Chp 49 and 50 med surg ?s

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? a) Administer enteral or parenteral nutrition. b) Carry out wound care as prescribed. c) Withhold oral feedings. d) Maintain the client in a semi-Fowler's position.

Maintain the client in a semi-Fowler's position. Correct Explanation: The nurse maintains the client in the semi-Fowler's position to decrease pressure on the diaphragm by a distended abdomen and to increase respiratory expansion. Respiratory distress and hypoxia are common, and the client may develop diffuse pulmonary infiltrates, dyspnea, tachypnea, and abnormal blood gas values. The client who has undergone surgery may have multiple drains or an open surgical incision and is at risk for skin breakdown and infection. Oral food or fluid intake is not permitted; therefore, enteral or parenteral feedings may be prescribed

The nurse is planning care for a patient following an incisional cholecystectomy for cholelithiasis. Which of the following interventions is the highest nursing priority for this patient? a) Performing range-of-motion (ROM) leg exercises hourly while the patient is awake b) Teaching the patient to choose low-fat foods from the menu c) Assisting the patient to ambulate the evening of the operative day d) Assisting the patient to turn, cough, and deep breathe every 2 hours

Assisting the patient to turn, cough, and deep breathe every 2 hours Correct Explanation: Assessment should focus on the patient's respiratory status. If a traditional surgical approach is planned, the high abdominal incision required during surgery may interfere with full respiratory excursion. The other nursing actions are also important, but are not as high a priority as ensuring adequate ventilation

Choice Multiple question - Select all answer choices that apply. A patient is admitted to the hospital with a possible common bile duct obstruction. What clinical manifestations does the nurse understand are indicators of this problem? (Select all that apply.) a) Jaundice b) Clay-colored feces c) Pruritus d) Pain in the left upper abdominal quadrant e) Amber-colored urine

Clay-colored feces • Pruritus • Jaundice Explanation: Jaundice occurs in a few patients with gallbladder disease, usually with obstruction of the common bile duct. The bile, which is no longer carried to the duodenum, is absorbed by the blood and gives the skin and mucous membranes a yellow color. This is frequently accompanied by marked pruritus (itching) of the skin. The excretion of the bile pigments by the kidneys gives the urine a very dark color. The feces, no longer colored with bile pigments, are grayish (like putty) or clay colored. (less)

Which of the following is clinical manifestation of cholelithiasis? a) Clay-colored stools b) Upper left quadrant abdominal pain c) Nonpalpable abdominal mass d) Epigastric distress prior to a meal

Clay-colored stools Explanation: The patient with gallstones has clay-colored stools, and excruciating upper right quadrant pain that radiates to the back or right shoulder. The excretion of bile pigments by the kidneys makes urine very dark. The feces, no longer colored with bile pigments, are grayish (like putty) or clay colored. The patient develops a fever and may have a palpable abdominal mass.

Choice Multiple question - Select all answer choices that apply. A mother brings her teenage son to the clinic, where tests show that he has hepatitis A virus (HAV). They ask the nurse how this could have happened. Which of the following explanations would the nurse correctly identify as possible causes? Select all that apply. a) Suboptimal sanitary habits b) Ingestion of undercooked beef c) Sexual activity d) Consumption of sewage-contaminated water or shellfish e) Infection at school

Correct response: • Infection at school • Suboptimal sanitary habits • Consumption of sewage-contaminated water or shellfish • Sexual activity Explanation: Typically, a child or a young adult acquires the infection at school through poor hygiene, hand-to-mouth contact, or close contact during play. The virus is carried home, where haphazard sanitary habits spread it through the family. An infected food handler can spread the disease, and people can contract it by consuming water or shellfish from sewage-contaminated waters. Outbreaks have occurred in day care centers and institutions as a result of poor hygiene among people with developmental disabilities. Hepatitis A can be transmitted during sexual activity. It is not contracted through the consumption of undercooked beef

A nurse is providing preoperative teaching to a client undergoing a cholecystectomy. Which topic should the nurse include in her teaching plan? a) Improve nutritional status during recovery. b) Increase respiratory effectiveness. c) Decrease the amount of postoperative analgesia needed. d) Eliminate the need for nasogastric intubation.

