NUR 213 test 5

3 Clay-colored stools and hemorrhoids are gastrointestinal effects of liver failure.

Which gastrointestinal assessment data should the nurse expect to find when assessing the client in end-stage liver failure? 1. Hypoalbuminemia and muscle wasting. 2. Oligomenorrhea and decreased body hair. 3. Clay-colored stools and hemorrhoids. 4. Dyspnea and caput medusae.

b if a needlestick injury occurs you should: 1. wash the wound with soapy water 2. tell the manager or supervisor about the injury 3. complete a report of the incident the client may be tests for HIN, hep B and C after the doctor is consulted

after administering an injection to a child the nurse scratches their wrist with the used needle. what is the next best action? a. complete an incident report b. wash the area with soapy water c. notify the unit manager d. call the clients doctor

b the first vaccine should be given within 12 hours of exposure

an unvaccinated healthcare worker has been exposed to hepatitis B through a needle stick. which of the following should the nurse anticipate administering as a post exposure prophylaxis? a. hepatitis B immune globulin b. hepatitis b vaccine and hepatitis b immune globulin c. hepatitis B surface antigen d. amphotericin B

c nursing is high risk for hep b because it is bloodborne pathogens

nurses and other healthcare workers are considered high risk for infection by bloodborne pathogens. which of the following vaccines is mandated by OSHA for healthcare workers? a. influenza b. TB c. Hepatitis B d. Hepatitis C

b the closer the individual is to the actual site the longer they are exposed to it the greater the psychological distress the individual will experience possibly leading to PTSD

nurses are working with the victims of disaster after a bombing at a school lunchroom. which persons have the greatest risk for factors of PTSD? a. first responders arriving just after the bombing b. cafeteria workers at the site closest to the bomb c. children who were being dropped off for school at the entrance d. disaster trained healthcare school nurses

b

select the classification of a medication used for depression that is accurately paired with its possible adverse effects. a. tricyclic antidepressants: hypertensive crisis b. SSRI: serotonin syndrome c. MAOI: cholinergic blockade d. SSRI: decreased seizure threshold

d they may develop s/s heart failure and dyspnea. this reaction is about 20% of transfusion related deaths

the nurse is preparing to administer on unit of whole blood. which of the following describes the most life threatening complication associated with blood transfusions? a. chill rigor reaction b. Hep A c. a febrile non-hemolytic reaction d. transfusion related circulatory overload

d

when receiving a transfusion a PRBCs a male client begins to vomit and becomes hypotensive with a BP of 88/52 and temp of 98.6. which of the following complications associated with a blood transfusion is most likely present? a. volume overload b. delayed transfusion reaction c. hyperkalemia d. septic shock

d, e

which of the following body body substances can transmit hepatitis C? select all that apply a. sweat b. urine c. stool d. blood e. semen

a

which of the following clients with symptoms of infection is most concerning for early onset of sepsis? a. a client with a blood pressure of 86/58 b. a client with a rr of 20 and O2 95% c. a client with a platelet count of 150,000 d. a client with a serum lactate level of 2

3 This is the main reason the HCP decreases the client's medication dose and is an explanation appropriate for the client.

The client is diagnosed with end-stage liver failure. The client asks the nurse, "Why is my doctor decreasing the doses of my medications?" Which statement is the nurse's best response? 1. "You are worried because your doctor has decreased the dosage." 2. "You really should ask your doctor. I am sure there is a good reason." 3. "You may have an overdose of the medications because your liver is damaged." 4. "The half-life of the medications is altered because the liver is damaged."

1 The U.S. Food and Drug Administration (FDA, 2001) has approved a combined hepatitis A and B vaccine (Twinrix) for vaccination of persons 18 years of age and older with indications for both hepatitis A and B vaccination. The Twinrix vaccination consists of three doses, given on the same schedule as that used for single-antigen hepatitis B vaccine—that is, initial dose, after 1 month, and at 6 months.

The client who is homeless comes to the free clinic. During the interview the client admits to using illegal intravenous drugs. Which intervention would the nurse recommend to the client? 1. Recommend the combined hepatitis A and B vaccine (Twinrix). 2. Recommend the client receive the hepatitis B vaccination. 3. Recommend the client go to the county rehabilitation center. 4. Recommend that the client receive the HIV vaccination.

4 SSRIs reduce the three core symptoms of PTSD: re-experiencing, avoidance/emotional numbing, and hyperarousal. The medication is most effective if taken within 3 months of the traumatic event and may take up to 2 or 3 months for maximal response.

The client who returned from the war 1 month ago is diagnosed with posttraumatic stress disorder (PTSD) and prescribed paroxetine (Paxil), an SSRI. The client asks the nurse, "Will this medication really help me? I don't like feeling this way." Which statement is the nurse's best response? 1. "The medication will make you feel better within a couple of days." 2. "Why do you think the medication won't help you feel better?" 3. "Nothing really helps PTSD unless you go to counseling weekly." 4. "Because the traumatic event was within 1 month, the Paxil should be helpful."

4 The hepatitis B vaccine must be administered intramuscularly in three doses, with the second and third doses at 1 and 6 months after the first dose. The third dose is very important in producing prolonged immunity.

The clinic nurse is preparing to administer the hepatitis B vaccine to the client. Which information should the nurse discuss with the client? 1. Instruct the client to come back to the clinic in 2 months for the last injection. 2. Teach the client not to wash the injection site for at least 24 hours. 3. Encourage the client to rotate the arms when receiving the hepatitis B vaccine. 4. Explain that the client must have two more doses of the vaccine at 1 and 6 months

4 The nurse should advise the client to avoid substances (medications, herbs, illicit drugs, and toxins) that may affect liver function; therefore, the nurse should determine if St. John's wort is hepatotoxic.

The male client diagnosed with chronic hepatitis C tells the nurse that he is taking the herb St. John's wort for depression. Which action should the nurse implement? 1. Tell the client to quit taking the herb immediately. 2. Document the information and take no action. 3. Encourage the client to take a prescribed antidepressant. 4. Determine if the herb has hepatotoxic properties.

