Advance Med Surg Exam #4
Which type of jaundice is the result of increased destruction of red blood cells?
Hemolytic
A client has a tumor of the head of the pancreas. What clinical manifestations will the nurse assess? Select all that apply.
Clay-colored stools Dark urine Jaundice
A client with a history of cirrhosis is admitted to the ICU with a diagnosis of bleeding esophageal varices; an attempt to stop the bleeding has been only partially successful. What would the critical care nurse expect the care team to prescribe for this client?
Packed red blood cells (PRBCs)
A nurse is caring for a client newly diagnosed with hepatitis A. Which statement by the client indicates the need for further teaching?
"How did this happen? I've been faithful my entire marriage."
A client with hepatic cirrhosis questions the nurse about the possible use of an herbal supplement—milk thistle—to help heal the liver. Which is the most appropriate response by the nurse?
"Silymarin from milk thistle has anti-inflammatory and antioxidant properties that may have beneficial effects, especially in hepatitis. However, you should always notify your primary care provider of any herbal remedies being used so drug interactions can be evaluated."
An important message for any nurse to communicate is that drug-induced hepatitis is a major cause of acute liver failure. The medication that is the leading cause is:
Acetaminophen
A client with esophageal varices is being cared for in the ICU. The varices have begun to bleed. The client has Ringer lactate at 150 cc/hr infusing. The nurse should also anticipate what intervention?
Administering volume expanders
A nursing student has been assigned to care for a client with pancreatic cancer. The student is aware that the risk for pancreatic cancer is most directly proportional to
Age
A client will be receiving a hepatitis B vaccination series prior to employment in a dialysis center. What type of immunity will this provide?
Artificially acquired active immunity
A nurse is caring for a client who has been admitted for the treatment of advanced cirrhosis. What assessment should the nurse prioritize in this client's plan of care?
Assessment for variceal bleeding
A student nurse is caring for a client who has a diagnosis of acute pancreatitis and who is receiving parenteral nutrition. The student should prioritize which of the following assessments?
Blood glucose levels
A client has a tumor of the head of the pancreas. What clinical manifestations will the nurse assess? Select all that apply.
Clay-color stool Dark Urine Jaundice
A nurse is caring for a client who was admitted with pain, tenderness, and rigidity of the upper right abdomen, suggesting a gall bladder issue. The client has also been experiencing nausea and vomiting for the past 3 days. The admitting service is planning for tests to be conducted in the morning.
Cholesterol is elevated in biliary obstruction. It is used to visualize calculi in the gallbladder. It is used to visualize calculi in the gallbladder.
A 70-year-old client is admitted with acute pancreatitis. The nurse understands that the mortality rate associated with acute pancreatitis increases with advanced age and attributes this to which gerontologic consideration associated with the pancreas?
Decreases in the physiologic function of major organs
A client with anemia has been admitted to the medical-surgical unit. Which assessment findings are characteristic of iron deficiency anemia?
Dyspnea, tachycardia, and pallor
A nurse has admitted a client suspected of having acute pancreatitis. The nurse knows that mild acute pancreatitis is characterized by:
Edema and inflammation
A client is receiving vasopressin for the urgent management of active bleeding due to esophageal varices. What most serious complication should the nurse assess the client for after the administration?
Electrocardiogram changes
A client is admitted to the healthcare facility suspected of having acute pancreatitis and undergoes laboratory testing. Which of the following would the nurse expect to find?
Elevated urine amylase levels
The nurse identifies which type of jaundice in an adult experiencing a transfusion reaction?
Hemolytic
The mode of transmission of hepatitis A virus (HAV) includes which of the following?
Fecal-oral
When the nurse is caring for a patient with acute pancreatitis, what intervention can be provided in order to prevent atelectasis and prevent pooling of respiratory secretions?
Frequent changes of positions
A client and spouse are visiting the clinic. The client recently experienced a seizure and says she has been having difficulty writing. Before the seizure, the client says that for several weeks she was sleeping late into the day but having restlessness and insomnia at night. The client's husband says that he has noticed the client has been moody and slightly confused. Which of the following problems is most consistent with the client's clinical manifestations?
Hepatic encephalopathy
A nurse who provides care in a busy ED is in contact with hundreds of clients each year. The nurse has a responsibility to receive what vaccine?
Hepatitis B vaccine
A nurse is preparing a presentation for a local community group about hepatitis. Which of the following would the nurse include?
Hepatitis C increases a person's risk for liver cancer.
When reviewing the history of a client with pancreatic cancer, the nurse would identify which of the following as a possible risk factor?
History of pancreatitis
Clients diagnosed with esophageal varices are at risk for hemorrhagic shock. Which is a sign of potential hypovolemia?
Hypotension Explanation: Signs of potential hypovolemia include cool, clammy skin; tachycardia; decreased blood pressure; and decreased urine output.
