AMS 5 2021

When planning care for a patient with cirrhosis, the nurse will give highest priority to which nursing diagnosis?

d. Ineffective breathing pattern related to pressure on diaphragm and reduced lung volume

1. A patient with cirrhosis who has scheduled doses of spironolactone (Aldactone) and furosemide (Lasix) has a serum potassium level of 3.2 mEq/L (3.2 mmol/L). Which action should the nurse take?

· Administer the spironolactone.

1. Patient with cirrhosis has +4 pitting edema of the feet and legs. The data indicate that it is most important for the nurse to monitor the Pt's?

· Albumin level (low protein high carb diet)

1. When assessing a client with suspected Hepatitis A, the nurse would expect the client to report the development of which of the following symptoms first?

· Anorexia

Which food item is most appropriate for pancreatic patient

· Baked fish

hep b

· Bed rest with commode privileges

1. 38-year-old patient with cirrhosis has ascites and 4+ edema of the feet and legs. Which nursing action will be included in the plan of care?

· Place on pressure- relieving mattress

1. The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Where should the nurse anticipate the location of the pain?

· Right upper quadrant, radiating to the right scapula and shoulder.

1. Which assessment information will be most important for the nurse to report to the health care provider about a patient with acute cholecystitis?

· The patient's stools are tan colored.

1. A patient newly diagnosed with acute hepatitis B asks about drug therapy to treat the disease. The most appropriate response by the nurse is informing the patient that:

· There are no specific drug therapies that are effective for treating acute viral hepatitis (most common)

1. When caring for a patient immediately following an incisional cholecystectomy for cholelithiasis, the nurse places the highest priority on assisting the patient to

· Turn and cough every 2 hrs.

A nurse is assessing a newly admitted client diagnosed with hepatitis A and would expect to find which of the following as the most common clinical manifestations? Select all that apply.

· jaundice · Fatigue · Anorexia

Which of the following findings is considered an abnormal gastrointestinal assessment finding

· visible peristaltic waves

1. Teaching to patient with jaundice, pt. needs more teaching when they say

· Taking acetaminophen every 4 hours

A patient with cirrhosis that is refractory to other treatments for esophageal varices undergoes a peritoneovenous shunt. As a result of this procedure, the nurse would expect the patient to experience

. improved hemodynamic function and renal perfusion

One of the most challenging nursing interventions to promote healing in the patient with viral hepatitis is

. providing adequate nutritional intake

Pt with hepatic encephalopathy, which s/s should be reported to the doctor?

1. Asterixis, Lethargy, LOC changes, fector hepaticus

Cholecystectomy sata for pain:

1. assess for pain, splinting, change positioning, help ambulate, not rub the back

Asthma exacerbation

1. nebulizer of beta adrenergic

to evaluate the effectiveness of treatment for a patient who has hepatic encephalopathy, which action should the nurse take?

Ask the patient to extend both arms to the front.

a nurse is caring for a client who has acute pancreatitis. after the client's pain has been addressed which of the following is the next intervention to include in the plan of care?

NPO

as the nurse reviews the patient's laboratory values, the nurse expects to find elevations in which test results to establish a diagnosis of acute liver failure?

Serum bilirubin and alkaline phosphatase levels

Glipizide

Stimulates pancreas to release insulin

1. Which laboratory test result will the nurse monitor when evaluating the effects of therapy for a 62-year-old female patient who has acute pancreatitis?

amylase

the health care provider plans a paracentesis for a patient with ascites caused by liver cancer. to prepare the patient for the procedure, the nurse implements which of the following?

asks the patient to empty the bladder.

a nurse is caring for a client with decreased liver function due to cirrhosis. when selecting a snack, which of the following sections indicates the client understands dietary requirements?

banana

In discussing long term management with the patient with alcoholic cirrhosis, the nurse advises the patient that

c. abstinence from alcohol is the most important factor in improvement of the patient's condition

1. Contraindicated with warfarin

cabbage

a nurse is assessing a clients circulatory system. which of the following pulse sites should the nurse avoid assessing bilaterally at the same time

carotid

Labs for pancreatitis

increased amylase

which outcomes would indicate that a client with advanced cirrhosis is experiencing a serious complication?

Frequent nosebleeds and bruising

During the treatment of the patient with bleeding esophageal varices, it is most important that the nurse

maintain the patient's airway and prevent aspiration of blood

Which goal has the highest priority in the plan of care for a 26-year-old homeless patient admitted with viral hepatitis who has severe anorexia and fatigue?

Maintain adequate nutrition.

a patient with cirrhosis who has been vomiting blood is admitted to the emergency department. which action should the nurse take first?

Check BP, heart rate, and respirations.

which finding indicates to the nurse that a patient's trans jugular intrahepatic portosystemic shunt (TIPS) placed 3 months ago has been effective?

Fewer episodes of bleeding varices

while talking with a client with a diagnosis of end stage liver disease, the nurse notices the client is unable to stay awake and seems to fall asleep in the middle of a sentence. the nurse recognizes these symptoms to be indicative of what condition?

