level: Application Text Reference: p. 1096 Nursing Process: Implementation NCLEX: Physiological Integrity
30. When the nurse is caring for the patient with pancreatic cancer, which nursing diagnosis is a priority? a. Chronic pain related to tumor pressure on abdominal structures b. Imbalanced nutrition: less than required related to anorexia c. Impaired skin integrity related to itching secondary to jaundice d. Grieving related to potentially terminal diagnosis
A Rationale: All of these nursing diagnoses are appropriate for a patient with pancreatic cancer, but treating the patient's pain is the priority because the patient will be unable to meet outcomes for the other nursing diagnoses unless the pain is controlled. Cognitive Level: Application Text Reference: pp. 1122, 1126 Nursing Process: Diagnosis NCLEX: Physiological Integrity
14. When assessing the neurologic status of a patient with a diagnosis of hepatic encephalopathy, the nurse asks the patient to a. stand on one foot. b. ambulate with the eyes closed. c. extend both arms. d. perform the Valsalva maneuver.
C Rationale: Extending the arms allows the nurse to check for asterixis, a classic sign of hepatic encephalopathy. The other tests might also be done as part of the neurologic assessment but would not be diagnostic for hepatic encephalopathy. Cognitive Level: Comprehension Text Reference: p. 1106 Nursing Process: Assessment NCLEX: Physiological Integrity
4. A patient in the outpatient clinic has positive serologic testing for anti-HCV. Which action by the nurse is appropriate? a. Schedule the patient for HCV genotype testing. b. Teach the patient that the HCV will resolve in 2 to 4 months. c. Administer immune globulin and the HCV vaccine. d. Instruct the patient on self-administration of -interferon.
A Rationale: Genotyping of HCV has an important role in managing treatment and is done before drug therapy with -interferon or other medications is started. HCV has a high percentage of conversion to the chronic state so the nurse should not teach the patient that the HCV will resolve in 2 to 4 months. Immune globulin or vaccine is not available for HCV. Cognitive Level: Application Text Reference: p. 1092 Nursing Process: Planning NCLEX: Physiological Integrity
27. The nurse identifies the collaborative problem of potential complication: electrolyte imbalance for a patient with severe acute pancreatitis. Assessment findings that alert the nurse to electrolyte imbalances associated with acute pancreatitis include a. muscle twitching and finger numbness. b. paralytic ileus and abdominal distention. c. hypotension. d. hyperglycemia.
A Rationale: Muscle twitching and finger numbness indicate hypocalcemia, a potential complication of acute pancreatitis. The other data indicate other complications of acute pancreatitis but are not indicators of electrolyte imbalance. Cognitive Level: Analysis Text Reference: p. 1122 Nursing Process: Assessment NCLEX: Physiological Integrity
32. When caring for a patient following an incisional cholecystectomy for cholelithiasis, the nurse places the highest priority on assisting the patient to a. turn, cough, and deep breathe every 2 hours. b. choose low-fat foods from the menu. c. perform leg exercises hourly while awake. d. ambulate the evening of the operative day.
A Rationale: Postoperative nursing care after a cholecystectomy focuses on prevention of respiratory complications because the surgical incision is high in the abdomen and impairs coughing and deep breathing. The other nursing actions are also important to implement but are not as high a priority as ensuring adequate ventilation. Cognitive Level: Application Text Reference: p. 1131 Nursing Process: Planning NCLEX: Physiological Integrity
5. A homeless patient with severe anorexia, fatigue, jaundice, and hepatomegaly is diagnosed with viral hepatitis and has just been admitted to the hospital. In planning care for the patient, the nurse assigns the highest priority to the patient outcome of a. maintaining adequate nutrition. b. establishing a stable home environment. c. increasing activity level. d. identifying the source of exposure to hepatitis.
