Test 1

Which assessment data should the nurse expect to find for the client who had an upper gastrointestinal (UGI) series? 1. Chalky white stools. 2. Increased heart rate. 3. A firm hard abdomen. 4. Hyperactive bowel sounds.

**1. A UGI requires the client to swallow barium, which passes through the intestines, making the stools a chalky white color. TEST-TAKING HINTS: Answer option "2" could be eliminated because it does not have anything to do with the gastrointestinal system. A firm hard abdomen is very seldom ever expected, so "3" could be eliminated.

The client two (2) hours postoperative laparoscopic cholecystectomy is complaining of severe pain in the right shoulder. Which nursing intervention should the nurse imple- ment? 1. Apply a heating pad to the abdomen for 15 to 20 minutes. 2. Administer morphine sulfate intravenously after diluting with saline. 3. Contact the surgeon for an order to x-ray the right shoulder. 4. Apply a sling to the right arm that was injured in surgery.

**1. A heating pad should be applied for 15 to 20 minutes to assist the migration of the CO2 used to insufflate the abdomen. TEST-TAKING HINT: The test taker must understand laparoscopic surgery to be able to answer this question. Option "4" could be eliminated because of the "injured during surgery" phrase that is making an assumption.

The client has end-stage liver failure secondary to alcoholic cirrhosis. Which compli- cation indicates the client is at risk for developing hepatic encephalopathy? 1. Gastrointestinal bleeding. 2. Hypoalbuminemia. 3. Splenomegaly. 4. Hyperaldosteronism.

**1. Blood in the intestinal tract is digested as a protein, which increases serum ammonia levels and increases the risk of developing hepatic encephalopathy. TEST-TAKING HINT: Some questions require the test taker to have specific knowledge to be able to identify the correct answer. This is one (1) of these questions.

The client diagnosed with liver failure is experiencing pruritus secondary to severe jaundice. Which action by the unlicensed assistant warrants intervention by the primary nurse? 1. Assisting the client to take a hot soapy shower. 2. Applying an emollient to the client's legs and back. 3. Putting mittens on both hands of the client. 4. Patting the client's skin dry with a clean towel.

**1. Hot water increases pruritus, and soap will cause dry skin, which increases pruritus; therefore, the nurse should discuss this with the assistant. TEST-TAKING HINT: A concept that is accepted for most clients during A.M. care is not to use hot water because it causes dilatation of vessels, which may cause orthostatic hypotension. This is not the rationale for not using hot water with a client who has pruritus, but sometimes the test taker can apply broad concepts when answering questions.

The client is in end-stage liver failure and has vitamin K deficiency. Which interventions should the nurse implement? Select all that apply. 1. Avoid rectal temperatures. 2. Use only a soft toothbrush. 3. Monitor the platelet count. 4. Use small-gauge needles. 5. Assess for asterixis.

**1. Vitamin K deficiency causes impaired coagulation; therefore rectal thermometers should be avoided to prevent bleeding. **2. Soft toothbrushes will help prevent bleeding of the gums. **3. Platelet count, PTT/PT, and INR should be monitored to assess coagulation status. **4. Injections should be avoided, if at all possible, because the client is unable to clot, but if they are absolutely necessarily, the nurse should use small-gauge needles. TEST-TAKING HINT: The test taker must know the function of specific vitamins. Vitamin K is responsible for blood clotting. This is an alternate-type question, which requires the test taker to select all interventions that apply; the test taker should select interventions that address bleeding.

The nurse is teaching a client recovering from a laparoscopic cholecystectomy. Which statement indicates the discharge teaching was effective? 1. "I will take my lipid-lowering medicine at the same time each night." 2. "I may experience some discomfort when I eat a high-fat meal." 3. "I need someone to stay with me for about a week after surgery." 4. "I should not splint my incision when I deep breathe and cough."

**2. After removal of the gallbladder, some clients experience abdominal discomfort when eating fatty foods. TEST-TAKING HINT: When answering questions that state "teaching is effective," the test taker should look for the correct information. Basic concepts should help the test taker answer questions and, because pain often occurs after surgeries, answer option "2" would probably be a correct answer if the test taker had no idea which option is correct.