Increase respiratory effectiveness. Explanation: The nurse must teach the client about using an incentive spirometer to promote lung expansion. The high abdominal incision used in a cholecystectomy interferes with respirations postoperatively, increasing the risk of atelectasis. The client will need to use incentive spirometry to promote lung expansion, increase alveolar inflation, and strengthen respiratory muscles. Most clients don't have a nasogastric tube in place after a cholecystectomy. It isn't appropriate to teach improved nutritional status before surgery. It isn't important for the client to be aware of how to decrease the amount of postoperative analgesia, because this is the responsibility of the health care team

When caring for a client with acute pancreatitis, the nurse should use which comfort measure? a) Encouraging frequent visits from family and friends b) Positioning the client on the side with the knees flexed c) Administering an analgesic once per shift, as ordered, to prevent drug addiction d) Administering frequent oral feeding

Positioning the client on the side with the knees flexed Correct Explanation: The nurse should place the client with acute pancreatitis in a side-lying position with knees flexed; this position promotes comfort by decreasing pressure on the abdominal muscles. The nurse should administer an analgesic, as needed and ordered, before pain becomes severe, rather than once each shift. Because the client needs a quiet, restful environment during the acute disease stage, the nurse should discourage frequent visits from family and friends. Frequent oral feedings are contraindicated during the acute stage to allow the pancreas to rest

A client being treated for pancreatitis faces the risk of atelectasis. Which of the following interventions would be important to implement to minimize this risk? a) Monitor pulse oximetry every hour. b) Withhold analgesics unless necessary. c) Instruct the client to cough only when necessary. d) Use incentive spirometry every hour.

Use incentive spirometry every hour. Correct Explanation: The nurse instructs the client in techniques of coughing and deep breathing and in the use of incentive spirometry to improve respiratory function. The nurse assists the client to perform these activities every hour. Repositioning the client every 2 hours minimizes the risk of atelectasis. The client should be instructed to cough every 2 hours to reduce atelectasis. Monitoring pulse oximetry helps show changes in respiratory status and promotes early intervention, but it would do little to minimize the risk of atelectasis. Withholding analgesics is not an appropriate intervention due to the severe pain associated with pancreatitis.

A client is actively bleeding from esophageal varices. Which of the following medications would the nurse most expect to be administered to this client? a) Vasopressin (Pitressin) b) Lactulose (Cephulac) c) Spironolactone (Aldactone) d) Propranolol (Inderal)

Vasopressin (Pitressin) Explanation: In an actively bleeding client, medications are administered initially because they can be obtained and administered quicker than other therapies. Vasopressin (Pitressin) may be the initial mode of therapy in urgent situations, because it produces constriction of the splanchnic arterial bed and decreases portal pressure. Propranolol (Inderal) and nadolol (Corgard), beta-blocking agents that decrease portal pressure, are the most common medications used both to prevent a first bleeding episode in clients with known varices and to prevent rebleeding. Beta-blockers should not be used in acute variceal hemorrhage, but they are effective prophylaxis against such an episode. Spironolactone (Aldactone), an aldosterone-blocking agent, is most often the first-line therapy in clients with ascites from cirrhosis. Lactulose (Cephulac) is administered to reduce serum ammonia levels in clients with hepatic encephalopathy. (less)

A client is admitted for suspected GI disease. Assessment data reveal muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendency. The nurse suspects the client has: a) cholelithiasis. b) cirrhosis. c) appendicitis. d) peptic ulcer disease.

cirrhosis. Correct Explanation: Muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendencies are all symptoms of cirrhosis. The client may also have mild fever, edema, abdominal pain, and an enlarged liver. Clients with peptic ulcer disease complain of a dull, gnawing epigastric pain that's relieved by eating. Appendicitis is characterized by a periumbilical pain that moves to the right lower quadrant and rebound tenderness. Cholelithiasis is characterized by severe abdominal pain that presents several hours after a large meal

A client is suspected of having cirrhosis of the liver. What diagnostic procedure will the nurse prepare the client for in order to obtain a confirmed diagnosis? a) A CT scan b) A prothrombin time c) A liver biopsy d) Platelet cou

A liver biopsy Correct Explanation: A liver biopsy, which reveals hepatic fibrosis, is the most conclusive diagnostic procedure. It can be performed in the radiology department with ultrasound or CT to identify appropriate placement of the trocar or biopsy needle. A prothrombin time and platelet count will assist with determining if the client is at increased risk for bleeding.

