LIVER (lippencott questions)

1 (pyrosis is heartburn and is expected in a client dx with GERD. The new grad can care for this client and administer an antacid.)

CS 1 Ms Kathy is making assignments. Which client should be assigned to the graduate nurse on the unit for 1 month? 1. The client dx with lower esophageal dysfunction who is complaining of pyrosis 2. The client who had an endoscopy this morning with absent bowel sounds 3. The client with gastroesophageal reflux disease who has bilateral wheezing 4. The client who is 1 day post op open cholecystectomy and refuses to deep breath

3 (This client should be placed on the right side, same side as liver, to prevent hemorrhaging after liver biopsy)

CS 7 Ms Kathy observes the UAP turning the client who has just had a liver biopsy to the supine position. Which action should Ms Kathy implement first? 1. Tell the UAP to keep the client on bed rest for 2 hrs 2. Praise the UAP for placing the client in the supine position 3. Instruct the UAP to place the client on the Right side 4. Complete an incident report on the UAPs behavior

2 (Ms Kathy must first have the nurse complete an adverse occurrence report so there is written documentation concerning the situation. Then Ms Kathy should notify the infection control nurse who will arrange for post-exposure prophylaxis and determine if the client has hepatitis.)

CS 8 One of the primary nurses tells Ms Kathy she stuck herself in the finger with a used needle and cleaned the site with soap and water. Which intervention should Ms. Kathy implement first? 1.. Notify the infection control nurse 2. Complete an adverse occurrence report 3. Request post exposure prophylaxis 4. Check the hepatitis status of the client

3 (The client with pruritis is stable and the UAP can assist with showering and am care, therefore this task can be delegated. WRONG: #1 The client with an inflated Sengstaken-Blakemore tube has acute esphageal varices bleeding and is NOT stable, therefore this task cannot be delegated. )

CS 9 Which nursing task is most appropriate to delegate to the UAP? 1. Bathe the client with liver failure who has a Sengstaken-Blakemore tube inflated 2. Teach the client with an open cholesectomy to splint the incision when coughing 3. Assist the client with pruritis to the bathroom for shower and am care 4. Tell the UAP to assist the nurse performing a paracentesis on the client with liver failure

4 (Hep B is considered a STD. and students should observe safe sex. Poor sanitary conditions in underdeveloped countries relate to the spread of Hep A and E. Focusing on routes of transmission and avoidance of infection can prevent the spread of hep. There is no vaccine for Hep D.)

College freshmen are participating in a study abroad program. When teaching them about hepatitis B the nurse should instruct the students need for: 1. water sanitation 2. Single dorm rooms 3. Vaccination for hep D 4. safe sex practices

d (Rationale Hepatorenal syndrome causes sodium​ retention, oliguria, and hypotension. Asterixis develops with hepatic​ encephalopathy, and fever with bacterial peritonitis. Esophageal varices are a complication of cirrhosis.)

For which complication should the nurse monitor a client with portal​ hypertension? a Hepatic encephalopathy b Esophageal varices c Steatohepatitis d Hepatitis C

d (Rationale Hepatorenal syndrome causes sodium​ retention, oliguria, and hypotension. Asterixis develops with hepatic​ encephalopathy, and fever with bacterial peritonitis. Esophageal varices are a complication of cirrhosis.)

For which manifestation should the nurse assess in a client with hepatorenal​ syndrome? a Esophageal varices b Asterixis c Fever d Sodium retention

3 (Interferon Alpha 2b most commonly causes flulike adverse effects such as myalgia, arthralgia, headache, N, fever and fatigue. Retinopathy is a potential adverse effect but not a common one. Diarrhea may develop as an adverse effect. Clients are advised to administer the drug at bedtime and get adequate rest. Medications may be prescribed to treat the symptoms. The drug may also cause hematologic changes, therefore lab tests such as a CBC and differential should be conducted monthly during drug therapy. Blood glucose levels should be monitored for HYPER glycemia.)

Interferon alfa-2b has been prescribed to treat a client with chronic Hep B. The nurse should assess the client for which common adverse side effect? 1. retinopathy 2. constipation 3. flulike symptoms 4. hypoglycemia

d

Mr. Manning is a​ 36-year-old client diagnosed with​ end-stage liver disease. He began drinking alcohol heavily at 13 years of age. Which symptoms of cirrhosis caused by alcohol abuse should the nurse anticipate Mr. Manning to exhibit upon​ assessment? a Profuse​ sweating, jaundice, and hypoglycemia ​b Low-grade fever, acute abdominal pain that radiates to distal areas upon​ palpation, nausea, and vomiting c Crushing chest​ pain, jaundice, and shortness of breath d Fluid buildup in the​ abdomen, bleeding in the esophagus and upper​ stomach, abdominal​ inflammation, infection, and portal systemic encephalopathy

d (While a​ beta-blocker can be used for esophageal​ varices, the best therapy at this time is a balloon tamponade​ (either a​ Sengstaken-Blakemore or Minnesota​ tube). A paracentesis is done to relieve severe ascites. A transjugular intrahepatic portosystemic shunt​ (TIPS) relieves portal hypertension and reduces the onset of esophageal varices and ascites.)