1 During ribavirin treatment, pregnancy must be ruled out. During treatment, pregnancy must be avoided both by females and by female partners of men taking ribavirin. To avoid pregnancy, couples should use two reliable forms of birth control during treatment and for 6 months after treatment.

The male client with chronic hepatitis C is being prescribed ribavirin (Virazole), an antiviral medication. Which information should the nurse discuss with the client? 1. Discuss the importance of using two reliable forms of birth control. 2. Explain the need to eat a diet high in vitamin K during treatment. 3. Instruct the client to avoid direct sunlight for long periods. 4. Teach the client that the medication might cause temporary impotence.

3 Hepatitis B immune globulin (HBIG) provides passive immunity against hepatitis B and is indicated for people exposed to the hepatitis B virus who have never had hepatitis B and have never received the hepatitis B vaccination.

The public health nurse notified a young woman that one of her sexual contacts was positive for hepatitis B. The woman denied ever having hepatitis B or having received the hepatitis B vaccinations. Which information is most important for the nurse to discuss with the woman? 1. Instruct the woman not to have unprotected sexual intercourse. 2. Advise the woman not to drink any type of alcoholic beverage. 3. Tell the woman to get hepatitis B immune globulin (HBIG). 4. Encourage the client to get the hepatitis B vaccination.

d ascites is caused by portal hypertension

a nurse is caring for a client with cirrhosis of the liver with ascites. the nurse knows that ascites is caused by which of the following? a. reduced production of coagulation factors b. increased albumin synthesis c. increased ammonia d. portal hypertension

2 Infants born to mothers of unknown hepatitis B antigen status should be given the hepatitis B immune globulin and hepatitis B vaccine within 12 hours of birth. If the mother is positive for hepatitis B antigen, then the baby should receive the hepatitis B immune globulin as soon as possible within 12 hours of birth. Timely administration of the hepatitis B vaccine is important to prevent passive acquisition of hepatitis B from the mother.

What would be the best plan of care for a newborn whose mother's hepatitis B antigen status is unknown? 1. Give the infant the hepatitis B vaccine within 12 hours of birth. 2. Give the infant the hepatitis B vaccine and hepatitis B immune globulin within 12 hours of birth. 3. Give the infant the hepatitis B vaccine within 24 hours of birth. 4. Give the infant the hepatitis B vaccine and hepatitis B immune globulin within 24 hours of birth.

3 The nurse must know when the client had the last alcoholic drink to be able to determine when and if the client will experience delirium tremens, the physical withdrawal from alcohol.

Which assessment question is priority for the nurse to ask the client diagnosed with end-stage liver failure secondary to alcoholic cirrhosis? 1. "How many years have you been drinking alcohol?" 2. "Have you completed an advance directive?" 3. "When did you have your last alcoholic drink?" 4. "What foods did you eat at your last meal?"

2 Adequate rest is needed for maintaining optimal immune function.

Which instruction should the nurse discuss with the client who is in the icteric phase of hepatitis C? 1. Decrease alcohol intake. 2. Encourage rest periods. 3. Eat a large evening meal. 4. Drink diet drinks and juices.

3 The UAP can perform a bedside glucometer check, but the nurse must evaluate the result and determine any action needed.

Which task is most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? 1. Draw the serum liver function test. 2. Evaluate the client's intake and output. 3. Perform the bedside glucometer check. 4. Help the ward clerk transcribe orders.

b gram negative infections are primarily spread through urinary catheterization in nursing homes and hospitals

a charge nurse is is providing staff education about HAIs. which of the following is the most effective way to reduce the risk of gram negative septicemia in clients admitted to healthcare facilities? a. limiting visitor contact b. limiting unnecessary urinary tract catheterizations c. using negative pressure airflow d. using n95 respirator

b

a nurse is assessing an elderly client with pneumonia. which of the following findings is potentially an early sign of sepsis? a. RR 19 b. Altered mental status c. WBC 11,000 d. hypoglycemia

2 The first dose of hepatitis B vaccine is recommended between birth and 2 months. Most hospitals give the vaccine prior to discharge home.

A 2-day-old girl is being discharged from the hospital. Her mother asks the nurse when she will receive her first hepatitis B immunization. Which is the nurse's best response? 1. "Babies receive the hepatitis B vaccine only if their mother is hepatitis B-positive." 2. "She will receive her first dose of the hepatitis B vaccine prior to discharge today." 3. "She will receive her first hepatitis B vaccine when she is 1 year of age." 4. "She will receive her first hepatitis B vaccine at 6 months of age."

3 Meningococcemia is a serious complication usually associated with meningococcal infection. A client with a severe allergic reaction and impending anaphylaxis would most likely have signs and symptoms of respiratory distress, GI problems (abdominal pain, cramps, and diarrhea), hypotension, hives, itching, and anxiety. SIADH can be an acute complication, but it would not be accompanied by the purpuric rash. Adhesive arachnoiditis occurs in the chronic phase of the disease and leads to obstructed flow of cerebrospinal fluid.

A child with a diagnosis of meningococcal meningitis develops signs of sepsis and a purpuric rash over both lower extremities. The primary health care provider would be notified immediately because these signs could be indicative of which complication? 1. a severe allergic reaction to the antibiotic regimen with impending anaphylaxis 2. onset of the SIADH 3. meningococcemia 4. adhesive arachnoiditis

2, 3, 4, 5, 6 PTSD is a serious condition that develops after a person has witnessed a traumatic or terrifying event in which serious physical harm has occurred or is threatened. Although PTSD is commonly associated with combat, it can manifest itself after any kind of trauma. If symptoms occur within 6 months of the traumatic event, the disorder is considered acute. If symptoms occur more than 6 months after the traumatic event, PTSD is considered delayed or chronic. PTSD is characterized by nightmares or flashbacks. Clients are hypervigilant but typically describe themselves as "empty inside." Sometimes, the events can present as a psychotic episode. Substance abuse is a common "symptom" used for coping.

