ICS PPT/CS questions

The nurse has an order to administer 1.5 ounces of lactulose to a client that has cirrhosis. How many milliliters of lactulose should the nurse administer?

45 ml (30ml=1oz)

A client is scheduled to undergo a liver transplantation. Which nursing intervention is most likely to prevent the complications of bile leakage and abscess formation? A. Preventing hypotension B. Keeping the T-tube in a dependent position C. Administering antibiotic vaccinations D. Administering immune-suppressant drugs

B. Keeping the T-tube in a dependent position

The nurse monitors a client with cirrhosis for the development of hepatic encephalopathy. Which would be an indication that hepatic encephalopathy is developing? a. Decreased mental status b. Elevated blood pressure c. Decreased urine output d. Labored respirations

a. Decreased mental status

When providing community education, the nurse emphasizes that which group needs to receive immunization for hepatitis B? A. Clients who work with shellfish B. Men who engage in sex with men C. Clients traveling to a third-world country D. Clients with elevations of aspartate aminotransferase and alanine aminotransferase

B. Men who engage in sex with men

A client with an esophagogastric tamponade tube has a sudden drop in SpO2 and an increase in respiratory rate to 40 breaths/min. What should the nurse do in order form first to last? All options must be used. a. Affirm airway obstruction by the tube b. Remove the tube c. Apply oxygen by face mask d. Deflate the tube by cutting with bedside scissors

1. Affirm airway obstruction by the tube 2. Deflate the tube by cutting with bedside scissors 3. Remove the tube 4. Apply oxygen by face mask

The nurse is taking care of a client who has an IV infusion pump. The pump alarm rings. What should the nurse do in order from first to last. All options must be used. a. Silence the pump alarm b. Assess the clients access site for infiltration or inflammation c. Assess the tubing for hindrances to flow of solution d. Determine if the infusion pump is plugged into an electrical outlet

1. Silence the pump alarm 2. Assess the clients access site for infiltration or inflammation 3. Assess the tubing for hindrances to flow of solution 4. Determine if the infusion pump is plugged into an electrical outlet

The nurse's assignment consists of four clients. From highest to lowest priority, in which order should the nurse assess the clients after receiving report? a. The client with cirrhosis who became confused and disoriented during the night b. The client with acute pancreatitis who is requesting pain medication c. The client who is 1 day postoperative following a cholecystectomy and has a T-tube inserted d. The client with hepatitis B who has questions about discharge instructions

1. The client with cirrhosis who became confused and disoriented during the night 2. The client with acute pancreatitis who is requesting pain medication 3. The client who is 1 day postoperative following a cholecystectomy and has a T-tube inserted 4. The client with hepatitis B who has questions about discharge instructions

A client who was awaiting liver transplantation is excluded from the procedure after the presence of which condition is discovered? A. Colon cancer with metastasis to the liver B. Hypertension C. Hepatic encephalopathy D. Ascites and shortness of breath.

A. Colon cancer with metastasis to the liver

When caring for a client with portal hypertension, the nurse assesses for which potential complications? SATA A. Esophageal varices B. Hematuria C. Fever D. Ascites E. Hemorrhoids

A. Esophageal varices D. Ascites E. Hemorrhoids

When caring for a client with Laennec's cirrhosis, which of these does the nurse expect to find on assessment? SATA A. Prolonged partial thromboplastin time B. Icterus of skin C. Swollen abdomen D. Elevated magnesium E. Currant jelly stool F. Elevated amylase level

A. Prolonged partial thromboplastin time B. Icterus of skin (jaundice) C. Swollen abdomen

The nurse is caring for a client who has cirrhosis of the liver. The client has exhibited hand flapping and mental confusion for several weeks. Although the mental confusion is worsening, the client has stopped exhibiting hand flapping movements. How will the nurse interpret these findings? A. The client's symptoms are progressing and getting worse. B. The client's serum ammonia levels are decreasing. C. The client probably has a decrease in serum proteins. D. The client is showing signs of improvement.