A Rationale: The highest priority outcome is to maintain nutrition because adequate nutrition is needed for hepatocyte regeneration. Finding a home for the patient and identifying the source of the infection would be appropriate activities, but they do not have as high a priority as having adequate nutrition. Although the patient's activity level will be gradually increased, rest is indicated during the acute phase of hepatitis. Cognitive Level: Application Text Reference: p. 1097 Nursing Process: Planning NCLEX: Physiological Integrity
22. A patient with cancer of the liver has severe ascites, and the health care provider plans a paracentesis to relieve the fluid pressure on the diaphragm. To prepare the patient for the procedure, the nurse a. asks the patient to empty the bladder. b. positions the patient on the right side. c. obtains informed consent for the procedure. d. assists the patient to lie flat in bed.
A Rationale: The patient should empty the bladder to decrease the risk of bladder perforation during the procedure. The patient would be positioned in Fowler's position and would not be able to lie flat without compromising breathing. The health care provider is responsible for obtaining informed consent. Cognitive Level: Application Text Reference: p. 1111 Nursing Process: Implementation NCLEX: Safe and Effective Care Environment
29. The health care provider prescribes pancreatin (Viokase) for a patient with chronic pancreatitis. The nurse teaches the patient that the drug is considered effective if the patient experiences a. normal-appearing stools. b. decreased jaundice. c. improved appetite. d. reduced abdominal pain.
A Rationale: The patient's steatorrhea should improve if the pancreatic enzymes are effective. The pancreatin will not decrease jaundice, improve appetite, or reduce abdominal pain. Cognitive Level: Application Text Reference: p. 1125 Nursing Process: Evaluation NCLEX: Physiological Integrity
24. A patient hospitalized with possible acute pancreatitis has severe abdominal pain and nausea and vomiting. The nurse would expect the diagnosis to be confirmed with laboratory testing that reveals elevated serum a. calcium. b. bilirubin. c. amylase. d. potassium.
C Rationale: Amylase is elevated early in acute pancreatitis. Changes in bilirubin, calcium, and potassium levels are not diagnostic for pancreatitis. Cognitive Level: Comprehension Text Reference: pp. 1120-1121 Nursing Process: Assessment NCLEX: Physiological Integrity
28. When obtaining a health history from a patient with acute pancreatitis, the nurse asks the patient specifically about a history of a. cigarette smoking. b. alcohol use. c. diabetes mellitus. d. high-protein diet.
B Rationale: Alcohol use is one of the most common risk factors for pancreatitis in the United States. Cigarette smoking, diabetes, and high-protein diets are not risk factors. Cognitive Level: Comprehension Text Reference: p. 1118 Nursing Process: Assessment NCLEX: Health Promotion and Maintenance
8. When taking a health history for a new patient, which information given by the patient would indicate that screening for hepatitis C is appropriate? a. The patient had a blood transfusion after surgery in 1998. b. The patient reports a one-time use of IV drugs 20 years ago. c. The patient eats frequent meals in fast-food restaurants. d. The patient recently traveled to an undeveloped country.
B Rationale: Any patient with a history of IV drug use should be tested for hepatitis C. Blood transfusions given after 1992, when an antibody test for hepatitis C became available, do not pose a risk for hepatitis C. Hepatitis C is not spread by the oral-fecal route and therefore is not caused by contaminated food or by traveling in underdeveloped countries. Cognitive Level: Application Text Reference: pp. 1090, 1098 Nursing Process: Assessment NCLEX: Health Promotion and Maintenance
17. A patient with cirrhosis has a massive hemorrhage from esophageal varices. In planning care for the patient, the nurse gives the highest priority to the goal of a. controlling bleeding. b. maintenance of the airway. c. maintenance of fluid volume. d. relieving the patient's anxiety.
B Rationale: Maintaining gas exchange has the highest priority because oxygenation is essential for life. The airway is compromised by the bleeding in the esophagus and aspiration easily occurs. The other goals would also be important for this patient, but they are not as high a priority as airway maintenance. Cognitive Level: Application Text Reference: pp. 1107, 1114 Nursing Process: Planning NCLEX: Physiological Integrity
40. A patient with acute pancreatitis has a nasogastric (NG) tube to suction and is NPO. Which information obtained by the nurse is the best indicator that these therapies have been effective? a. Bowel sounds are present. b. Abdominal pain is decreased. c. Electrolyte levels are normal. d. Grey Turner sign resolves.