A nurse is providing preoperative teaching to a client undergoing a cholecystectomy. Which topic should the nurse include in her teaching plan? a) Increase respiratory effectiveness. b) Eliminate the need for nasogastric intubation. c) Decrease the amount of postoperative analgesia needed. d) Improve nutritional status during recovery.

Increase respiratory effectiveness. Explanation: The nurse must teach the client about using an incentive spirometer to promote lung expansion. The high abdominal incision used in a cholecystectomy interferes with respirations postoperatively, increasing the risk of atelectasis. The client will need to use incentive spirometry to promote lung expansion, increase alveolar inflation, and strengthen respiratory muscles. Most clients don't have a nasogastric tube in place after a cholecystectomy. It isn't appropriate to teach improved nutritional status before surgery. It isn't important for the client to be aware of how to decrease the amount of postoperative analgesia, because this is the responsibility of the health care team. (less)

A client with cholelithiasis has a gallstone lodged in the common bile duct. When assessing this client, the nurse expects to note: a) black, tarry stools. b) circumoral pallor. c) light amber urine. d) yellow sclerae.

yellow sclerae. Explanation: Yellow sclerae are an early sign of jaundice, which occurs when the common bile duct is obstructed. Urine normally is light amber. Circumoral pallor and black, tarry stools don't occur in common bile duct obstruction; they are signs of hypoxia and GI bleeding, respectively.

A client with a history of alcohol abuse comes to the emergency department and complains of abdominal pain. Laboratory studies help confirm a diagnosis of acute pancreatitis. The client's vital signs are stable, but the client's pain is worsening and radiating to his back. Which intervention takes priority for this client? a) Administering morphine I.V. as ordered b) Providing mouth care c) Placing the client in a semi-Fowler's position d) Maintaining nothing-by-mouth (NPO) status

Administering morphine I.V. as ordered Explanation: The nurse should address the client's pain issues first by administering morphine I.V. as ordered. Placing the client in a Semi-Fowler's position, maintaining NPO status, and providing mouth care don't take priority over addressing the client's pain issues.

Which of the following terms is used to describe a chronic liver disease in which scar tissue surrounds the portal areas? a) Postnecrotic cirrhosis b) Compensated cirrhosis c) Biliary cirrhosis d) Alcoholic cirrhosis

Alcoholic cirrhosis Explanation: This type of cirrhosis is due to chronic alcoholism and is the most common type of cirrhosis. In postnecrotic cirrhosis, there are broad bands of scar tissue, which are a late result of a previous acute viral hepatitis. In biliary cirrhosis, scarring occurs in the liver around the bile ducts. Compensated cirrhosis is a general term given to the state of liver disease in which the liver continues to be able to function effectively.

A patient who had developed jaundice 2 months previous is brought to the ED after attending a party and developing excruciating pain that radiated over the abdomen and into the back. Upon assessment, which additional symptom would the nurse expect this patient to have? a) Weight loss b) Warm, dry skin c) Hypertension d) Bile-stained vomiting

Bile-stained vomiting Explanation: Nausea and vomiting are common in acute pancreatitis. The emesis is usually gastric in origin, but may also be bile stained. Fever, jaundice, mental confusion, and agitation may also occur.

When assessing a client with cirrhosis of the liver, which of the following stool characteristics is the client likely to report? a) Blood tinged b) Clay-colored or whitish c) Yellow-green d) Black and tarry

Clay-colored or whitish Correct Explanation: Many clients report passing clay-colored or whitish stools as a result of no bile in the gastrointestinal tract. The other stool colors would not be absolute indicators of cirrhosis of the liver but may indicate other GI tract disorders.

A client with cirrhosis has portal hypertension, which is causing esophageal varices. What is the goal of the interventions that the nurse will provide? a) Promote optimal neurologic function. b) Cure the cirrhosis. c) Treat the esophageal varices. d) Reduce fluid accumulation and venous pressure.

