Final 100 questions.

46. A client w/ cirrhosis is receiving lactulose. The nurse notes the client is more confused & has asterixis. What should the nurse do NEXT? 1. Assess for GI bleeding 2. W/hold the lactulose 3. Increase protein in the diet 4. Monitor serum bilirubin levels

1.

52. What diet should be implemented for a client who is in the early stages of cirrhosis ? 1. High-cal, high-carb 2. High protein, low-fat 3. low-fat, low-protein 4. high-carb, low-sodium

1.

56. Which position would be appropriate for a client w/ severe ascites? 1. Fowler's 2. Side-lying 3. Revere trendelenburg 4. Sims'

1.

58. A client w/ cirrhosis who has ascites receives 100 mL of 25% serum albumin IV. Which finding would BEST indicate the albumin is having its desired effect? 1. Reduces ascites 2. Increased serum albumin level 3. Decreased anorexia 4. Increased ease of breathing

1.

61. The nurse monitors a client w/ cirrhosis for the development of hepatic encephalopathy. Which would be an indication that hepatic encephalopathy is developing ? 1. Decreased mental status 2. Elevated blood pressure 3. Decreased urine output 4. Labored respirations

1.

65. The nurse is preparing a client for a paracentesis. What should the nurse do? 1. Have the client void immediately before the procedure 2. Place the client in a side-lying positions 3. Initiate an IV line to administer sedatives 4. Place the client on NPO status 6 hours before the procedure

1.

44. A client had a liver biopsy 1 hour ago. What should the nurse do FIRST? 1. Auscultate lung sounds 2. Check for fever 3. Obtain CBC 4. Apply packing to the biopsy site

1. Bc the biopsy needle insertion site is close to the lung, there is a risk of lung puncture & pneumothorax; therefore, immediately after the procedure, the nurse should determine diminished or absent lung sounds in the right lung. Although ferver indicates infection, a rise in temperaature is not seen immediately. A CBC is warranted if the vital sings & client symptoms indicate potential hemorrhage. The needle insertion site is covered w/ a pressure dressing; there is no need for a dressing requiring packing.

49. A nurse is developing a care plan for a client w/ hepatic encephalopathy. Which are goals for the care for this client? SATA 1. Prevent constipation 2. Administer lactulose to recuse blood ammonia levels 3. Monitor coordination while walking 4. Check the pupil reaction 5. Provide food & fluids high in carbohydrate 6. Encourage physical activity

1. 2. 3. 4. 5.

59. A client w/ a Sengstaken-Blakemore tube has a sudden drop in SpO2, & an increase in respiratory rate to 40 breaths/min. What should the nurse do in order from first to last ? 1. Affirm airway obstruction by the tube 2. Remove the tube 3. Deflate the tube by cutting w/ bedside scissors 4. Apply oxygen via face mask

1. 3. 2. 4.

51. A client w/ 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? 1. Constipation 2. Hyperkalemia 3. Irregular pulse 4. Dysuria

2.

54. Which health promotion activity should the nurse suggest that the client w/ cirrhosis add to the daily routine at home? 1. Supplement the diet w/ daily multivitamin 2. Abstain from drinking alcohol 3. Take a sleeping pill at bedtime 4. Limit contact w/ other people whenever possible

2.

63. A client is to be discharged w/ a prescription for lactulose. The nurse teaches the client how to administer this medication. Which statement would indicate that the client has understood the information? 1. "I will take it w/ an anti acid" 2. "I will mix it w/ apple juice" 3. "I will take it w/ a laxative" 4. "I will mix the crushed tablets in some gelatin"

2.

53. A client w/ jaundice has pruritus & areas of irritation form scratching. What measures can the nurse suggest that client use to prevent skin breakdown? SATA 1. Avoid lotion containing calamine 2. Add baking soda to the water in a tube bath 3. Keeps nails short & clean 4. Rub the skin when it itches w/ knuckles instead of nails 5. Massage skin w/ alcohol 6. Increase sodium intake in diet

2. 3. 4.

1. On a visit to the clinic, a client reports the onset of early symptoms of rheumatoid arthritis. The nurse should conduct a focused assessment for which symptoms? 1. Limited motion of the joints 2. Deformed joints of the hands 3. Early morning stiffness 4. Rheumatoid nodules

3.

47. The nurse is assessing a client w/ cirrhosis who has developed hepatic encephalopathy. The nurse should notify the HCP of a decrease in which serum lab value that is a potential precipitating factor for hepatic encephalopathy? 1. Aldosterone 2. Creatinine 3. Potassium 4. Protein

3.

50. The nurse is assessing a client who is in the early stages of cirrhosis of the liver. Which focused assessment is appropriate? 1. Peripheral edema 2. Ascites 3. Anorexia 4. Jaundice

3.

60. The HCP instructs a client w/ alcohol induced cirrhosis to stop drinking alcohol. The nurse should assess the client for which expected outcome? 1. Absence of delirium tremendous 2. Having a balance diet 3. Improved liver function 4. Reduce weight

3.

62. A client's serum ammonia level is elevated, & the HCP prescribes 30 mL of lactulose. Which effect is common for this drug? 1. Increased urine output 2. Improved level of consciousness 3. Increased bowel movements 4. Nausea & vomiting

3.

64. The nurse is proving D/C instructions for a client w/ cirrhosis. Which statement BEST indicated that the client has understood this teaching? 1. "I should eat a high-protein, high-carbohydrate diet to provide energy" 2. "It is safer for me to take acetaminophen for pain instead of aspirin' 3. "I should avoid constipation to decrease chances of bleeding" 4. "If i get enough rest & follow my diet, it's possible for my cirrhosis to be cured."

3.

66. A client with ascites & peripheral edema is at risk for impaired skin integrity. To prevent skin breakdown, what should the nurse do? 1. Institute ROM exercises every 4 hours 2. Massage the abdomen once a shift 3. Use an alternating wire pressure mattress 4. Elevate the lower extremities

3.

48. 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 prove the most accurate explanation of the disease process? 1. "He must have been eating too many food w/ salt in them. Salt pulls water w/ it." 2. "The swelling in his ankles must have moved up closer to his heart so the fluid circulates better." 3. "He must have forgotten to take his daily water pill." 4. "Blood is not able to flow readily through the liver now, & the liver cannot make protein to keep fluid inside the blood vessels."

4.

55. The nurse is reviewing the chart information for a client w/ increased ascites. The data include the following: temp. 98.9F, HR 118bpm, shallow respirations 26 breaths/min, BP 128/76, & SpO2 89% on RA. What should the nurse do FIRST? 1. Assess heart sounds 2. Obtain prescription for blood cultures 3. Prepare for a paracentesis 4. Raise the head of the bed

4.

57. The nurse is caring for a client w/ esophageal varices. The nurse should discuss which laboratory report finding w/ the HCP? 1. Normal serum albumin 2. Decreased ammonia 3. Slightly decreased levels of calcium 4. Elevated PT/INR

4.

Asterixis

aka Liver Flap, a flapping tremor of the hands. When the client extends the arms & hands in front of the body, the hands rapidly flex & extend.