A. The client's symptoms are progressing and getting worse.

- Weight that represents the metabolically active lean body tissue - Gives more calories to underweight - Gives less calories to overweight

Adjusted body weight

3.5-5 - Affected by hydration, edema, ascites

Albumin

The nurse is caring for clients in the outpatient clinic. Which of these phone calls would the nurse return first? A. Client with hepatitis A reporting severe and ongoing itching B. Client with severe ascites who has a temperature of 101.4°F (38°C) C. Client with cirrhosis who has had a 3-pound (1.4 kg) weight gain over 2 days D. Client with esophageal varices and mild right upper quadrant pain

B. Client with severe ascites who has a temperature of 101.4°F (38°C)

Which activity by the nurse will best relieve symptoms associated with ascites? A. Administering oxygen B. Elevating the head of the bed C. Monitoring serum albumin levels D. Administering intravenous fluids

B. Elevating the head of the bed

- hypermetabolism, hypercatabolism - high calorie, high protein - enteral ASAP post burn

Burn

The nursing team consists of an RN, an LPN/LVN, and a nursing assistant. Which client should be assigned to the RN? A. Client who is taking lactulose and has diarrhea B. Client with hepatitis C who requires a dressing change C. Client with end-stage cirrhosis who needs teaching about a low-sodium diet D. Obtunded client with alcoholic encephalopathy who needs a blood draw

C. Client with end-stage cirrhosis who needs teaching about a low-sodium diet

What teaching does the home health nurse give the family of a client with hepatitis C to prevent the spread of the infection? A. The client must not consume alcohol. B. Avoid sharing the bathroom with the client. C. Members of the household must not share toothbrushes. D. Drink only bottled water and avoid ice.

C. Members of the household must not share toothbrushes.

A client with a history of esophageal varices has just been admitted to the emergency department after vomiting a large quantity of blood. Which action does the nurse take first? A. Obtain the charts from the previous admission. B. Listen for bowel sounds in all quadrants. C. Obtain pulse and blood pressure. D. Ask about abdominal pain.

C. Obtain pulse and blood pressure.

Which problem for a client with cirrhosis takes priority? A. Insufficient knowledge related to the prognosis of the disease process B. Discomfort related to the progression of the disease process C. Potential for injury related to hemorrhage D. Inadequate nutrition related to an inability to tolerate usual dietary intake

C. Potential for injury related to hemorrhage

When assessing a client with hepatitis B, the nurse anticipates which assessment findings? SATA A. Recent influenza infection B. Brown stool C. Tea-colored urine D. Right upper quadrant tenderness E. Itching

C. Tea-colored urine D. Right upper quadrant tenderness E. Itching

The nurse administers lactulose (Evalose) to a client with cirrhosis for which purpose? A. To aid in digestion of dairy products B. To reduce portal pressure C. To promote gastrointestinal (GI) excretion of ammonia D. To reduce the risk of GI bleeding

C. To promote gastrointestinal (GI) excretion of ammonia

- anorexia - bowel edema, GI hypomotility - EN should begin following cardiac surgery when hemodynamic stability is achieved

Cardiac failure

A health care worker believes that he may have been exposed to hepatitis A. Which intervention is the highest priority to prevent him from developing the disease? A. Requesting vaccination for hepatitis A B. Using a needleless system in daily work C. Getting the three-part hepatitis B vaccine D. Requesting an injection of immunoglobulin

D. Requesting an injection of immunoglobulin

Which statement by a client with cirrhosis indicates that further instruction is needed about the disease? A. "Cirrhosis is a chronic disease that has scarred my liver." B. "The scars on my liver create problems with blood circulation." C. "Because of the scars on my liver, blood clotting and blood pressure are affected." D. "My liver is scarred, but the cells can regenerate themselves and repair the damage."