Correct response: Reduce fluid accumulation and venous pressure. Explanation: Methods of treating portal hypertension aim to reduce fluid accumulation and venous pressure. There is no cure for cirrhosis; treating the esophageal varices is only a small portion of the overall objective. Promoting optimal neurologic function will not reduce portal hypertension.

A patient is diagnosed with mild acute pancreatitis. What does the nurse understand is characteristic of this disorder? a) Disseminated intravascular coagulopathy b) Edema and inflammation c) Sepsis d) Pleural effusion

Edema and inflammation Correct Explanation: Mild acute pancreatitis is characterized by edema and inflammation confined to the pancreas. Minimal organ dysfunction is present, and return to normal function usually occurs within 6 months.

The mode of transmission of hepatitis A virus (HAV) includes which of the following? a) Semen b) Saliva c) Blood d) Fecal-oral

Fecal-oral Correct Explanation: The mode of transmission of hepatitis A virus (HAV) occurs through fecal-oral route, primarily through person to person contact and/or ingestion of fecal contaminated food or water. Hepatitis B virus (HBV) is transmitted primarily through blood. HBV can be found in blood, saliva, semen, and can be transmitted through mucous membranes and breaks in the skin.

A nurse is preparing a presentation for a local community group about hepatitis. Which of the following would the nurse include? a) Hepatitis C increases a person's risk for liver cancer. b) Hepatitis A is frequently spread by sexual contact. c) Infection with hepatitis G is similar to hepatitis A. d) Hepatitis B is transmitted primarily by the oral-fecal route.

Hepatitis C increases a person's risk for liver cancer. Correct Explanation: Infection with hepatitis C increases the risk of a person developing hepatic (liver) cancer. Hepatitis A is transmitted primarily by the oral-fecal route; hepatitis B is frequently spread by sexual contact and infected blood. Hepatitis E is similar to hepatitis A whereas hepatitis G is similar to hepatitis C

A client is being prepared to undergo laboratory and diagnostic testing to confirm the diagnosis of cirrhosis. Which test would the nurse expect to be used to provide definitive confirmation of the disorder? a) Coagulation studies b) Liver biopsy c) Magnetic resonance imaging d) Radioisotope liver scan

Liver biopsy Correct Explanation: A liver biopsy which reveals hepatic fibrosis is the most conclusive diagnostic procedure. Coagulation studies provide information about liver function but do not definitively confirm the diagnosis of cirrhosis. Magnetic resonance imaging and radioisotope liver scan help to support the diagnosis but do not confirm it. These tests provide information about the liver's enlarged size, nodular configuration, and distorted blood flow

A nurse is planning care for a patient with acute pancreatitis. Which of the following patient outcomes does the nurse assign as the highest priority? a) Adequate fluid and electrolyte balance b) Developing no acute complications from the pancreatitis c) Maintenance of normal respiratory function d) Maintaining satisfactory pain control

Maintenance of normal respiratory function Correct Explanation: Airway and breathing are always the priority assessment. Acute pancreatitis produces retroperitoneal edema, elevation of the diaphragm, pleural effusion, and inadequate lung ventilation. Intra-abdominal infection and labored breathing increase the body's metabolic demands, which further decreases pulmonary reserve and can lead to respiratory failure. Maintenance of adequate respiratory function is the priority goal. The other outcomes would also be appropriate for the patient.

Which of the following would be included as a postoperative intervention for the patient undergoing a laparoscopic cholecystectomy? a) Semi-Fowler's position b) Observe color of sclera c) Low-carbohydrate, low-protein diet immediately after surgery d) NPO status postop for 2 days

Observe color of sclera Explanation: The nurse should be particularly observant of the color of the sclera. After recovery from anesthesia, the patient is placed in the low Fowler's position. Water and other fluids may be administered within hours after laparoscopic procedures. A soft diet is started after bowel sounds return

A nurse assesses a patient diagnosed with hepatic encephalopathy. She observes a number of clinical signs, including asterixis and fetor hepaticus; the patient's electroencephalogram (EEG) is abnormal. The nurse documents that the patient is exhibiting signs of which stage of hepatic encephalopathy? a) Stage 3 b) Stage 1 c) Stage 4 d) Stage 2

Stage 2 Explanation: The signs listed in the question plus disorientation, mood swings, and increased drowsiness are all indicators of stage 2 hepatic encephalopathy. Refer to Table 25-2 in the text.