Which assessment data indicate that the client recovering from an open cholecystectomy requires pain medication? 1. The client's pulse is 65 beats per minute. 2. The client has shallow respirations. 3. The client's bowel sounds are 20 per minute. 4. The client uses a pillow to splint when coughing

**2. Clients having abdominal pain frequently have shallow respirations. When assessing clients for pain, the nurse should discuss pain medication with any client who has shallow respirations. TEST-TAKING HINT: The stem asks which data would warrant pain medication. Therefore the test taker should select an answer that is not expected or is not normal for clients who are postoperative abdominal surgery.

The nurse identifies the client problem as "excess fluid volume" for the client in liver failure. Which short-term goal would be most appropriate for this problem? 1. The client will not gain more that two (2) kg a day. 2. The client will have no increase in abdominal girth. 3. The client's vital signs will remain within normal limits (WNL). 4. The client will receive a low-sodium diet.

**2. Excess fluid volume could be secondary to portal hypertension. Therefore, no increase in abdominal girth would be an appropriate short-term goal, indicating no excess of fluid volume. TEST-TAKING HINT: Remember that goals evaluate the interventions; therefore option "4" could be eliminated as the correct answer because it is an intervention, not a goal. Short-term weight fluctuations tend to reflect fluid balance, and any weight gain in 24 hours indicates retention of fluid, which is not an appropriate goal.

The client is admitted with end-stage liver failure and is prescribed the laxative lactu- lose (Chronulac). Which statement indicates the client needs more teaching concern- ing this medication? 1. "I should have two to three soft stools a day." 2. "I must check my ammonia level daily." 3. "If I have diarrhea, I will call my doctor." 4. "I should check my stool for any blood."

**2. There is no instrument that can be used at home to test daily ammonia levels. The ammonia level is a serum level that requires venipuncture and laboratory diagnostic equipment. TEST-TAKING HINT: This is an "except" question. The test taker must realize that three (3) options indicate an understanding of the teaching. If the test taker does not know the answer, notice that all the options except "2" have something to do with stool, and laxative affects the stool.

The client diagnosed with end-stage liver failure is admitted to the medical unit diag- nosed with esophageal bleeding. The HCP inserts and inflates a triple-lumen nasogas- tric tube (Sengstaken-Blakemore). Which nursing action should the nurse implement for this treatment? 1. Assess the gag reflex every shift. 2. Stay with the client at all times. 3. Administer the laxative lactulose (Chronulac). 4. Monitor the client's ammonia level.

**2. While the balloons are inflated, the client must not be left unattended in case they become dislodged and occlude the airway. This is a safety issue. TEST-TAKING HINT: In most cases, the test taker should not select an option that contains the word "all," but in some instances, it may be the correct answer. Although the ammonia level is elevated in liver failure, the test taker must be clear as to what the question is asking. "Inflate" is the key to answering the question correctly.

The client is in end-stage liver failure. Which gastrointestinal assessment data would the nurse expect to find when assessing the client? 1. Hypoalbuminemia and muscle wasting. 2. Oligomenorrhea and decreased body hair. 3. Clay-colored stools and hemorrhoids. 4. Dyspnea and caput medusae.

**3. Clay-colored stools and hemorrhoids are gastrointestinal effects of liver failure. TEST-TAKING HINT: The adjective "gastrointestinal" is the key word that guides the test taker to select the correct answer. The test taker must rule out options that do not involve gastrointestinal symptoms. Although liver failure affects every body system, the question asks for a gastrointestinal effect.

The client has had a liver biopsy. Which post-procedure intervention should the nurse implement? 1. Instruct the client to void immediately. 2. Keep the client NPO for eight (8) hours. 3. Place the client on the right side. 4. Monitor blood urea nitrogen (BUN) and creatinine level.

**3. Direct pressure is applied to the site, and then the client is placed on the right side to maintain site pressure. TEST-TAKING HINT: The adjective "post-proce- dure" should help the test taker rule out option "1." Knowing the anatomical position of the liver should help the test taker select "3" as the correct answer. The test taker must know laboratory data for each organ, which would help rule out "4" as a possible correct answer.