D. "My liver is scarred, but the cells can regenerate themselves and repair the damage."

The nurse asks a client with liver disease to raise the arms to shoulder level and dorsiflex the hands. A few moments later, the hand begins to flap upward and downward. How does the nurse correctly document this in the medical record? A. Positive Babinski's sign B. Hyperreflexia C. Kernig's sign D. Asterixis

D. Asterixis

It is essential that the nurse monitor the client returning from hepatic artery embolization for hepatic cancer for which potential complication? A. Right shoulder pain B. Polyuria C. Bone marrow suppression D. Bleeding

D. Bleeding

When providing discharge teaching to a client with cirrhosis, it is essential for the nurse to emphasize avoidance of which of these? A. Vitamin K-containing products B. Potassium-sparing diuretics C. Nonabsorbable antibiotics D. Nonsteroidal anti-inflammatory drugs (NSAIDs)

D. Nonsteroidal anti-inflammatory drugs (NSAIDs)

The RN is caring for a client with end-stage liver disease who has ascites. Which action does the RN delegate to unlicensed assistive personnel (UAP)? A. Assessing skin integrity and abdominal distention B. Drawing blood from a central venous line for electrolyte studies C. Evaluating laboratory study results for the presence of hypokalemia D. Placing the client in a semi-Fowler's position

D. Placing the client in a semi-Fowler's position

How does the home care nurse best modify the client's home environment to manage side effects of lactulose (Evalose)? A. Provides small frequent meals for the client B. Suggests taking daily potassium supplements C. Elevates the head of the bed in high-Fowler's position D. Requests a bedside commode for the client

D. Requests a bedside commode for the client

Following paracentesis, during which 2500 mL of fluid was removed, which assessment finding is most important to communicate to the health care provider (HCP)? A. The dressing has a 2-cm area of serous drainage. B. The client's platelet count is 135,000/mm3 (135 × 109/L). C. The client's albumin level is 2.8 g/dL (28 g/L). D. The client's heart rate is 122 beats/min.

D. The client's heart rate is 122 beats/min.

- micronutrient deficiency - small frequent feeds - lactulose - replace Mg, Phosphate, Vitamins: A,D,E,PT, zince, thiamine

Liver failure

Low protein affects: - impair wound healing - after fluid shifts - increase risk of gut bacterial translocation - inhibit immune response

Low protein affects:

- decreased albumin, transferrin, and pre albumin - avoid overfeeding - High fat, low carb/sugar

Pulmonary failure

- when food is introduced too quickly after a period of malnourishment - occurs after 5-7 days of fast - food and fluids need to be introduced gradually to prevent fluid/elect shifts - K, Phosphorus, Mg, Ca, and thiamine are affected

Refeeding syndrome

- low protein - supplement with water soluble vitamins

Renal failure

- cannot store glucose - unable to do anaerobic metabolism - increased catecholamines

TBI

There are many factors that are included in the palliative plan of care for the elderly client. Which intervention would be a low priority on the plan? a) Assess extent of disease b) Identify coping strategies c) Determine family burden d) Financial burden

a) Assess extent of disease

Complementary and Alternative therapies may be initiated to provide comfort to the client. Which course of action would not be recommended? a) Group Therapy. b) Massage Therapy. c) Music Therapy. d) Aromatherapy.

a) Group Therapy.

A client presents with end stage renal disease and makes inquiries about end of life treatment. Which of the following would be recommended for Palliative-End-of-Life Care goals? a) Improve quality of life. b) Assessment and treatment of underlying disease. c) Improve quantity of life d) Care of physical, psychological, and spiritual needs of only the client.

a) Improve quality of life.

The Practitioners Orders for Life Sustaining Treatment (POLST) document is presented to the medical team. How does this form help establish criteria for treatment? a) Informs the medical team what to do for a client who is seriously ill or approaching the end of life. b) Tells the medical team to call the patient's physician. c) Does not need to be completed by a physician. d) Needs to be notarized before being legal.

a) Informs the medical team what to do for a client who is seriously ill or approaching the end of life.

Which of the following would distinguish the difference between Palliative-End-of-Life Care and Hospice Care? a) Palliative End-of-Life care occurs in last part of a client's life and Hospice Care is initiated when the client has six months or less to live. b) Hospice is initiated first instead of Palliative-End-of-Life Care. c) It does not make a difference the both are the same. d) The nurse should avoid answering the question.

a) Palliative End-of-Life care occurs in last part of a client's life and Hospice Care is initiated when the client has six months or less to live.