B Rationale: NG suction and NPO status will decrease the release of pancreatic enzymes into the pancreas and decrease pain. Although bowel sounds may be hypotonic with acute pancreatitis, the presence of bowel sounds does not indicate that treatment with NG suction and NPO status have been effective. Electrolyte levels will be abnormal with NG suction and must be replaced by appropriate IV infusion. Although Grey Turner sign will eventually resolve, it would not be appropriate to wait for this occur to determine whether treatment was effective. Cognitive Level: Application Text Reference: p. 1120 Nursing Process: Evaluation NCLEX: Physiological Integrity
25. In planning care for a patient with acute pancreatitis, the nurse assigns the highest priority to the patient outcome of a. developing no acute complications. b. maintenance of normal respiratory function. c. expressing satisfaction with pain control. d. having adequate fluid and electrolyte balance.
B Rationale: Respiratory failure can occur as a complication of acute pancreatitis, and maintenance of adequate respiratory function is the priority goal. The other outcomes would also be appropriate for the patient. Cognitive Level: Application Text Reference: p. 1122 Nursing Process: Planning NCLEX: Physiological Integrity
12. A 32-year-old patient has early alcoholic cirrhosis diagnosed by a liver biopsy. When planning patient teaching, the priority information for the nurse to include is the need for a. vitamin B supplements. b. abstinence from alcohol. c. maintenance of a nutritious diet. d. long-term, low-dose corticosteroids.
B Rationale: The disease progression can be stopped or reversed by alcohol abstinence. The other interventions may be used when cirrhosis becomes more severe to decrease symptoms or complications, but the priority for this patient is to stop the progression of the disease. Cognitive Level: Application Text Reference: pp. 1114-1115 Nursing Process: Planning NCLEX: Physiological Integrity
11. A patient with cirrhosis has 4+ pitting edema of the feet and legs and massive ascites. The data indicate that it is most important for the nurse to monitor the patient's a. temperature. b. albumin level. c. hemoglobin. d. activity level.
B Rationale: The low oncotic pressure caused by hypoalbuminemia is a major pathophysiologic factor in the development of ascites and edema. The other parameters should also be monitored, but they are not contributing factors to the patient's current symptoms. Cognitive Level: Application Text Reference: p. 1104 Nursing Process: Assessment NCLEX: Physiological Integrity
16. A patient who is admitted with acute hepatic encephalopathy and ascites receives instructions about appropriate diet. The nurse determines that the teaching has been effective when the patient's choice of foods from the menu includes a. an omelet with cheese and mushrooms and milk. b. pancakes with butter and honey and orange juice. c. baked beans with ham, cornbread, potatoes, and coffee. d. baked chicken with french-fries, low-fiber bread, and tea.
B Rationale: The patient with acute hepatic encephalopathy is placed on a low-protein diet to decrease ammonia levels. The other choices are all higher in protein and would not be as appropriate for this patient. In addition, the patient's ascites indicate that a low-sodium diet is needed and the other choices are all high in sodium. Cognitive Level: Application Text Reference: p. 1110 Nursing Process: Evaluation NCLEX: Physiological Integrity
9. A patient is admitted with an abrupt onset of jaundice, nausea and vomiting, hepatomegaly, and abnormal liver function studies. Serologic testing is negative for viral causes of hepatitis. Which question by the nurse is most appropriate? a. "Have you been around anyone with jaundice?" b. "Do you use any prescription or over-the-counter (OTC) drugs?" c. "Are you taking corticosteroids for any reason?" d. "Is there any history of IV drug use?"