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 boardlike and no bowel sounds are detected. What is the major concern for this patient? a) The patient has developed peritonitis. b) The patient is developing a paralytic ileus. c) The patient has developed renal failure. d) The patient requires more pain medication.

The patient has developed peritonitis. Correct Explanation: Abdominal guarding is present. A rigid or boardlike abdomen may develop and is generally an ominous sign, usually indicating peritonitis

Which of the following is the most effective strategy to prevent hepatitis B infection? a) Avoid sharing toothbrushes b) Covering open sores c) Barrier protection during intercourse d) Vaccin

Vaccine Correct Explanation: The most effective strategy to prevent hepatitis B infection is through vaccination. Recommendations to prevent transmission of hepatitis B include vaccination of sexual contacts of individuals with chronic hepatitis, use of barrier protection during sexual intercourse, avoidance of sharing toothbrushes, razors with others, and covering open sores or skin lesion

Which of the following medications is used to decrease portal pressure, halting bleeding of esophageal varices? a) Nitroglycerin b) Cimetidine (Tagamet) c) Spironolactone (Aldactone) d) Vasopressin (Pitressin)

Vasopressin (Pitressin) Correct Explanation: Vasopressin may be the initial therapy for esophageal varices, because it constricts the splanchnic arterial bed and decreases portal hypertension. Nitroglycerin has been used to prevent the side effects of vasopressin. Aldactone and Tagamet do not decrease portal hypertension.

A client being treated for pancreatitis faces the risk of atelectasis. Which of the following interventions would be important to implement to minimize this risk? a) Instruct the client to avoid coughing. b) Monitor pulse oximetry every hour. c) Withhold oral feedings for the client. d) Reposition the client every 2 hours.

eposition the client every 2 hours. Explanation: Repositioning the client every 2 hours minimizes the risk of atelectasis in a client who is being treated for pancreatitis. The client should be instructed to cough every 2 hours to reduce atelectasis. Monitoring the pulse oximetry helps show changes in respiratory status and promote early intervention, but it would do little to minimize the risk of atelectasis. Withholding oral feedings limits the reflux of bile and duodenal contents into the pancreatic duct.

Choice Multiple question - Select all answer choices that apply. The nurse is assessing a patient with hepatic cirrhosis for mental deterioration. For what clinical manifestations will the nurse monitor? Select all that apply. a) Insomnia b) Agitation c) Alterations in mood d) Complaints of headache e) Decreased deep tendon reflexes

• Alterations in mood • Agitation • Insomnia Explanation: The earliest symptoms of hepatic encephalopathy include both mental status changes and motor disturbances. The patient appears confused and unkempt and has alterations in mood and sleep patterns. The patient tends to sleep during the day and has restlessness and insomnia at night. To assess for mental deterioration, the nurse will assess general behavior, orientation, and speech as well as cognitive abilities and speech patterns.

A nurse is caring for a client with cholelithiasis. Which sign indicates obstructive jaundice? a) Elevated urobilinogen in the urine b) Straw-colored urine c) Reduced hematocrit d) Clay-colored stools

Clay-colored stools Correct Explanation: Obstructive jaundice develops when a stone obstructs the flow of bile in the common bile duct. When the flow of bile to the duodenum is blocked, the lack of bile pigments results in a clay-colored stool. In obstructive jaundice, urine tends to be dark amber (not straw-colored) as a result of soluble bilirubin in the urine. Hematocrit levels aren't affected by obstructive jaundice. Because obstructive jaundice prevents bilirubin from reaching the intestine (where it's converted to urobilinogen), the urine contains no urobilinogen.

A nurse has admitted a client suspected of having acute pancreatitis. The nurse knows that mild acute pancreatitis is characterized by: a) Sepsis b) Disseminated intravascular coagulopathy c) Edema and inflammation d) Pleural effusion

Edema and inflammation Correct Explanation: Severe abdominal pain is the major symptom of pancreatitis that causes the client to seek medical care. Abdominal pain and tenderness and back pain result from irritation and edema of the inflamed pancreas

What test should the nurse prepare the client for that will locate stones that have collected in the common bile duct? a) Colonoscopy b) Cholecystectomy c) Endoscopic retrograde cholangiopancreatography (ERCP) d) Abdominal x-ra

Endoscopic retrograde cholangiopancreatography (ERCP) Correct Explanation: ERCP locates stones that have collected in the common bile duct. A colonoscopy will not locate gallstones but only allows visualization of the large intestine. Abdominal x-ray is not a reliable locator of gallstones. A cholecystectomy is the surgical removal of the gallbladder.