A client is being seen in the clinic after returning from military service abroad. The nurse documents restlessness at night with nightmares leaving the veteran irritable and fatigued during the day. When discussing the possibility of posttraumatic stress disorder (PTSD), which statements about PTSD are accurate? Select all that apply. 1. PTSD is a syndrome that is only associated with military personnel. 2. PTSD is characterized by nightmares and flashbacks. 3. Hypervigilance is characteristic of clients with PTSD. 4. Substance abuse is a common coping mechanism used by clients with PTSD. 5. Psychotic episodes can occur in clients with PTSD. 6. Clients with PTSD may complain of feeling empty inside.

3 Within 12 hours of birth, the baby should receive both the first injection of hepatitis B vaccine and HBIG.

A woman who is hepatitis B-surface antigen positive is in active labor. Which action by the nurse is appropriate at this time? 1. Obtain an order from the obstetrician to prepare the client for cesarean delivery. 2. Obtain an order from the obstetrician to administer intravenous ampicillin during labor and the immediate postpartum. 3. Obtain an order from the pediatrician to administer hepatitis B immune globulin and hepatitis B vaccine to the baby after birth. 4. Obtain an order from the pediatrician to place the baby in isolation after delivery.

c in clients with sepsis renal failure may occur resulting in rising creatinine and oliguria

a nurse is monitoring a client who is suspected of developing sepsis. which of the following is a sign of organ system failure due to sepsis? a. decreased serum lactate b. hypertension c. increased creatinine d. thrombocytosis

2 Some of the flulike symptoms (fever, headache, myalgia) can be reduced with acetaminophen.

The client diagnosed with chronic hepatitis C who is taking interferon alfacon (Infergen), an antiviral medication, reports having fever, muscle pain, and headaches to the nurse. Which action should the nurse take? 1. Instruct the client to taper off the medications immediately. 2. Encourage the client to take acetaminophen (Tylenol). 3. Explain that the client will just have to live with these side effects. 4. Recommend that the client see the health-care provider.

2 While the balloons are inflated, the client must not be left unattended in case they become dislodged and occlude the airway. This is a safety issue.

The client diagnosed with end-stage liver failure is admitted with esophageal bleeding. The HCP inserts and inflates a triple-lumen nasogastric tube (Sengstaken- Blakemore). Which nursing intervention should the nurse implement for this treatment? 1. Assess the gag reflex every shift. 2. Stay with the client at all times. 3. Administer the laxative lactulose (Chronulac). 4. Monitor the client's ammonia level.

4 Ammonia is a by-product of protein metabolism and contributes to hepatic encephalopathy. Reducing protein intake should decrease ammonia levels.

The client diagnosed with end-stage liver failure is admitted with hepatic encephalopathy. Which dietary restriction should be implemented by the nurse to address this complication? 1. Restrict sodium intake to 2 g/day. 2. Limit oral fluids to 1,500 mL/day. 3. Decrease the daily fat intake. 4. Reduce protein intake to 60 to 80 g/day.

3 The client is at risk for hypovolemia; therefore, vital signs will be assessed frequently to monitor for signs of hemorrhaging.

The client diagnosed with end-stage renal failure and ascites is scheduled for a paracentesis. Which client teaching should the nurse discuss with the client? 1. Explain the procedure will be done in the operating room. 2. Instruct the client a Foley catheter will have to be inserted. 3. Tell the client vital signs will be taken frequently after the procedure. 4. Provide instructions on holding the breath when the HCP inserts the catheter.

1 Hot water increases pruritus, and soap will cause dry skin, which increases pruritus; therefore, the nurse should discuss this with the UAP

The client diagnosed with liver failure is experiencing pruritus secondary to severe jaundice. Which action by the unlicensed assistive personnel (UAP) warrants intervention by the nurse? 1. The UAP is assisting the client to take a hot soapy shower. 2. The UAP applies an emollient to the client's legs and back. 3. The UAP puts mittens on both hands of the client. 4. The UAP pats the client's skin dry with a clean towel.

2 Bilirubin, the by-product of red blood cell destruction, is metabolized in the liver and excreted via the feces, which causes the feces to be brown in color. If the liver is damaged, the bilirubin is excreted via the urine and skin.

The client diagnosed with liver problems asks the nurse, "Why are my stools clay- colored?" On which scientific rationale should the nurse base the response? 1. There is an increase in serum ammonia level. 2. The liver is unable to excrete bilirubin. 3. The liver is unable to metabolize fatty foods. 4. A damaged liver cannot detoxify vitamins.

4 A sensitivity report indicating a resistance to the antibiotic being administered indicates the medication the client is receiving is not appropriate for the treatment of the infectious organism, and the HCP needs to be notified so the antibiotic can be changed.

The client diagnosed with septicemia is receiving a broad-spectrum antibiotic. Which laboratory data require the nurse to notify the health-care provider? 1. The client's potassium level is 3.8 mEq/L. 2. The urine culture indicates high sensitivity to the antibiotic. 3. The client's pulse oximeter reading is 94%. 4. The culture and sensitivity is resistant to the client's antibiotic.

3 This is correct information. An immune globulin injection within 2 weeks of exposure will help prevent the client from getting hepatitis A.

The client exposed to hepatitis A calls the clinic and wants to know if anything can be done to prevent getting hepatitis A. Which information should the nurse tell the client? 1. Explain that there is a hepatitis A vaccine available that the client can receive. 2. Inform the client that there is nothing available to help prevent hepatitis A. 3. Instruct the client to get an immune globulin injection within 2 weeks. 4. Tell the client to go to the nearest emergency department as soon as possible.

1 Blood in the intestinal tract is digested as a protein, which increases serum ammonia levels and increases the risk of developing hepatic encephalopathy.

The client has end-stage liver failure secondary to alcoholic cirrhosis. Which complication indicates the client is at risk for developing hepatic encephalopathy? 1. Gastrointestinal bleeding. 2. Hypoalbuminemia. 3. Splenomegaly. 4. Hyperaldosteronism.

3 Direct pressure is applied to the site, and then the client is placed on the right side to maintain site pressure.

The client has had a liver biopsy. Which postprocedure intervention should the nurse implement? 1. Instruct the client to void immediately. 2. Keep the client NPO for eight (8) hours. 3. Place the client on the right side. 4. Monitor BUN and creatinine level.