B Rationale: The patient's symptoms, lack of antibodies for hepatitis, and the abrupt onset of symptoms suggest toxic hepatitis, which can be caused by commonly used OTC drugs such as acetaminophen (Tylenol). Exposure to a jaundiced individual and a history of IV drug use are risk factors for viral hepatitis. Corticosteroid use does not cause the symptoms listed. Cognitive Level: Application Text Reference: pp. 1099-1100 Nursing Process: Assessment NCLEX: Health Promotion and Maintenance
3. During evaluation of a patient at an outpatient clinic, the nurse determines that administration of hepatitis B vaccine has been effective when a specimen of the patient's blood reveals a. HBsAg. b. anti-HBs. c. anti-HBc IgM. d. anti-HBc IgG
B Rationale: The presence of surface antibody to HBV (anti-HBs) is a marker of a positive response to the vaccine. The other laboratory values indicate current infection with HBV. Cognitive Level: Application Text Reference: pp. 1089, 1093 Nursing Process: Evaluation NCLEX: Health Promotion and Maintenance
7. Combination therapy of -interferon and ribavirin (Rebetol) is being used to treat hepatitis C in a patient with human immunodeficiency virus (HIV). The nurse will plan to monitor a. blood glucose. b. lymphocyte count. c. potassium level. d. serum creatinine.
B Rationale: Therapy with ribavirin and -interferon may decrease lymphocyte counts. The other laboratory values should not be changed by the drug therapy. Cognitive Level: Application Text Reference: p. 1095 Nursing Process: Planning NCLEX: Physiological Integrity
36. A patient with severe cirrhosis has a new prescription for propranolol (Inderal). The nurse will teach the patient that the medication is ordered to a. decrease systemic BP. b. prevent the development of ischemia. c. lower the risk for bleeding varices. d. reduce fluid retention and edema.
C Rationale: -blockers have been shown to decrease the risk for bleeding in esophageal varices. Although propranolol will decrease BP and prevent cardiac ischemia, these are not the purposes for this patient. Propranolol will not decrease fluid retention or edema. Cognitive Level: Application Text Reference: p. 1107 Nursing Process: Implementation NCLEX: Physiological Integrity
34. When providing discharge instructions to a patient following a laparoscopic cholecystectomy at an outpatient surgical center, the nurse recognizes that teaching has been effective when the patient states, a. "I should plan to limit my activities and not return to work for 4 to 6 weeks." b. "I can expect some reddish yellow drainage from the incisions for a few days." c. "I can remove the bandages on my incisions tomorrow and take a shower." d. "I will always need to maintain a low-fat diet since I no longer have a gallbladder."
C Rationale: After a laparoscopic cholecystectomy, the patient will have Band-Aids in place over the incisions; patients are discharged the same (or next) day and have few restrictions on activities of daily living. Drainage from the incisions would be abnormal, and the patient should be instructed to call the health care provider if this occurs. A low-fat diet may be recommended for a few weeks after surgery but will not be a life-long requirement. Cognitive Level: Application Text Reference: p. 1132 Nursing Process: Evaluation NCLEX: Physiological Integrity
10. When teaching a patient recovering from hepatitis B about management of the illness, the nurse determines that additional teaching is needed when the patient says a. "I should not drink alcohol for at least the next year." b. "My family members should be tested for hepatitis B." c. "When the jaundice is gone, I have recovered from my illness and the infection is cured." d. "Until my tests for the virus are negative, I should use a condom for sexual intercourse."
C Rationale: After the acute (icteric) phase, there is a convalescent phase lasting several months. The other patient statements are correct and indicate that teaching has been effective. Cognitive Level: Application Text Reference: pp. 1091, 1098 Nursing Process: Evaluation NCLEX: Health Promotion and Maintenance
26. A patient with acute pancreatitis has a nasogastric (NG) tube to suction and is NPO. The nurse explains to the patient that the major purpose of this treatment is a. control of fluid and electrolyte imbalance. b. relief from nausea and vomiting. c. reduction of pancreatic enzymes. d. removal of the precipitating irritants.