A client has developed drug-induced hepatitis from a drug reaction to antidepressants. What treatment does the nurse anticipate the client will receive to treat the reaction? a) Liver transplantation b) Paracentesis c) Azathioprine (Imuran) d) High-dose corticosteroids

High-dose corticosteroids Explanation: Drug-induced hepatitis occurs when a drug reaction damages the liver. This form of hepatitis can be severe and fatal. High-dose corticosteroids usually administered first to treat the reaction. Liver transplantation may be necessary. Paracentesis would be used to withdrawal fluid for the treatment of ascites. Azathioprine (Imuran) may be used for autoimmune hepatitis

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? a) Anxiety b) Disturbed body image c) Nausea d) Impaired nutrition: less than body requirements

Impaired nutrition: less than body requirements Correct Explanation: While each diagnosis may be applicable to this client, the priority nursing diagnosis is impaired nutrition: less than body requirements. The physician, nurse, and dietitian emphasize to the client and family the importance of avoiding alcohol and foods that have produced abdominal pain and discomfort in the past. Oral food or fluid intake is not permitted during the acute phase.

The nurse should assess for an important early indicator of acute pancreatitis, which is a prolonged and elevated level of: a) Serum amylase b) Serum bilirubin c) Serum calcium d) Serum lipase

Serum lipase Explanation: Serum amylase and lipase levels are elevated within 24 hours of the onset of symptoms. Serum amylase usually returns to normal within 48 to 72 hours, but serum lipase levels may remain elevated days longer than amylase. (less)

A nurse is caring for a client with cirrhosis. The nurse assesses the client at noon and discovers that the client is difficult to arouse and has an elevated serum ammonia level. The nurse should suspect which situation? a) The client's hepatic function is decreasing. b) The client is avoiding the nurse. c) The client is relaxed and not in pain. d) The client didn't take his morning dose of lactulose (Cephulac).

The client's hepatic function is decreasing. Correct Explanation: The decreased level of consciousness caused by an increased serum ammonia level indicates hepatic disfunction. If the client didn't take his morning dose of lactulose, he wouldn't have elevated ammonia levels and decreased level of consciousness this soon. These assessment findings don't indicate that the client is relaxed or avoiding the nurse.

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 boardlike and no bowel sounds are detected. What is the major concern for this patient? a) The patient has developed peritonitis. b) The patient requires more pain medication. c) The patient is developing a paralytic ileus. d) The patient has developed renal failure.

The patient has developed peritonitis. Explanation: Abdominal guarding is present. A rigid or boardlike abdomen may develop and is generally an ominous sign, usually indicating peritonitis

Which of the following is clinical manifestation of cholelithiasis? a) Upper left quadrant abdominal pain b) Epigastric distress prior to a meal c) Clay-colored stools d) Nonpalpable abdominal mass

Clay-colored stools Explanation: The patient with gallstones has clay-colored stools, and excruciating upper right quadrant pain that radiates to the back or right shoulder. The excretion of bile pigments by the kidneys makes urine very dark. The feces, no longer colored with bile pigments, are grayish (like putty) or clay colored. The patient develops a fever and may have a palpable abdominal mass

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) Ataxia b) Constructional apraxia c) Fetor hepaticus d) Asterixis

Correct response: Asterixis Explanation: Asterixis, an involuntary flapping of the hands, may be seen in stage II encephalopathy (Fig. 49-13).