The client diagnosed with end-stage renal failure with ascites is scheduled for a para- centesis. Which client teaching should the nurse discuss with the client? 1. Explain that the procedure will be done in the operating room. 2. Instruct the client that a Foley catheter will have to be inserted. 3. Tell the client that vital signs will be taken frequently after the procedure. 4. Provide instructions on holding the breath when the HCP inserts the catheter.

**3. The client is at risk for hypovolemia; therefore, vital signs will be assessed frequently to monitor for signs of hemorrhaging. TEST-TAKING HINT: If the test taker had no idea what the answer is, knowing that vital signs are assessed after all procedures should make the test taker select this option.

Which assessment question would be priority for the nurse to ask the client diagnosed with end-stage liver failure secondary to alcoholic cirrhosis? 1. How many years have you been drinking alcohol? 2. Have you completed an advanced directive? 3. When did you have your last alcoholic drink? 4. What foods did you eat at your last meal?

**3. The nurse must know when the client had the last alcoholic drink to be able to determine when and if the client will experience delirium tremens, the physical withdrawal from alcohol. TEST-TAKING HINT: Because the word "alcohol" is in the stem of the question, and if the test taker had no idea what the correct answer is, the test taker should select options that have the word "alcohol" in them and look closely at options "1" and "3."

The nurse is caring for the immediate postoperative client who had a laparoscopic cholecystectomy. Which task could the nurse delegate to the unlicensed nursing assistant? 1. Check the abdominal dressings for bleeding. 2. Increase the IV fluid if the blood pressure is low. 3. Document the amount of output on the I & O sheet. 4. Listen to the breath sounds in all lobes.

**3. This intervention would be appropriate for the nursing assistant to implement. TEST-TAKING HINT: The nurse cannot delegate teaching, assessing, and evaluating to a nursing assistant. The nurse cannot delegate any nursing task unless the client is stable and the task does not require judgment.

The client is six (6) hours postoperative open cholecystectomy and the nurse finds a large amount of red drainage on the dressing. Which intervention should the nurse implement? 1. Measure the abdominal girth. 2. Palpate the lower abdomen for a mass. 3. Turn client onto side to assess for further drainage. 4. Remove the dressing to determine the source.

**3. Turning the client to the side to assess the amount of drainage and possible bleeding is important prior to contacting the surgeon. TEST-TAKING HINT: The adjectives "large" and "red" indicate that the client is bleeding, and assessment is always priority when the client is having a possible complication of a surgery. Remember assessment is the first step in the nursing process.

The client diagnosed with end-stage liver failure is admitted with hepatic encephalopathy. Which dietary restriction should be implemented by the nurse to address this complication? 1. Restrict sodium intake to 2 g/day. 2. Limit oral fluids to 1500 mL/day. 3. Decrease the daily fat intake. 4. Reduce protein intake to 60 to 80 g/day.

**4. Ammonia is a byproduct of protein metabolism and contributes to hepatic encephalopathy. Reducing protein intake should decrease ammonia levels. TEST-TAKING HINT: The test taker could eliminate options "1" and "2" based on the knowledge that sodium and water work together and address edema, not encephalopathy. The test taker's knowledge of biochemistry—protein breaks down to ammonia, carbohydrates break down to glucose, and fat breaks down to ketones—may be helpful in selecting the correct answer.

The client is four (4) hours postoperative open cholecystectomy. Which data would warrant immediate intervention by the nurse? 1. Absent bowel sounds in all four (4) quadrants. 2. The T-tube with 60 mL of green drainage. 3. Urine output of 100 mL in the past three (3) hours. 4. Refusal to turn, deep breathe, and cough.

**4. Refusing to turn, deep breathe, and cough puts the client at risk for pneumonia. This client needs immediate intervention to prevent complications. TEST-TAKING HINT: The test taker should recognize normal data such as the normal urine output and normal data for postopera- tive clients. The test taker should apply basic concepts when answering questions. Normal or expected outcomes do not require action.

