NURS 5 Hepatic ATI

which of the following is a characteristic feature of ascites?

abnormal accumulation of fluid in the peritoneal cavity

what is the primary cause of portal hypertension?

increased resistance to blood flow though the liver

a patient with ascites is admitted to the med-surg unit. which nursing priority should be the focus of care for this patient?

monitoring fluid balance and electrolyte levels

a nurse is teaching a client about causes of biliary cirrhosis. which of the following information should the nurse include in the teaching?

obstruction of the bile duct

what is the primary purpose of performing a paracentesis procedure?

to diagnose or relieve ascites.

a nurse is caring for a client who has cirrhosis and a new prescription for lactulose. which of the following manifestations indicates an adverse effect of the med?

vomiting

a nurse is planning care for a client who has cirrhosis of the liver. which of the following actions should the nurse include in the plan?

Administer furosemide is correct. The nurse should administer furosemide to the client to reduce fluid accumulation in the abdomen.Administer warfarin is incorrect. The nurse should avoid administering warfarin to the client due to possible destruction of platelets caused by splenomegaly, which can result in spontaneous bleeding.Propranolol is prescribed instead to discourage bleeding.Implement a low-sodium diet is correct. The nurse should implement a low-sodium diet to control fluid accumulation in the abdomen.Measure the client's abdominal girth is correct. The nurse should measure the client's abdominal girth. Daily weights are an even more reliable indicator of fluid accumulation.Encourage weight lifting during physical therapy is incorrect. The nurse should understand weight lifting can cause bleeding.

which interventions are essential in managing a patient with esophageal varices to prevent bleeding?

Managing esophageal varices to prevent bleeding involves a combination of pharmacological and procedural interventions. Non-selective beta-blockers and octreotide help to reduce portal hypertension, while endoscopic variceal ligation directly addresses the varices. Monitoring for hypovolemic shock is essential to detect bleeding early. High-protein diets and diuretics are not directly related to the prevention of bleeding esophageal varices.

a nurse is teaching a community education course about the physical complications related to substance use disorder. which of the following findings should the nurse identify as primary cause of liver cirrhosis?

alcohol

a nurse is preparing to administer a dose of lactulose to a client who has cirrhosis. the client states "i dont need this med. i am not constipated". the nurse should explain that in clients who have cirrhosis, lactulose is used to decrease levels of the following components in the bloodstream?

ammonia Lactulose, a disaccharide, is a sugar that works as an osmotic diuretic. It prevents absorption of ammonia in the colon. Accumulation of ammonia in the bloodstream, which occurs in pathologic conditions of the liver, such as cirrhosis, may affect the central nervous system, causing hepatic encephalopathy or coma.

which of the following symptoms is most commonly associated with encephalopathy due to hepatic cirrhosis?

asterixis (flapping tremor) Asterixis is a hallmark sign of hepatic encephalopathy, characterized by a flapping tremor of the hands.

a nurse is planning care for a client who has cirrhosis and ascites. which of the following interventions should the nurse include in the plan of care?

decrease the client's fluid intake. The nurse should restrict fluids for a client who has cirrhosis and ascites due to the client's risk for increased fluid retention.

a nurse is reviewing the lab results of a client who has liver failure with ascites and is receiving spironolactone. which of the followings should the nurse expect?

decreased sodium level The nurse should expect a decreased sodium level. Spironolactone is a potassium-sparing diuretic that inhibits the action of aldosterone, resulting in an increased excretion of sodium.

a nurse is caring for a client who has liver cirrhosis with ascites, bleeding esophageal varices, and portal hypertension. the nruse recognizes which of the following lab findings as indicating the client's GI tract is digesting and absorbing blood?

elevated BUN

a nurse is caring for a client who has cirrhosis and has a prescription for bumetanide. when delivering the client's lunch tray, which of the following items should the nurse identify as contraindicated for the client?

ham sandwich

which of the following is a complication of hepatic encephalopathy?

hepatic coma

which of the following is a potential complication of ascites?

hepatic encephalopathy

a nurse is preparing a client who is scheduled to undergo a paracentesis. into which of the following positions should the nurse assist the client for this procedure?

high-fowler's

a nurse is caring for a client who has esophageal varices and is hypotensive after vomiting 500ml of blood. which of the following actions is the nurses priority>

increase the client's IV fluid rate

which of the following is a characteristic of portal hypertension?

increased blood pressure in the portal vein

a nurse is caring for a client who was admitted with bleeding esophageal varices and has an esophagogastric balloon tamponade with sengstaken-blakemore tube to control the bleeding. which of the following actions should the nurse take?

provide frequent oral and nares care

a nurse is planning care for a client who has end-stage cirrhosis of the liver with encephalopathy. which of the following interventions should the nurse plan to implement to decrese the client's ammonia level?

reduce the client's intake of protein Ammonia is formed in the gastrointestinal tract by the action of bacteria on protein. Limiting dietary protein intake can assist with decreasing the client's ammonia level. Protein is necessary for healing, so strict limitation of dietary protein is not recommended.

a nurse is assessing a client who has cirrhosis. which of the following is an expected finding for this client?

spider angiomas Spider angiomas are lesions with a red center and numerous extensions that spread out like a spider web. This is an expected finding for a client who has cirrhosis.

a nurse is planning care for a client who is postoperative following a liver transplant, and weights 65kg. which of the following actions should the nurse plan to take?

stress the importance of safe-food handling practices

a nurse is caring for a client who has cirrhosis and prothrombin time of 30 seconds. which of the following medications should the nurse plan to adminster?

vitamin K A prothrombin time of 30 seconds indicates the clotting time is prolonged and bleeding could occur. Vitamin K injection increases the synthesis of prothrombin by the liver; therefore, the nurse should plan to administer vitamin k.