What test should the nurse prepare the client for that will locate stones that have collected in the common bile duct? a) Cholecystectomy b) Abdominal x-ray c) Colonoscopy d) Endoscopic retrograde cholangiopancreatography (ERCP)

Endoscopic retrograde cholangiopancreatography (ERCP) Explanation: ERCP locates stones that have collected in the common bile duct. A colonoscopy will not locate gallstones but only allows visualization of the large intestine. Abdominal x-ray is not a reliable locator of gallstones. A cholecystectomy is the surgical removal of the gallbladder. (less)

The nurse identifies which of the following types of jaundice in an adult experiencing a transfusion reaction? a) Hepatocellular b) Nonobstructive c) Hemolytic d) Obstructive

Hemolytic Correct Explanation: Hemolytic jaundice occurs because, although the liver is functioning normally, it cannot excrete the bilirubin as quickly as it is formed. This type of jaundice is encountered in patients with hemolytic transfusion reactions and other hemolytic disorders. Obstructive jaundice is the result of liver disease. Nonobstructive jaundice occurs with hepatitis. Hepatocellular jaundice is the result of liver disease. (less)

A client is admitted with increased ascites related to cirrhosis. Which nursing diagnosis should receive top priority? a) Imbalanced nutrition: Less than body requirements b) Ineffective breathing pattern c) Excess fluid volume d) Fatigue

Ineffective breathing pattern Correct Explanation: In ascites, accumulation of large amounts of fluid causes extreme abdominal distention, which may put pressure on the diaphragm and interfere with respiration. If uncorrected, this problem may lead to atelectasis or pneumonia. Although fluid volume excess is present, the diagnosis Ineffective breathing pattern takes precedence because it can lead more quickly to life-threatening consequences. The nurse can deal with fatigue and altered nutrition after the client establishes and maintains an effective breathing pattern. (less)

A physician orders spironolactone (Aldactone), 50 mg by mouth four times daily, for a client with fluid retention caused by cirrhosis. Which finding indicates that the drug is producing a therapeutic effect? a) Serum potassium level of 3.5 mEq/L b) Serum sodium level of 135 mEq/L c) Blood pH of 7.25 d) Loss of 2.2 lb (1 kg) in 24 hours

Loss of 2.2 lb (1 kg) in 24 hours Correct Explanation: Daily weight measurement is the most accurate indicator of fluid status; a loss of 2.2 lb (1 kg) indicates loss of 1 L of fluid. Because spironolactone is a diuretic, weight loss is the best indicator of its effectiveness. This client's serum potassium and sodium levels are normal. A blood pH of 7.25 indicates acidosis, an adverse reaction to spironolactone.

A patient has a nasogastric (NG) tube for suction and is NPO following a pancreaticoduodenectomy. Which of the following explanations made by the nurse is the major purpose of this treatment? a) The tube will allow the gastrointestinal (GI) tract to rest. b) The tube will help control fluid and electrolyte imbalance. c) The tube will allow the removal of toxins. d) The tube will provide relief from nausea and vomiting.

The tube will allow the gastrointestinal (GI) tract to rest. Correct Explanation: Postoperative management of patients who have undergone a pancreatectomy or a pancreaticoduodenectomy is similar to the management of patients after extensive gastrointestinal or biliary surgery. An NG tube with suction and parenteral nutrition allows the GI tract to rest while promoting adequate nutrition. (

Choice Multiple question - Select all answer choices that apply. The nurse admits a woman reporting severe right upper quadrant pain after eating Christmas dinner. The nurse suspects gallbladder disease. Statistics show that incidence of gallbladder disease is greater for women who are a) Thin b) Multiparous c) Older than 40 years d) Obese

• Obese • Older than 40 years • Multiparous Correct Explanation: Two to three times more women than men develop cholesterol stones and gallbladder disease; affected women are usually older than 40 years, multiparous, and obese.

A nurse is caring for a client with cirrhosis. The nurse assesses the client at noon and discovers that the client is difficult to arouse and has an elevated serum ammonia level. The nurse should suspect which situation? a) The client didn't take his morning dose of lactulose (Cephulac). b) The client is avoiding the nurse. c) The client's hepatic function is decreasing. d) The client is relaxed and not in pain

The client's hepatic function is decreasing. Explanation: The decreased level of consciousness caused by an increased serum ammonia level indicates hepatic disfunction. If the client didn't take his morning dose of lactulose, he wouldn't have elevated ammonia levels and decreased level of consciousness this soon. These assessment findings don't indicate that the client is relaxed or avoiding the nurse.