2 An elevated ammonia level affects the client's neurological status. Lactulose is prescribed to remove ammonia through the intestinal tract. Assessing the client's neurological status will determine the effectiveness of the medication.

The client in end-stage liver failure has an elevated ammonia level. The health-care provider prescribes lactulose (Cephulac), a laxative. Which intervention should the nurse implement to determine the effectiveness of the medication? 1. Monitor the client's intake and output. 2. Assess the client's neurological status. 3. Measure the client's abdominal girth. 4. Document the number of bowel movements.

1, 2, 3, 4 Vitamin K deficiency causes impaired coagulation; therefore, rectal thermometers should be avoided to prevent bleeding. Soft-bristle toothbrushes will help pre- vent bleeding of the gums. Platelet count, PTT/PT, and INR should be monitored to assess coagulation status.Injections should be avoided, if at all possible, because the client is unable to clot, but if they are absolutely necessarily, the nurse should use small- gauge needles.

The client in end-stage liver failure has vitamin K deficiency. Which interventions should the nurse implement? Select all that apply. 1. Avoid rectal temperatures. 2. Use only a soft toothbrush. 3. Monitor the platelet count. 4. Use small-gauge needles. 5. Assess for asterixis.

3 The client in end-stage liver failure would have hepatic encephalopathy, which affects the client's neurological status. Therefore, sedatives, tranquilizers, and analgesic medications are not administered to the client. The nurse would question this order.

The client in end-stage liver failure is being admitted to the medical floor. Which health-care provider's order would the nurse question? 1. Prepare the client for a paracentesis. 2. Administer vitamin C 100 mg po daily. 3. Administer morphine 2 mg IVP for pain. 4. Give D5W 0.9 NS at 25 mL/hour.

3 Antihistamines are prescribed to help the itching (pruritus) but should be used as directed because decreased liver function increases the risk for altered drug responses.

The client in end-stage liver failure is complaining of pruritus. Which information should the nurse discuss with the client? 1. Encourage the client to sit in a hot spa before going to bed. 2. Instruct the client to not use emollients or lotions on the skin. 3. Explain the need to take the prescribed antihistamine as directed. 4. Apply hydrocortisone 1.0% cream to the affected areas.

2 Vasopressin is prescribed for a client with end-stage liver failure because it produces constriction of the splanchnic arterial bed, resulting in a decrease in portal pressure, which will help decrease esophageal bleeding. Vasopressin is administered intravenously or by intraarterial infusion.

The client in end-stage liver failure is experiencing esophageal bleeding. The health- care provider has prescribed vasopressin (Pitressin). Which statement is the scientific rationale for administering this medication? 1. It lowers portal pressure by venodilation and decreased cardiac output. 2. Vasopressin produces constriction of the splanchnic arterial bed. 3. This medication causes vasoconstriction of the coronary arteries. 4. Vasopressin causes the liver to decrease in size and vascularity.

4 Neomycin sulfate is administered to help reduce the ammonia level by reducing the number of ammonia- forming bacteria in the bowel.

The client in end-stage liver failure is prescribed neomycin sulfate. Which statement best describes the scientific rationale for administering this medication? 1. Neomycin sulfate helps lower the hepatic venous pressure. 2. It helps increase the excretion of fluid through the kidneys. 3. Neomycin is administered to help prevent a systemic infection. 4. It reduces the number of ammonia-forming bacteria in the bowel.

1 End-stage liver failure causes inadequate absorption of vitamins. Vitamin K deficiency results in hypoprothrombinemia, which results in spontaneous bleeding and ecchymosis.

The client in end-stage liver failure is prescribed vitamin K. The client asks the nurse, "Why do I have to take vitamin K?" Which statement is the nurse's best response? 1. "It will help your blood to clot so you won't have spontaneous bleeding." 2. "It may help prevent eye and skin changes along with night blindness." 3. "Vitamin K helps prevent skin and mucus membrane lesions." 4. "It prevents a complication called Wernicke-Korsakoff psychosis."

2 Although the drug may cause nausea, the client should keep taking it because it decreases the ammonia level. The nurse should instruct the client to take the medication with crackers or a soft drink, which may decrease the nausea. This statement indicates the client does not understand the medication teaching and needs more teaching.

The client in end-stage liver failure is taking the laxative lactulose (Cephulac). Which statement indicates the client needs more teaching concerning this medication? 1. "I will notify my doctor if I have any watery diarrhea." 2. "If I get nauseated, I will quit taking the lactulose." 3. "I will take my lactulose with fruit juice." 4. "I should have two or three soft stools a day."

1, 2, 4, 5 Aldactone addresses one of the causes of ascites, which is increased aldosterone levels that cause water retention. Aldactone is a potassium-sparing diuretic; therefore, the client should be monitored for hyperkalemia. Diuretics cause excretion of fluid, and a daily weight check is an excellent assessment of the effectiveness of the medication. Also, 1000 mL is approximately 1 pound Diuretics cause excretion of fluid, and intake and output levels evaluate the effectiveness of the diuretic therapy. Diuretic therapy is prescribed to help decrease ascites, which results from third spacing; assessing the abdominal girth will help determine if the medication is effective.

The client in end-stage liver failure with ascites is prescribed spironolactone (Aldactone). Which interventions should the nurse implement? Select all that apply. 1. Check the serum potassium level. 2. Weigh the client daily at the same time. 3. Assess the client's bowel sounds. 4. Monitor the client's intake and output. 5. Monitor the client's abdominal girth.

2 There is no instrument used at home to test daily ammonia levels. The ammonia level is a serum level requiring venipuncture and laboratory diagnostic equipment.

The client is admitted with end-stage liver failure and is prescribed the laxative lactulose (Chronulac). Which statement indicates the client needs more teaching concerning this medication? 1. "I should have two to three soft stools a day." 2. "I must check my ammonia level daily." 3. "If I have diarrhea, I will call my doctor." 4. "I should check my stool for any blood."

4 "Flu-like" symptoms are the first com- plaints of the client in the preicteric phase of hepatitis, which is the initial phase and may begin abruptly or insidiously.