Increased blood ammonia levels

African american jaundice

check hard palate

a nurse is caring for a client who has a history of pancreatitis. which of the following food choices should the nurse avoid?

cheddar cheese

1. A patient is getting a blood transfusion; how do you know they are having an allergic reaction?

generalized urticaria

Following laparoscopic cholecystectomy, the nurse would expect the patient to

have four small abdominal incisions covered with small dressings

a nurse is assessing a client who is admitted for elective surgery and has a history of Addisons disease. which of the following findings should the nurse expect?

hyperpigmentation

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

implement a low sodium diet measure the clients abdominal girth administer furosemide

1. When teaching a client with cirrhosis about the expected outcomes after intravenous administration of furosemide, the nurse would include which outcome?

increased urine output

1. Levothyroxine toxicity

insomnia

a nurse is teaching a client schedules for an activated partial thromboplastin time (aPTT). which of the following statements by the client indicates an understanding of the teaching?

it measures deficiencies in clotting factors

Cirrhosis

no ham sandwich

a nurse is creating a plan of care for a client who has advanced cirrhosis. which of the following manifestation should the nurse expect to find?

petechiae

1. Wound healing

protein

for a patient with cirrhosis, which of the following nursing actions can the registered nurse delegate to UAP?

providing oral hygiene after a meal

During discharge instructions for a patient following a laparoscopic cholecystectomy, the nurse advises the patient to

report any bile colored or purulent drainage from the incisions

a nurse is providing discharge teaching for a client who has acute pancreatitis and has a prescription for fat soluble vitamin supplements. the nurse should instruct the client to take a supplement for which of the following

vitamin a

a nurse is caring for a client with cirrhosis who has a prothrombin time of 30 seconds. which of the following medications does the nurse anticipate the provider will prescribe?

vitamin k

a 23 year old has been admitted with acute liver failure. which assessment data are most important for the nurse to communicate to the health care provider?

asterixis and lethargy

The nurse recognizes early signs of hepatic encephalopathy in the patient who

d. is irritable and lethargic

a nurse is caring for a client with cirrhosis who has a new prescription for cephulac (Lactulose). following administration, the nurse will monitor the client for which adverse effect of this medication?

diarrhea

a nurse is caring for a client who has impaired mobility. which of the following support devices should the nurses plan to use to prevent the client from developing plantar flexion contractures?

footboard

a nurse is interviewing a client who has acute pancreatitis. which of the following factors should the nurse anticipate in the client's history

gallstones

a nurse is providing discharge teaching to a client who will be receiving total parenteral nutrition at home. which of the following instructions should the nurse include? SATA

keep the TPN refrigerated when not in use maintain TPN infusion rate when behind schedule infuse 10% dextrose and water if the solution runs out

1. A nurse is providing discharge instructions to a client newly diagnosed with cirrhosis. Which statement, if made by the client, indicates a need for further teaching?

· "I can eat anything that appeals to me."

1. The nurse is developing a weight loss plan for a 21-year-old patient who is morbidly obese. Which statement by the nurse is most likely to help the patient in losing weight on the planned 1000-calorie diet?

· "You are likely to start to notice changes in how you feel with just a few weeks of diet and exercise."

1. A client with Cirrhosis of the liver for the past 3 years is hospitalized for treatment of recently diagnosed esophageal varices. What is the most important for the nurse to include in the teaching plan?

· Avoid straining during defecation to keep venous press low.

1. A 67-year-old male patient with acute pancreatitis has a nasogastric (NG) tube to suction and is NPO. Which information obtained by the nurse indicates that these therapies have been effective?

· Decreased abdominal pain

1. nurse is caring for a pt who has cirrhosis. Which of the following medications can the nurse expect to administer to this client (SATA)

· Diuretic · Beta-blocker · Lactulose

1. The nurse will plan to monitor a patient with obstructed common bile duct (Cholelithiasis) for which expected findings?

· Fatty stools (steatorrhea)

Patient has ascites and is scheduled to have paracentesis, what should the nurse do

· Have patient void before procedure

1. Accumulation of ammonia and other toxins normally detoxified by the liver can produce which of the following?

· Hepatic encephalopathy

Patient has hepatitis; what kind of diet should you implement

· High carb diet

1. Cholecystectomy select all that apply

· Incisional splinting · Change position · Rate the pain

1. A patient had a Left AC cath placement, what pulse do you check after the procedure?

· Left Radial pulse

1. The nurse will plan to teach the patient diagnosed with acute hepatitis B about dietary teaching

· Measures for improving the appetite

1. Which assessment finding would the nurse need to report most quickly to the health care provider regarding a patient with acute pancreatitis?

· Muscle twitching and finger numbness.

1. Which assessment finding is of most concern for a 46-year-old woman with acute pancreatitis?

· Palpable abdominal mass

1. The client diagnosed with acute pancreatitis is in pain. Which position should the nurse assist the client to assume to help decrease the pain?

· Place in side-lying position with knees flexed.

1. The client has been admitted to the hospital with a diagnosis of acute pancreatitis and the nurse is assessing the client's pain. What type of pain is consistent with this diagnosis?

· severe and unrelenting, located in the epigastric area and burning radiating to the back.