A client with cirrhosis is receiving lactulose. The nurse notes the client is more confused and has asterixis. The nurse should: a. Assess for gastrointestinal (GI) bleeding b. Withhold the lactulose c. Increase protein in the diet d. Monitor serum bilirubin levels

a. Assess for gastrointestinal (GI) bleeding

The patient had a liver biopsy one hour ago. The nurse should first: a. Auscultate lung sounds b. Check for fever c. Obtain a CBC d. Apply packing to the biopsy site

a. Auscultate lung sounds

The nurse is preparing a client for a paracentesis. The nurse should: a. Have the client void immediately before the procedure b. Place the client in a side-lying position c. Initiate an IV line to administer sedatives d. Place the client on nothing by mouth (NPO) status 6 hours before the procedure

a. Have the client void immediately before the procedure

What diet should be implemented for a client who is in the early stages of cirrhosis? a. High-calorie, high- CHO b. Low-protein, low-CHO c. Low-fat, low-protein d. High-CHO, low-sodium

a. High-calorie, high- CHO

What is the priority intervention in the management of a patient with decompensated cirrhosis? a. Limiting protein intake b. Monitoring fluid intake and output c. Managing N/V d. Elevating the HOB > 30 degrees

a. Limiting protein intake

The client is diagnosed with renal failure and needs to be educated on the type of diet that should be initiated. The client responds that he understands if he states the following diet: a. Low Sodium, Low Potassium, Low Phosphorus b. High Sodium, Low Potassium, High Phosphorus c. High Sodium, High Potassium, Low Phosphorus d. Low Sodium, High Potassium, Low Phosphorus

a. Low Sodium, Low Potassium, Low Phosphorus - Limit sodium, phosphorus and potassium intake since kidney dysfunction may cause high levels of these electrolytes.

A nurse is developing a care plan for a client with hepatic encephalopathy. Which are goals for the care for this client? SATA a. Prevent constipation b. Administer lactulose to reduce blood ammonia levels c. Monitor coordination when walking d. Check the pupil reaction e. Provide food and fluids high in carbohydrate f. Encourage physical activity

a. Prevent constipation b. Administer lactulose to reduce blood ammonia levels c. Monitor coordination when walking d. Check the pupil reaction e. Provide food and fluids high in carbohydrate

A client with cirrhosis who has ascites receives 100ml of 25% serum albumin IV. Which finding would best indicate that the albumin is having its desired effect? a. Reduced ascites b. Increased serum albumin level c. Decreased anorexia d. Increased ease of breathing

a. Reduced ascites

When a complete assessment of this pt is performed, what other manifestation would the nurse expect? SATA a. ecchymosis b. spider angiomas c. personality changes d. peripheral dependent edema e. muscle twitching f. dry skin with rash

a. ecchymosis b. spider angiomas c. personality changes d. peripheral dependent edema e. muscle twitching

Pt is experiencing anaerobic metabolism, the nurse anticipate which of the following labs will be drawn? a. lactic acid b. pyruvate c. glucose d. none of the above

a. lactic acid

Which laboratory value is the best indicator of current nutritional status? a. prealbumin b. albumin c. transferrin d. BUN

a. prealbumin

Which assessment parameter requires immediate intervention in a patient with severe ascites? a. shallow respiration, rate 32 breaths/min b. temperature 38.2C c. confusion d. tachycardia, rate 110 beats/min

a. shallow respiration, rate 32 breaths/min

A hospice client is experiencing severe pain associated with disease process. What actions should the nurse initiate? a) Call 911. b) Administer pain medications as prescribed. c) Notify family. d) Call provider to clarify orders.

b) Administer pain medications as prescribed.

