Chapter 49 NCLEX style questions

The nurse is caring for a patient with ascites as a result Of hepatic dysfunction. What intervention can the nurse provide to determine if the ascites is increasing? (Select all that apply) A. measure urine output every eight hours B. assess and document vital signs every four hours C. measure abdominal girth daily D. perform daily weights E. monitor number of bowel movements per day

C. measure abdominal girth daily D. perform daily weights

The nurse is concerned about potassium loss when a diuretic is prescribed for a patient with ascites and edema. What diuretic may be ordered that spares potassium and prevents hypokalemia? A. Furosemide B. Spironolactone C. Acetazolamide D. Bumetanide

B. Spironolactone

The nurse is providing care to a patient with gross ascites who is maintaining a position of comfort in the high semi fowlers position. What is the nurses priority assessment of this patient? A. Respiratory assessment related to increased thoracic pressure B. urinary output related to increased sodium retention C. peripheral vascular assessment related to immobility D. skin assessment related to increase in bile salts

A. Respiratory assessment related to increased thoracic pressure

A patient is scheduled for a diagnostic paracentesis, but when coagulation studies are reviewed, the nurse observes results outside of normal parameters. How does the nurse anticipate the health care provider we'll proceed with the paracentesis? A. An ultrasound guided paracentesis will be performed B. the procedure will be cancelled until the laboratory results are within normal parameters C. the paracentesis will be performed at the bedside D. the nurse will administer packed red blood cells prior to the paracentesis

A. An ultrasound guided paracentesis will be performed

A patient with bleeding esophageal varices Has had pharmacologic therapy with octreotide 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? A. Transjugular intrahepatic portosystemic shunting TIPS B. administration of vasopressin C. sclerotherapy D. balloon Tamponade

A. Transjugular intrahepatic portosystemic shunting TIPS

The nurse is administering Lactulose to decrease the amount of ammonia level in a patient who has hepatic encephalopathy. What should the nurse carefully monitor for that may indicate a medication overdose? A. Watery diarrhea B. Vomiting C. ringing in the ears D. the presence of asterixis

A. Watery diarrhea

The nurse is educating a patient with cirrhosis about the importance of maintaining a low sodium diet. What food item would be permitted on a low sodium diet? A. Peanut butter B. a pear C. hot dog D. sliced ham

B. a pear

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 foods and fluids? A. For two hours after the last dose of medication is given B. until the gag reflex returns C. until the patient expresses thirst D. for six hours after the procedure

B. until the gag reflex returns

A student accepted into a nursing program must begin receiving the hepatitis B series of injections. The student asks when the next two injections should be administered. What is the best response by the instructor? A. You must have the second one in two weeks and the third in one month B. you must have the second one in one month and the third in six months C. you must have the second one in six months and the third in one year D. you must have the second one in one year and the third the following year

B. you must have the second one in one month and the third in six months

A patient who had a recent myocardial infarction was brought to the emergency department with bleeding esophageal varices and is presently receiving fluid resuscitation. what first line pharmacologic therapy does the nurse anticipate administering to control the bleeding from the varices? A. Vasopressin B. Epinephrine C. Octreotide D. Glucagon

C. Octreotide

The nurse is educating a patient who has been treated for hepatic encephalopathy about dietary restrictions to prevent ammonia accumulation. What should the nurse include in the teaching? A. Decrease the amount of fats in the diet B. increase the amount of potassium in the diet C. decrease the amount of protein in the diet D. increase the amount of magnesium in the diet

C. decrease the amount of protein in the diet

The nurse is caring for a patient with cirrhosis of the liver and observes that the patient is having hand flapping tremors. What does the nurse document this finding as? A. Constructional apraxia B. Fector hepaticus C. Ataxia D. Asterixis

D. Asterixis

What intervention does the nurse anticipate providing for the patient with ascites that will help correct the decrease in effective arterial blood volume that leads to sodium retention A. administration of diuretic therapy B. assisting with a therapeutic paracentesis C. infusing platelets D. infusing albumin

D. infusing albumin

The nurse is caring for a patient with ascites due to cirrhosis of the liver. What position does the nurse recognize will activate the renin- angiotensin -aldosterone and sympathetic nervous system and decrease responsive nis to diuretic therapy? A. Prone B. Supine C. left lateral Sims D. up right

D. up right

A patient with severe chronic liver dysfunction comes to the clinic with bleeding of the gums and blood in the stool. What vitamin deficiency does the nurse suspect the patient may be experiencing? A. Riboflavin deficiency B. folic acid deficiency C. Vitamin A deficiency D. vitamin K deficiency

D. vitamin K deficiency