The client is in the preicteric phase of hepatitis. Which signs/symptoms should the nurse expect the client to exhibit during this phase? 1. Clay-colored stools and jaundice. 2. Normal appetite and pruritus. 3. Being afebrile and left upper quadrant pain. 4. Complaints of fatigue and diarrhea.

1 At this time, there is no vaccination for the prevention of hepatitis C; therefore, this is the nurse's best response.

The client tells the nurse, "I would like to get the vaccine for hepatitis C." Which response would be most appropriate by the nurse? 1. "There is no vaccination against hepatitis C." 2. "The vaccination must be administered in two doses." 3. "Have you received the hepatitis B vaccination?" 4. "Why are you interested in receiving this vaccine?"

1 Clients diagnosed with PTSD are easily startled and can react violently if awakened from sleep by being touched.

The client who was abused as a child is diagnosed with post-traumatic stress disorder (PTSD). Which intervention should the nurse implement when the client is resting? 1. Call the client's name to awaken him or her, but don't touch the client. 2. Touch the client gently to let him or her know you are in the room. 3. Enter the room as quietly as possible to not disturb the client. 4. Do not allow the client to be awakened at all when sleeping.

4 Antacids may be administered after the procedure to counteract the effect of gastric reflux.

The client with esophageal varices undergoes endoscopic sclerotherapy. Which post- procedure intervention will the nurse implement? 1. Administer the proton-pump inhibitor omeprazole (Prilosec). 2. Do not allow the client to eat or drink anything for 24 hours. 3. Administer promethazine (Phenergan), an antiemetic. 4. Administer the antacid aluminum hydroxide (Maalox).

2 Milk thistle has an active ingredient, silymarin, which has been used to treat liver disease for more than 2,000 years. It is a powerful oxidant and promotes liver cell growth.

The client with hepatitis asks the nurse, "I went to an herbalist, who recommended I take milk thistle. What do you think about the herb?" Which statement is the nurse's best response? 1. "You are concerned about taking an herb." 2. "The herb has been used to treat liver disease." 3. "I would not take anything that is not prescribed." 4. "Why would you want to take any herbs?"

2 A yeast-recombinant hepatitis B vaccine (Recombivax HB) is used to provide active immunity; therefore, the nurse should specifically ask the employee if he or she is allergic to yeast.

The employee health nurse is preparing to administer the first dose of hepatitis B vaccine to an employee. Which question would be most important for the nurse to ask the employee before administering this medication? 1. "Do you have any known allergies to medications?" 2. "Are you allergic to yeast or any type of yeast products?" 3. "Have you ever had an allergic reaction to egg yolks?" 4. "Are you allergic to any type of milk or milk products?"

2 The nurse should first clean the needle stick with soap and water and attempt stick bleed to help remove any virus injected into the skin.

The female nurse sticks herself with a contaminated needle. Which action should the nurse implement first? 1. Notify the infection control nurse. 2. Cleanse the area with soap and water. 3. Request postexposure prophylaxis. 4. Check the hepatitis status of the client.

2 Excess fluid volume could be secondary to portal hypertension. Therefore, no increase in abdominal girth would be an appropriate short-term goal, indicating no excess of fluid volume.

The nurse identifies the client problem "excess fluid volume" for the client in liver failure. Which short-term goal would be most appropriate for this problem? 1. The client will not gain more than two (2) kg a day. 2. The client will have no increase in abdominal girth. 3. The client's vital signs will remain within normal limits. 4. The client will receive a low-sodium diet.

4 Playing with puzzles is a developmentally appropriate activity for a 3-year- old on bedrest.

The nurse in the pediatric clinic is providing instructions to the parents of a 2-year- old child who has just been diagnosed with acute hepatitis. Which of the following would be an appropriate activity for the nurse to recommend? 1. Riding a bike in an enclosed area such as a basement. 2. Playing basketball. 3. Playing video games in bed. 4. Playing with puzzles in bed.

1 The early stages of acute hepatitis are referred to as the anicteric phase, during which the child usually complains of nausea, vomiting, and generalized malaise.

The nurse is caring for a 6-year-old in the early stages of acute hepatitis. Which of the following manifestations should the nurse expect to find? 1. Nausea, vomiting, and generalized malaise. 2. Nausea, vomiting, generalized malaise, and pain in the left upper quadrant. 3. Nausea, vomiting, generalized malaise, and yellowing of the skin and sclera. 4. Yellowing of the skin and sclera without any other generalized complaints.

1 A diet that is high in protein and carbohydrates helps maintain caloric intake and protein stores while preventing muscle wasting. A low-fat diet prevents abdominal distention.

The nurse is caring for a 6-year-old with hepatitis. The child is hungry and wants to eat dinner. Which of the following foods should be offered? 1. A tuna sandwich on whole wheat bread and a cup of skim milk. 2. Clear liquids, such as broth, and Jell-O. 3. A hamburger, French fries, and a diet soda. 4. A peanut butter sandwich and a milkshake.

1 The hypodynamic phase is the last and irreversible phase of septic shock, characterized by low cardiac output with vasoconstriction. It reflects the body's effort to compensate for hypovolemia caused by the loss of intravascular volume through the capillaries.

The nurse is caring for a client diagnosed with septic shock who has hypotension, decreased urine output, and cool, pale skin. Which phase of septic shock is the client experiencing? 1. The hypodynamic phase. 2. The compensatory phase. 3. The hyperdynamic phase. 4. The progressive phase.

3 The client must have a urinary output of at least 30 mL/hr, so 90 mL in the last four (4) hours indicates impaired renal perfusion, which is a sign of worsening shock and warrants immediate intervention.

The nurse is caring for a client diagnosed with septic shock. Which assessment data warrant immediate intervention by the nurse? 1. Vital signs T 100.4 ̊F, P 104, R 26, and BP 102/60. 2. A white blood cell count of 18,000/mm3. 3. A urinary output of 90 mL in the last four (4) hours. 4. The client complains of being thirsty.