A client is experiencing a change in breathing pattern, cool extremities, decreased fluid and food intake, and restlessness. The nurse should inform the caretakers of the following: a) This is normal, do not worry about it. b) These are physiological signs that the client is approaching death. c) The client is going to die in the next hour. d) Notify the Physician.

b) These are physiological signs that the client is approaching death.

A client is to be discharged with a prescription for lactulose. The nurse teaches the client and the client's spouse how to administer this medication. Which statement would indicate that the client has understood the information? a. "I will take it with an antacid" b. " I will mix it with apple juice" c. " I will take it with a laxative" d. " I will mix the crushed tablets in some gelatin"

b. " I will mix it with apple juice"

Which health promotion activity should the nurse suggest that the client with cirrhosis add to the daily routine at home? a. Supplement the diet with daily multivitamins b. Abstain from drinking alcohol c. Take a sleeping pill at bedtime d. Limit contact with other people whenever possible

b. Abstain from drinking alcohol

A client with jaundice has pruritus and areas of irritation from scratching. What measures can the nurse suggest the client use to prevent skin breakdown. SATA a. Avoid lotions containing calamine b. Add baking soda to the water in a tub bath c. Keep nails short and clean d. Rub the skin when it itches with knuckles instead of nails e. Massage skin with alcohol f. Increase sodium intake in the diet

b. Add baking soda to the water in a tub bath c. Keep nails short and clean d. Rub the skin when it itches with knuckles instead of nails

The nurse should institute which measures to prevent transmission of the hepatitis C virus to healthcare personnel? a. Administer the hepatitis C vaccine to all healthcare personnel b. Decreasing contact with blood and blood- contaminated fluids c. Wearing gloves when emptying the bedpan d. Wearing a gown and mask when providing direct care

b. Decreasing contact with blood and blood- contaminated fluids

The client is admitted to burn unit and to promote healing. The nurse understands that designing a diet for a burn patient requires the following components to meet hypermetabolic and hypercatabolic states: a. Low protein, low carbohydrate, fat content > 50% b. High protein, High carbohydrates, fat content >70% c. High protein, High carbohydrates, fat content < 30% d. Low protein, High carbohydrates, fat content<10%

b. High protein, High carbohydrates, fat content >70%

A client with cirrhosis begins to develop ascites. Spironolactone is prescribed to treat the ascites. The nurse should monitor the client closely for which drug related adverse effect? a. Constipation b. Hyperkalemia c. Irregular pulse d. Dysuria

b. Hyperkalemia

The client presents to your department with a history of ETOH Abuse and is currently intoxicated. The client drinks approximately twelve beers a day. Their abdomen is firmly distended, skin, sclera and mucosa jaundiced, liver enzymes are elevated and hepatomegaly is noted. An IV has been established. Which treatment would not be initiated for liver failure? a. Lactulose b. Large meals c. Removal of precipitating cause d. Replacement of Magnesium, Phosphate, Vitamins A, D, E, Potassium, Zinc, Thiamine

b. Large meals - Liver failure can lead to malnourishment, eating small frequent meals may be more tolerable and ensure your ingesting the proper amount of calories

A client is admitted to your unit with a diagnosis of malnutrition, and has an allergy to eggs. The provider orders to initiate Lipid Therapy. The nurse should do which of the following: a. Initiated Lipid Therapy: b. Lipids use egg substrates. Notify the provider regarding the client's allergy to eggs c. Ignore the order d. Call the nursing supervisor about the situation

b. Lipids use egg substrates. Notify the provider regarding the client's allergy to eggs - Closed Loop Communication. Clarification of order.

Illustrate different ways a nurse can prevent hyperglycemia when administering any type of parenteral feeding? a. Overfeed, check the blood sugar only in the morning, administer diuretics b. Monitor intake closely, monitor blood sugars frequently, and administer insulin as directed c. Underfeed the patient, monitor blood sugars frequently, and administer insulin as directed d. Initiate 500 cc Normal Saline boluses every six hours

b. Monitor intake closely, monitor blood sugars frequently, and administer insulin as directed - Monitor intake closely, blood sugars should be monitored frequently, and administering of insulin should be done on a sliding scale

The client was admitted with an exacerbation of COPD and is being discharged. The client asks for dietary guidelines on what to eat? What type of meal would be recommended? a. Fried chicken, French fries, and ice cream b. Peas, kidney beans, and steamed fish c. McDonalds Happy Meal: Sodium content high d. Potatoes, Salami sandwich, and broccoli

b. Peas, kidney beans, and steamed fish - Low carbs and higher protein recommended. CHO metabolism increases CO2.