A student nurse is preparing a plan of care for a client with chronic pancreatitis. What nursing diagnosis related to the care of a client with chronic pancreatitis is the priority?
Impaired nutrition: less than body requirements
A client with a diagnosis of esophageal varices has undergone endoscopy to gauge the progression of this complication of liver disease. Following the completion of this diagnostic test, what nursing intervention should the nurse perform?
Keep client NPO until the client's gag reflex returns.
A critical care nurse is caring for a client with acute pancreatitis. One potentially severe complication involves the respiratory system. Which of the following would be an appropriate intervention to prevent complications associated with the respiratory system?
Maintain the client in a semi-Fowler's position.
A client with cirrhosis has a massive hemorrhage from esophageal varices. Balloon tamponade is used temporarily to control hemorrhage and stabilize the client. In planning care, the nurse gives the highest priority to which goal?
Maintaining the airway Explanation: Esophageal varices are almost always caused by portal hypertension, which results from obstruction of the portal circulation within the damaged liver. Maintaining the airway is the highest priority because oxygenation is essential for life. The airway can be compromised by possible displacement of the tube and the inflated balloon into the oropharynx, which can cause life-threatening obstruction of the airway and asphyxiation.
A client with acute pancreatitis has been started on total parenteral nutrition (TPN). Which action should the nurse perform after administration of the TPN?
Measure blood glucose concentration every 4 to 6 hours
Which is the most common cause of esophageal varices?
Portal hypertension
A client with pancreatic cancer has the following blood chemistry profile: Glucose, fasting: 204 mg/dl; blood urea nitrogen (BUN): 12 mg/dl; Creatinine: 0.9 mg/dl; Sodium: 136 mEq/L; Potassium: 2.2 mEq/L; Chloride: 99 mEq/L; CO2: 33 mEq/L. Which result should the nurse identify as critical and report immediately?
Potassium
A client with cirrhosis has portal hypertension, which is causing esophageal varices. What is the goal of the interventions that the nurse will provide?
Reduce fluid accumulation and venous pressure.
A client with gallstones is diagnosed with acute pancreatitis and is requesting information about the physiology of the gallbladder. Which information will the nurse include about the function of this organ?
Releases bile in response to cholecystokinin
The nurse is admitting a patient to the intensive care unit with a diagnosis of acute pancreatitis. What does the nurse expect was the reason the patient came to the hospital?
Severe abdominal pain
The nursing student has just reviewed material in the course textbook regarding pancreatitis. The student knows that a major symptom of pancreatitis that causes the client to seek medical care is:
Severe abdominal pain
A nursing instructor is explaining the pathophysiology and clinical manifestations of pancreatitis to a group of nursing students. The instructor evaluates the teaching as effective when a student correctly identifies which symptom as that most commonly reported by clients with pancreatitis?
Severe, radiating abdominal pain
A patient with bleeding esophageal varices has had pharmacologic therapy with Octreotide (Sandostatin) and endoscopic therapy with esophageal varices banding, but the patient has continued to have bleeding. What procedure that will lower portal pressure does the nurse prepare the patient for?
Transjugular intrahepatic portosystemic shunting (TIPS)
Ammonia, the major etiologic factor in the development of encephalopathy, inhibits neurotransmission. Increased levels of ammonia are damaging to the body. The largest source of ammonia is from:
The digestion of dietary and blood proteins.
A patient with acute pancreatitis puts the call bell on to tell the nurse about an increase in pain. The nurse observes the patient guarding; the abdomen is board-like and no bowel sounds are detected. What is the major concern for this patient?
The patient has developed peritonitis.
A client with metastatic pancreatic cancer underwent surgery to remove a malignant tumor in the pancreas. Despite the tumor being removed, the physician informs the client that chemotherapy must be started. Why might the physician opt for chemotherapy?
To prevent metastasis
The nurse is caring for a patient with acute pancreatitis. The patient has an order for an anticholinergic medication. The nurse explains that the patient will be receiving that medication for what reason?
To reduce gastric and pancreatic secretions
A patient with suspected esophageal varices is scheduled for an upper endoscopy with moderate sedation. After the procedure is performed, how long should the nurse withhold food and fluids?
Until the gag reflex returns Explanation: After the endoscopic examination, fluids are not given until the patient's gag reflex returns.
The nurse is caring for a client with blood loss from esophageal varices. Which assessment finding indicates that the client is exhibiting signs of acute kidney injury (AKI) related to the loss of volume?
Urine output that has been <0.5 mL/kg/hr for several hours
Which of the following is the most effective strategy to prevent hepatitis B infection?
Vaccine
Which medication is used to decrease portal pressure, halting bleeding of esophageal varices?
Vasopressin
A client has just been diagnosed with hepatitis A. On assessment, the nurse expects to note:
anorexia, nausea, and vomiting.