1, 2, 5, 6 Hepatitis A is inflammation (irritation and swelling) of the liver from the hepatitis A virus. The hepatitis A virus is found mostly in the blood and stools of the infected person. Clients with hepatitis would abstain from alcohol to prevent exacerbation of the disease. Standard precautions and meticulous hand washing would be practiced by all family members. All family members would avoid close contact with the client; this includes avoiding intercourse, kissing, and the use of any personal items (such as bath towels and eating utensils) that may be contaminated with the client's feces. Because hepatitis A is transmitted by the oral-fecal route, not the respiratory route, wearing a mask is not necessary. The hepatitis A vaccine would be given prophylactically to all family members and close contacts to prevent disease transmission.

The nurse is evaluating how a client with hepatitis A understands the discharge teaching given. Which client statements indicate that further teaching is needed? Select all that apply. 1. "I can have an occasional glass of wine with my meal as I recover." 2. "My family and I do not need to take any special precautions as long as I take my medication." 3. "My bath towels shouldn't be used by any other family members." 4. "My family members should receive the hepatitis A vaccine to prevent them from getting the disease." 5. "My spouse and I can have intercourse and kiss." 6. "I should wear a mask when visitors come."

3 This client's potassium level is above normal level (3.5-5.5 mEq/L); there- fore, the nurse should question administering this potassium-sparing diuretic.

The nurse is preparing to administer medications to the following clients. To which client would the nurse question administering the medication? 1. Lactulose (Cephulac), a laxative, to a client who has an ammonia level of 50 g/dL. 2. Furosemide (Lasix), a loop diuretic, to a client who has a potassium level of 3.7 mEq/L. 3. Spironolactone (Aldactone), a potassium-sparing diuretic, to a client with a potassium level of 5.9 mEq/L. 4. Vasopressin (Pitressin) to a client with a serum sodium level of 137 mEq/L.

1, 3 The Centers for Disease Control and Prevention (CDC) has released a 2017-2020 National Viral Hepatitis Action Plan to prevent new infections and improve the lives of those with the chronic disease. Hepatitis C is the most common chronic liver disease. Hepatitis C clients may have no symptoms until later stages of the disease. There is no vaccine for the disease that leaves the clients fatigued after minimal exertion. Periods of rest are needed throughout the day. The primary mode of transmission is through blood exposure such as through bleeding from the oral mucosa or blood on razors. Meticulous care to prevent cross contamination is needed. Epigastric pain is a common symptom because of the enlarging liver. A client should not have alcoholic beverages due to the impact on the liver

The nurse is providing discharge instructions to a client newly diagnosed with the hepatitis C virus (HCV). When evaluating the teaching, which statement made by the client indicates a need for further teaching? Select all that apply. 1. "I will make sure that my family has had the vaccine against hepatitis C." 2. "I will not share my personal items such as toothbrush or razor with others." 3. "Having an occasional alcoholic beverage will not be a problem." 4. "I know I get tired easily. I will rest periodically throughout the day." 5. "I realize that epigastric pain is a symptom of my liver growing."

1, 2, 3, 5 A client with sepsis (a systemic response to infection) can rapidly deteriorate into septic shock (hypotension and hypoperfusion). The nurse must be aware of the following objective data: an elevated temperature due to invading pathogens, tachycardia as the heart tries to circulate oxygen, a falling blood pressure due to vasodilation, decreased kidney perfusion leading to a decreased urine output, and an elevated respiration rate to obtain more oxygen.

The nurse receives shift handoff on an assigned client who had a surgical procedure. What objective assessment suggests that the client may be developing sepsis and is at risk for septic shock? Select all that apply. 1. temperature increase 2. blood pressure decrease 3. 32ml of urine in 2 hours 4. pulse rate of 32 beats per minute 5. tachypnea

1 Sufficient energy is required for healing. Adequate carbohydrate intake can spare protein. The client should eat approximately 16 carbohydrate kilocalories for each kilogram of ideal body weight daily.

The nurse writes the problem "imbalanced nutrition: less than body requirements" for the client diagnosed with hepatitis. Which intervention should the nurse include in the plan of care? 1. Provide a high-calorie intake diet. 2. Discuss total parenteral nutrition (TPN). 3. Instruct the client to decrease salt intake. 4. Encourage the client to increase water intake

3 Hepatitis A vaccine provides long-term protection against hepatitis A infection, which is transmitted by the fecal-oral route via contaminated shellfish or other food or water and by direct contact with an infected person.

The public health nurse is administering the hepatitis A vaccine to a client. Which statement indicates the client understands the medication teaching about the vaccine? 1. "I will not need to have another dose of the vaccine." 2. "I will notify the clinic if there is pain at the injection site." 3. "This vaccine will provide long-term protection against hepatitis A." 4. "This medication will be injected in my buttocks."

1, 2, 3 Hepatitis B can be transmitted by sharing any type of needles, especially those used by drug abusers. Hepatitis B can be transmitted through sexual activity; therefore, the nurse should recommend abstinence, mutual monogamy, or barrier protection. Three doses of hepatitis B vaccine pro- vide immunity in 90% of healthy adults.

The public health nurse is discussing hepatitis B with a group in the community. Which health promotion activities should the nurse discuss with the group? Select all that apply. 1. Do not share needles or equipment. 2. Use barrier protection during sex. 3. Get the hepatitis B vaccine. 4. Obtain immune globulin injections. 5. Avoid any type of hepatotoxic medications.

1 The hepatitis A virus is in the stool of infected people and takes up to two(2) weeks before symptoms develop.

The public health nurse is teaching day-care workers. Which type of hepatitis is transmitted by the fecal-oral route via contaminated food, water, or direct contact with an infected person? 1. Hepatitis A. 2. Hepatitis B. 3. Hepatitis C. 4. Hepatitis D.

4 Hepatitis A is transmitted via the fecal-oral route. Good hand washing helps to prevent its spread. Singing the happy birthday song takes approximately 30 seconds, which is how long an individual should wash his or her hands.

The school nurse is discussing methods to prevent an outbreak of hepatitis A with a group of high school teachers. Which action is the most important to teach the high school teachers? 1. Do not allow students to eat or drink after each other. 2. Drink bottled water as much as possible. 3. Encourage protected sexual activity. 4. Sing the happy birthday song while washing hands.