A 55 yr old pt with a history of alcohol abuse spanning 10 yrs has been diagnosed with cirrhosis. The pt will be undergoing abdominal paracentesis on the medical unit today. Which assessment finding would alert the nurse that the paracentesis has been successful? a. a substantial decrease in blood pressure b. decrease in post-procedure weight c. no residual obtained during procedure d. immediate sensation of need to urinate

b. decrease in post-procedure weight

The pt tells the nurse that once he is discharged to home, he has no intention to stop drinking alcohol. What is the appropriate nursing response? a. why do you continue to drink? b. does it frighten you to consider quitting? c. its your choice to drink or not to drink d. if you continue to drink, you are going to die

b. does it frighten you to consider quitting?

What is a primary reason for a higher incidence of liver cancer in the US? a. incidence of illicit drug use b. rising obesity c. incidence of hepatitis C d. increased asian population

b. rising obesity

The client's wife is concerned about her husband's diagnosis of Congestive Heart Failure. She inquires what spices they could incorporate into their daily living. Based on your knowledge of this disease process which would you recommend? a. Garlic Salt and Onion Powder: Increased Na intake causes the body to withhold fluids b. Garlic Powder and Celery Salt: Increased Na intake causes the body to withhold fluids c. Parsley and Pepper: Decreasing sodium intake and trying different herbs with lead to eating a healthier diet d. Kosher Salt and Dry Italian Seasoning: Increased Sodium intake causes the body to withhold fluids

c . Parsley and Pepper - Decreasing sodium intake and trying different herbs with lead to eating a healthier diet

Nurses initiate interventions for providing psychosocial support to the client and family in many different forms. Which intervention would not be appropriate? a) Life Review. b) Spirituality. c) Isolation. d) Presence.

c) Isolation.

The nurse is informed that the client is experiencing shortness of breath at night. Which of the following treatments are best to be utilized to alleviate their symptoms? a) Leave the client alone. b) Ignore it because it is part of the process. c) Provide oxygen therapy and a prescribed sedative. d) Lay the bed flat.

c) Provide oxygen therapy and a prescribed sedative.

The nurse is providing discharge instructions for a client with cirrhosis. Which statement best indicates that the client has understood the teaching? a. "I should eat a high- protein, high- carbohydrate diet to provide energy" b. "It is safer for me to take acetaminophen for pain instead of aspirin" c. "I should avoid constipation to decrease chances of bleeding" d. "If I get enough rest and follow my diet, it is possible for my cirrhosis to be cured"

c. "I should avoid constipation to decrease chances of bleeding"

The nurse is assessing a client who is in the early stages of cirrhosis of the liver. Which focused assessment is appropriate? a. Peripheral edema b. Ascites c. Anorexia d. Jaundice

c. Anorexia

The client has a history of an intestinal resection, malabsorption syndrome, and bowel obstructions. The client has been admitted to the medical surgical unit. Which of the following should not be initiated for Parenteral Nutrition? a. Obstruction b. Paralytic Ileus c. Functioning Gastrointestinal Tract d. Malnourished due to NPO status

c. Functioning Gastrointestinal Tract - If the gut works- use it. Always use the GI tract for oral intake if it is functional