Which expected outcome would be appropriate for the client scheduled to have a cholecystectomy? 1. Decreased pain management. 2. Ambulate first day postoperative. 3. No break in skin integrity. 4. Knowledge of postoperative care.

**4. This would be an expected outcome for the client scheduled for surgery. This indicates that preoperative teaching has been effective. TEST-TAKING HINT: The time element is impor- tant in this question. The "expected outcome" that is required is for before the client's surgery. Option "1" is wrong because of the adjective "decreased." Adjectives commonly determine the accuracy of answer options.

When assessing the client recovering from an open cholecystectomy, which signs and symptoms should the nurse report to the health-care provider? Select all that apply. 1. Clay-colored stools. 2. Yellow-tinted sclera. 3. Dark yellow urine. 4. Feverish chills. 5. Abdominal pain.

1. Clay-colored stools are caused by recurring stricture of the common bile duct, which is a sign of post-cholecystectomy syndrome. 2. Yellow-tinted sclera and skin indicate residual effects of stricture of the common bile duct, which is a sign of post-cholecystectomy syndrome. 5. Abdominal pain indicates a residual effect of a stricture of common bile duct, inflammation, or calculi, which is a sign of postcholecystectomy syndrome. TEST-TAKING HINT: The test taker must use knowledge of anatomy to answer this question. All answer options have something to do with the abdominal area, and the common bile duct is anatomically near the hepatic duct, which causes the liver signs/symptoms.

Which laboratory value would the nurse expect to find indicating a chronic inflammation in the client with cholecystitis? 1. An elevated white blood cell (WBC) count. 2. A decreased lactate dehydrogenase (LDH) 3. An elevated alkaline phosphatase. 4. A decreased direct bilirubin level.

1. This value would be elevated in clients with chronic inflammation. TEST-TAKING HINT: If the test taker does not know what the values mean, the test taker should look to the disease process. The "itis" means inflammation, and an educated guess would be that WBCs are elevated in inflammatory processes.

The client is one (1) hour post-endoscopic retrograde cholangiopancreatogram (ERCP). Which intervention should the nurse include in the plan of care? 1. Instruct the client to cough forcefully. 2. Encourage early ambulation. 3. Assess for return of a gag reflex. 4. Administer held medications.

3. The endoscopic retrograde cholangiopancreatogram (ERCP) requires that an anesthetic spray be used prior to insertion of the endoscope. If medications, food, or fluid is given orally prior to the return of the gag reflex, the client may aspirate, causing pneumonia that could be fatal. TEST-TAKING HINTS: The test taker must notice adjectives such as "endoscopic," which means the procedure includes going down the mouth; "3" is the only option that has anything to do with the mouth. If the test taker had no idea of the correct answer, selecting a distracter addressing assessment would be appropriate because assessment is the first step of the nursing process.

The client is diagnosed with end-stage liver failure. The client asks the nurse, "Why is my doctor decreasing the doses of my medications?" Which statement is the nurse's best response? 1. "You are worried that your doctor has decreased the dosage." 2. "You really should ask your doctor. I am sure there is a good reason." 3. "You may have an overdose of the medication because your liver is damaged." 4. "The half-life is altered because the liver is damaged."

3. This is the main reason the HCP decreases the client's medication dose, and it is an explanation appropriate for the client. TEST-TAKING HINT: The test taker should provide factual information when the client asks "why." Therefore, "1" and "2" could be eliminated as possible correct answers. Both "3" and "4" explain the rationale for decreas- ing the medication dose, but the nurse should answer in terms the client can understand. Would a layperson know what half-life means?

Which nursing diagnosis would be highest priority for the client who had an open cholecystectomy surgery? 1. Alteration in nutrition. 2. Alteration in skin integrity. 3. Alteration in urinary pattern. 4. Alteration in comfort.

4. Acute pain management is the highest priority client problem after surgery because pain may indicate a life-threatening problem. TEST-TAKING HINT: When a question asks for the highest priority, the test taker should look for life-threatening problems that would be the highest priority for intervention. Pain may be expected, but it may indicate a complication.