3 The newborn should receive both hepatitis B vaccine and hepatitis B immune globulin within 12 hours of birth to prevent hepatitis B infection.

Which of the following would be the priority intervention for the newborn of a mother positive for hepatitis antigen? 1. The newborn should be given the first dose of hepatitis B vaccine by 2 months of age. 2. The newborn should receive the hepatitis B vaccine and hepatitis B immune globulin within 12 hours of birth. 3. The newborn should receive the hepatitis B vaccine and hepatitis B immune globulin within 24 hours of birth. 4. The newborn should receive hepatitis B immune globulin only within 12 hours of birth.

4 The client needs to understand some types of cough syrup have alcohol and all alcohol must be avoided to prevent further injury to the liver; therefore, this statement requires intervention.

Which statement by the client diagnosed with hepatitis warrants immediate intervention by the clinic nurse? 1. "I will not drink any type of beer or mixed drink." 2. "I will get adequate rest so I don't get exhausted." 3. "I had a big hearty breakfast this morning." 4. "I took some cough syrup for this nasty head cold."

2 Standard Precautions apply to blood, all body fluids, secretions, and excretions, except sweat, regardless of whether they contain visible blood

Which type of precaution should the nurse implement to protect from being exposed to any of the hepatitis viruses? 1. Airborne Precautions. 2. Standard Precautions. 3. Droplet Precautions. 4. Exposure Precautions.

c the greatest risk for the client is apnea caused by the serotonin syndrome

a nurse in an ED is caring for a client who has major depressive disorder and is admitted with severe manifestations of serotonin syndrome. which of the following actions should the nurse take first? a. administer an anticonvulsant med to the client b. reconstitute a vial of dantrolene to administer to the client via intermittent IV infusion c. prepare the client for artificial ventilation d. apply a cooling blanket to the client

d

a nurse is assessing a client who has PTSD following a natural disaster. which of the following finding should the nurse expect? a. increasingly cautious behavior b. increasing sense of attachment to others c. constant need to talk about the event d. increasing feelings of anger

c clay colored stools indicate an obstruction of the bile ducts

a nurse is assessing a client with jaundice who has clay colored stool. what is the most likely cause of these findings? a. increased cholecystokinin production b. increased production of bile c. decreased flow of bile into the intestine d. increased breakdown of hemoglobin

c Hepatitis B is transmitted through blood so preventing the scab from coming off will decrease the risk of transmission

a nurse is caring for a 45 year old client who has been diagnosed with hepatitis B infection. while dressing the clients wound blood splashed on a scab on the nurses arm. which of the following is the most important nursing action? a. apply ice to the scab b. cover the scab with dry gauze c. cleanse the area without peeling off the scab d. wash the scab off using a betadine solution

a this is the patients body trying to compensate for the initial losses

a nurse is caring for a client going into septic shock. following the initiation stage the client develops vasoconstriction, an increased HR, and hyperglycemia in an attempt to counteract the initial effects. which of the following best describes this stage? a. compensatory stage b. hemodynamic stage c. advancement stage d. evolutionary stage

a increase in bowel movements mean that the ammonia is being excreted

a nurse is caring for a client who is admitted with a new diagnosis of hepatic encephalopathy and has a prescription for lactulose. which of the following indicates to the nurse that the treatment was effective? a. increased bowel movements b. increased bruising c. increased sedation d. hypoactive bowel sounds

b

a nurse is caring for a client who is going into septic shock. the client is in the compensatory stage of shock. which of the following signs and symptoms would the nurse expect to see in this stage? a. acute respiratory failure b. diminished bowel sounds c. metabolic acidosis d. no clinical signs

c if stopping the medication abruptly will cause withdrawal symptoms

a nurse is caring for a client who is to begin taking paroxetine for treatment of generalized anxiety disorder. which of the following statements indicates that the client understands the use of this medication? a. i will take the medication at bedtime b. i should expect to have an elevated temp while taking this medication c. i should not stop this medication abruptly d. i will weigh myself once each month

c hallucinations are s/s of PTSD and are related to traumatic events

a nurse is caring for a client with PTSD. which nursing diagnosis is most appropriate for this client? a. at risk for histrionics related to the events surrounding the trauma b. at risk for obsessive talking about the traumatic events c. at risk for hallucinations related to the traumatic events d. at risk for impaired sensory and motor functioning related to PTSD

c

a nurse is caring for a client with a GI bleed who has been diagnosed with liver failure due to hepatitis B. which of the following blood products will most likely be prescribed to achieve hemostasis? a. PRBCs b. cryoprecipitate c. platelets d. whole blood

a, e

a nurse is caring for a client with a history of alcohol abuse and cirrhosis expects to find which of the following abnormalities when reviewing the clients lab tests? select all that apply a. increased PTT b. decreased bilirubin c. decreased ammonia d. increased albumin e. decreased sodium

c

a nurse is caring for a client with acute hepatitis A infection. which of the following nursing interventions should be implemented? a. provide a low calorie diet with fluid restriction b. remind the client to limit alcohol consumption to 1-2 drinks per day c. administer antipruritic medication only as needed d. keep the client on strict bedrest

a vitamin K deficiency results is increased PT and INR. with that you would be able to see easy bruising, petechiae, purpura, and bleeding gums

a nurse is caring for a client with chronic hepatitis B and cirrhosis. which of the following findings would indicate deficient vitamin K absorption as a result of the clients disease? a. petechiae and purpura b. asterixis c. gynecomastia d. ascites

c asterixis is a sign of hepatic encephalopathy in individuals with cirrhosis of the liver

a nurse is caring for a client with chronic hepatitis C and cirrhosis who was admitted for hepatic encephalopathy. which of the following does the nurse expect when assessing the client? a. hyperactive reflexes b. agitation and restlessness c. asterixis d. enlarged liver

c turning them on their right side helps provide pressure at the site and prevent bleeding