A client's serum ammonia level is elevated and the HCP prescribes 30ml of lactulose. Which effect is common for this drug? a. Increased urine output b. Improved level of consciousness c. Increased bowel movements d. Nausea and vomiting

c. Increased bowel movements

The patient's assmt reveals yellowish coloration of skin and sclerae. Which lab values would the nurse expect to find? a. Increased direct bilirubin, decreased indirect bilirubin b. Decreased direct bilirubin, increased indirect bilirubin c. Increased direct bilirubin, increased indirect bilirubin

c. Increased direct bilirubin, increased indirect bilirubin

The nurse is assessing a client with cirrhosis who has developed hepatic encephalopathy. The nurse should notify the healthcare provider (HCP) of a decrease in which serum lab value that is a potential precipitating factor for hepatic encephalopathy? a. Aldosterone b. Creatinine c. Potassium d. Protein

c. Potassium

The client, an elderly gentleman, is admitted from home with poor oral intake, a stroke, and other neurological disorders. requiring enteric nutrition. Which of the following would not be recommended for enteric nutrition via a tube? a. Dysphagia b. Anorexia c. Prostate Cancer d. Parkinson's Disease

c. Prostate Cancer - Prostate cancer is not a treatment for enteric nutrition via a tube

A client with ascites and peripheral edema is at risk for impaired skin integrity. To prevent skin breakdown, the nurse should: a. Institute range- of- motion (ROM) exercises every 4 hours b. Massage the abdomen once per shift c. Use an alternating air pressure mattress d. Elevate the lower extremities

c. Use an alternating air pressure mattress

A low serum albumin may be caused by which of the following? a. liver disease b. kidney disease c. chronic malnutrition d. acute malnutrition

c. chronic malnutrition

Included below are some nonpharmacologic treatments that can support dyspnea management for your client. Select the treatment that would not be justified for the client. a) Cool Air b) Encourage imagery and deep breathing c) Frequent rest periods d) Perform rapid purse lip breathing

d) Perform rapid purse lip breathing

A client has advanced cirrhosis of the liver. The client's spouse asks the nurse why his abdomen is swollen, making it very difficult for him to fasten his pants. How should the nurse respond to provide the most accurate explanation of the disease process? a. "He must have eaten too many foods with salt in them. Salt pulls water with it." b. "The swelling in his ankles must have moved up closer to his heart so the fluid circulates better." c. "He must have forgotten to take his daily water pill." d. "Blood is not able to flow readily through the liver now, and the liver cannot make protein to keep fluid inside the blood vessels."

d. "Blood is not able to flow readily through the liver now, and the liver cannot make protein to keep fluid inside the blood vessels."

After completing assessment rounds, which client should the nurse discuss with the HCP first? a. A client with cirrhosis who is depressed and has refused to eat for the past 2 days b. A client with stable vital signs that has been receiving IV ciprofloxacin following a cholecystectomy for 1 day and has developed a rash on the chest and arms c. A client with pancreatitis whose family requests to speak with the HCP regarding the treatment plan d. A client with hepatitis whose pulse was 84 bpm and is now 118bpm and is irregular

d. A client with hepatitis whose pulse was 84 bpm and is now 118bpm and is irregular

The client is admitted to a medical surgical unit for gastrointestinal symptoms. Which of the following would be an indication for starting enteric nutrition via a tube? a. Gastrointestinal bleeding b. Paralytic Ileus c. High output fistulas d. Anorexia

d. Anorexia - Recommended treatment to improve caloric intake

The nurse is caring for a client with esophageal varices. The nurse should discuss which laboratory finding with the HCP? a. Normal serum albumin b. Decreased ammonia c. Slightly decreased levels of calcium d. Elevated PT/INR

d. Elevated PT/INR

The nurse is reviewing the chart information for a client with increased ascites. The data include the following: temperature 98.9°F (37.2°C), heart rate 118, shallow respirations 26/min, BP 128/76 mmHg, and SpO2 89% on room air. The nurse should first: a. Assess heart sounds b. Obtain a prescription for blood cultures c. Prepare for a paracentesis d. Raise the bed of the bed

d. Raise the bed of the bed

Which precautions should the healthcare team observe when caring for patients with Hepatitis A? a. Gowning when entering the client's room b. Wearing a mask when providing care c. Assigning the client to a private room d. Wearing gloves when giving direct care

d. Wearing gloves when giving direct care