C Rationale: Pancreatic enzymes are released when the patient eats. NG suction and NPO status decrease the release of these enzymes. Fluid and electrolyte imbalances will be caused by NG suction and require that the patient receive IV fluids to prevent this. The patient's nausea and vomiting may decrease, but this is not the major reason for these treatments. The pancreatic enzymes that precipitate the pancreatitis are not removed by NG suction. Cognitive Level: Application Text Reference: p. 1120 Nursing Process: Implementation NCLEX: Physiological Integrity
31. A patient who is admitted to the hospital with a sudden onset of severe right upper-quadrant pain that radiates to the right shoulder is diagnosed with cholecystitis. Which assessment information will be most important for the nurse to report to the health care provider? a. The patient has an increase in pain after eating. b. The patient needs 4 mg of morphine for pain relief. c. The patient's stools are clay colored. d. The patient's urine is bright yellow.
C Rationale: The clay-colored stools indicate biliary obstruction, which requires rapid intervention to resolve. The other data are not unusual for a patient with this diagnosis, although the nurse would also report the other assessment information to the health care provider. Cognitive Level: Application Text Reference: p. 1128 Nursing Process: Assessment NCLEX: Physiological Integrity
23. A patient with end-stage liver disease who is to undergo a liver transplant tells the nurse, "I have a friend who has already rejected two kidney transplants. I am concerned that I will reject this liver." The nurse's best response to the patient is a. "Perhaps your friend did not have a good tissue match with the kidney transplants." b. "You would not be scheduled for a transplant if there was a concern about rejection." c. "The problem of rejection is not as common in liver transplants as in kidney transplants." d. "It is easier to get a good tissue match with liver transplants than with kidney transplants."
C Rationale: The liver is less susceptible to rejection than the kidney. The other statements are inaccurate or will not decrease the patient's anxiety. Cognitive Level: Application Text Reference: p. 1118 Nursing Process: Implementation NCLEX: Physiological Integrity
18. During treatment of a patient with a Minnesota balloon tamponade for bleeding esophageal varices, which nursing action will be included in the plan of care? a. Encourage the patient to cough and deep breathe. b. Insert the tube and verify its position q4hr. c. Monitor the patient for shortness of breath. d. Deflate the gastric balloon q8-12hr.
C Rationale: The most common complication of balloon tamponade is aspiration pneumonia. In addition, if the gastric balloon ruptures, the esophageal balloon may slip upward and occlude the airway. Coughing increases the pressure on the varices and increases the risk for bleeding. The health care provider inserts the tube and verifies the position. The esophageal balloon is deflated every 8 to 12 hours to avoid necrosis, but if the gastric balloon is deflated, the esophageal balloon may occlude the airway. Cognitive Level: Application Text Reference: p. 1114 Nursing Process: Implementation NCLEX: Physiological Integrity
39. When taking the BP of a patient with severe acute pancreatitis, the nurse notices carpal spasm of the patient's hand. Which action should the nurse take next? a. Notify the health care provider immediately. b. Retake the patient's blood pressure. c. Check the calcium level on the chart. d. Ask the patient about any arm pain.
C Rationale: The patient with acute pancreatitis is at risk for hypocalcemia, and the assessment data indicate a positive Trousseau's sign. The health care provider should be notified after the nurse learns the patient's calcium level. There is no indication that the patient needs to have the BP rechecked or that there is any arm pain. Cognitive Level: Analysis Text Reference: p. 1122 Nursing Process: Assessment NCLEX: Physiological Integrity
33. An appropriate collaborative problem for the nurse to include in the care plan for a patient with cholelithiasis and obstruction of the common bile duct is a. potential complication: bleeding. b. potential complication: gastritis. c. potential complication: thromboembolism. d. potential complication: biliary cirrhosis.
D Rationale: With obstruction of the common bile duct, bile will back up into the liver and damage liver cells. Bleeding, gastritis, and thromboembolism are not common complications of biliary obstruction. Cognitive Level: Comprehension Text Reference: pp. 1128-1129 Nursing Process: Planning NCLEX: Physiological Integrity