a nurse is caring for a client with chronic hepatitis c who has returned to the unit after a liver biopsy. which of the following is the priority nursing intervention? a. educate the client about cirrhosis and its progression b. review preprocedure coagulation studies c. turn the client on the right side to provide pressure at the side d. perform a detailed assessment

d hepatic encephalopathy is a complication of cirrhosis of the liver and can be detected with an ammonia level

a nurse is caring for a client with hepatic encephalopathy who has been hospitalized for treatment for 2 days. the nurse notices on the assessment that the client is hard to arouse. which of the following is an appropriate nursing intervention? a. assist the client with ambulation b. increase the protein content of the clients next meal c. assess the clients proprioception and peripheral sensation d. notify the HCP to request a prescription for a serum ammonia level

c hep A can be transmitted through stool and sometimes urine and nasotracheal secretions

a nurse is caring for a client with hepatitis A. which of the following precautions is indicated when caring for this client? a. prevent he spread of infection using reverse isolation techniques b. use caution when bringing foo to the client c. wear gloves when emptying the clients urinal d. don a mask, gown, and gloves before entering the clients room

a, b, d, e

a nurse is collecting data from a toddler who has major burns and suspected septic shock. which of the following findings indicate the toddler is experiencing septic shock? select all that apply a. increased body temperature b. altered sensorium c. rapid capillary refill d. decreased urine output e. chills

a Hepatitis b vaccine if given at birth, 1 month old, and 6 months old as recommended by the CDC

a nurse is counseling a 20 year old client with multiple sexual partners about the hepatitis b vaccine. which of the following is indicated for adequate immunization? a. a complete series of 3 HBV vaccines b. a vaccine with a booster every 10 years c. hepatitis B immune globulin followed by the vaccine d. 1-time HBV vaccination

d flashbacks are signs of PTSD

a nurse is facilitating a support group for veterans who were involved in combat and observed war casualties. which of the following client statements should the nurse include in the nurse identify as an indication the client may be experiencing PTSD? a. my marriage has improved since i left the military b. my child was born with a birth defect due to an exposure i had overseas c. i killed four enemy soldiers with my bare hands and saved my entire batallion d. in my dreams all i can see are the wounded reaching out and trying to grab me

d clients with hepatitis are at an increased risk for inadequate nutrition. they need more protein and calories since they usually have nausea and vomiting

a nurse is planning care for a client who has hep B with jaundice. which of the following interventions should the nurse include in the plan? a. initiate contact precautions b. administer acetaminophen q6h c. provide warm compresses to the areas of pruritus d. provide a high calorie, high protein diet

c this medication produces passive artificial immunity and contains antibodies to help protect against hepatitis B for several weeks to months

a nurse is preparing to administer immune globulin to a client who has been exposed to hepatitis B. which of the following statements should the nurse make? a. this medication will provide a permanent immunity to hepatitis B b. this medication involves 2 injections that are administered over several months c. this medication provides an immune response more quickly than your body can produce it d. this medication contains an attenuated virus to help your body create antibodies

a, b, e

a nurse is providing discharge teaching for a client who has hepatitis B. which of the following instructions should the nurse include in the teaching? select all that apply a. limit physical activity b. avoid alcohol c. wait 6 months before donating blood d. wear a mask in public places e. eat small, frequent meals

c, f

a nurse is providing education to a client recently diagnosed wit viral hepatitis. which of the following are true about viral hepatitis? select all that apply a. hep A has an incubation period of 6-24 weeks b. hep A is transmitted via body fluids c. hepatitis d can cause fulminant hepatitis d. hepatitis C can be prevented by vaccine e. lab studies for hep B show HDV

c hep A is transmitted from contaminated foods, so good hand and skin hygiene is key to preventing transmission

a nurse is providing teaching about hepatitis A with a client who plans to travel. which of the following statements should the nurse make? a. if exposed expect to have manifestations within 10 days b. avoid donating blood or tissue for one year if you develop the infection c. practice meticulous skin and hand hygiene d. expect if you are exposed to have severe joint pain

a, b, d, e

a nurse is providing teaching to the parent of a child who has a new diagnosis of PTSD. which of the following information should the nurse include? select all that apply a. children who has PTSD can benefit from psychotherapy b. phobias can be manifestations of PTSD c. personality disorders are a complication of PTSD d. PTSD develops following a traumatic event e. there are 3 phases of PTSD

b

a nurse is reviewing the prescription for a client who is being evaluated for the presence of hepatitis C. which of the following prescribed lab tests should the nurse identify as diagnostic for hepatitis C? a. indirect bilirubin b. HCV RNA testing c. AST d. ALT

d contraindications are conditions in the recipient of a vaccine that increase the risk of a serious adverse reaction. hypersensitivity to yeast is an absolute contraindication to the hep B virus

a nurse who is employed in a community outpatient clinic should question which of the following prescriptions for vaccine administration? a. a MMR in a client who hopes to become pregnant within the next 6 months b. DTaP to a client who has a family history of seizures c. DTaP to a client who develops a rash when exposed to latex d. Hepatitis B for a client with hypersensitivity to yeast

d the client can have the vaccine any time since the child is 12 months old

the mother of a 12 month old child tells the nurse that the child never received the hepatitis B vaccine but she would like to consider this option now. which response from the nurse is accurate? a. this usually starts at birth it is too late to start now b. we must first check his antigen levels before giving the vaccine c. he can have the vaccine but he must wait until he is at least 24 months d. we can start the series whenever you are ready

b

the nurse is assessing a client with PTSD. the client is currently taking clonazepam (klonopin). which of the following instructions is not appropriate for this client? a. avoid alcohol intake b. drink grapefruit juice c. report jaundice if it occurs d. report the occurrence of fever, sore throat, and bruising

a, d, g, h

the nurse is assessing a client with hepatitis. which of the following diagnostic tests will be recommended for this type of client? select all that apply a. LDH b. Potassium c. sodium d. HBV surface antigen e. chloride f. chest xray g. ALP h. AST

a, c, d

the nurse is charting findings from a client with cirrhosis. which of the following findings are specifically related to the clients diagnosis? select all that apply a. anemia b. hypoglycemia c. bruising d. gynecomastia e. bradycardia