Ms. Charlotte is​ 66-years-old and admits to being an alcoholic for most of her adult life. She is brought to the emergency department with bleeding esophageal varices. Which therapy should be the most effective for Ms. Charlotte at this​ time? a Transjugular intrahepatic portosystemic shunt​ (TIPS) b Paracentesis ​c Beta-blocker d Minnesota tube

a,b (Rationale: Clients undergoing paracentesis for the manual removal of excess fluid from the abdomen should be monitored closely for electrolyte imbalance and a drop in intravascular volume (blood pressure) as the pressure of the ascites fluid is relieved. Tachycardia, jaundice, and constipation are not expected complications of paracentesis.)

Paracentesis is prescribed for an adult client with chronic cirrhosis and ascites that is not responding to diuretic therapy. The nurse should monitor the client for which complications of this procedure? (Select all that apply.) a Electrolyte imbalance b Drop in blood pressure c Constipation d Jaundice e Tachycardia

3

The HCP instructs a client with alcohol induced cirrhosis to stop drinking alcohol. The expected outcome of this intervention is: 1 absence of deirium tremens 2. having a balanced diet 3. improved liver function 4. reduced weight

1 (Hot water increases pruritis and soap will cause dry skin, which increases pruritis, 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 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 clients legs and back 3. The UAP puts mittens on both hands of the client 4. The UAP pats the clients skin dry with a towel

1 (hepatoxicity. Death can occur)

The client dx with bipolar disorder has been taking valproic acid (Depakote) an anticonvulsant for 4 months. Which assess,emt data would warrant the medication being discontinued? 1. The clients eyes are yellow 2 The client has mood swings 3. The clients BP is 164/94 4. The clients serum level is 75 mcg/mL

3 (The client is at risk for hypovolemia, therefore VS will be assessed freq to monitor for signs of hemorrhaging. The procedure is done in the clients room with the client seated on the bed or chair The client should empty the bladder prior, no need for Foley The client does not have to hold the breath when the cath is inserted into the peritoneum. This is done when obtaining a liver biopsy)

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

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 clients throat is not anesthetized during the insertion of a NG tube so the gag reflex does not need to be assessed. This laxative is administered to decrease the ammonia level, but the question does not say the ammonia level is elevated Esophageal bleeding does not cause the ammonia level to be elevated)

The client dx 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 clients ammonia level

4 (Ammonia is a byproduct of protein metabolism and contributes to hepatic encephalopathy Reducing protein intake should decrease ammonia levels. Sodium is restricted to reduce ascites and generalized edema, not for hepatic encephalopathy Fluids are calculated based on diuretic therapy, urine output and serum electrolyte values; fluids do not affect hepatic encephalopathy A diet high in calories and moderate in fat intake is recommended to promote healing)

The client dx 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 the sodium intake to 2 g/day 2. Limit oral fluids to 1500 mL/day 3. Decrease the daily fat intake 4. Reduce protein intake to 60-80 g/day

2 (Bilirubin the by product of RBC 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 the skin. The serum ammonia level is increased but does not cause clay colored stools The liver excretes bile into the gallbladder and the body uses the bile to digest fat, but does not affect the feces Vitamin deficiency, resulting from the livers inability to detoxify vitamins may cause steatorrhea, but does not cause clay colored stool)

The client dx 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

3 (Direct pressure is applied to the site and then the client is placed on the R side to maintain pressure. The client should empty the bladder prior to the procedure Foods and fluids are usually withheld 2 hrs after the biopsy, after which the client can resume the usual diet BUN and creatinine levels are monitored for kidney function and the renal system is not affected by liver biopsy)

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

1 (Blood in the GI tract is digested as a protein, which increases serum ammonia levels and increases the risk of developing hepatic encephalopathy. Decreased albumin causes ascites An enlarged spleen increases the rate at which RBCs, WBCs, and platelets are destroyed, causing the client to develop anemia, leukopenia, and thrombocytopenia, but not hepatic encephalopathy. An increase in aldosterone causes sodium and water retention, resulting in ascites and general edema)

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

1,2,3,4 (Vitamin K deficiency causes impaired coagulation. no rectal temps Soft bristle toothbrushes help prevent gums bleeding 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 necessary, the nurse should use small gauge needles. Asterixis is a flapping tremor of the hands when the arms are extended and indicates an elevated ammonia level not associated with vitamin K deficiency)

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

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. 2-3 soft stools indicates the med is effective. Diarrhea indicates an OD of the med, possibly requiring the dosage to be decreased. The HCP needs to make this change in dosage, so the client understands the teaching. The client should check the stool for bright red blood as well as dark tarry stool)

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 2-3 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

3 (This is the main reason the HCP decreases dosage of clients medications. #4 is the medical explanation of why, but not the layperson answer)

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

4 (Flu like symptoms are the first complaints of the client in the preicteric phase of hepatitis. Which is the initial phase and may begin abruptly or insidiously. Clay colored stools and jaundice occur in the icteric phase Normal appetite and itching occur in the icteric phase Fever subsides in the icteric phase, and the pain is in the RUQ)

The client is in the preicteric phase of hepatitis. Which S/s should the nurse expect the client to exhibit during this phase? 1. Clay colored stools and jaundice 2. Normal appetite and pruritis 3. Being afebrile and LUQ pain 4. Complaint of fatigue and diarrhea

1,2,3,4 (TElemetry should be monitored during therapy, client is at risk for ARDS and pulmonary toxicity, When the IV med, monitoring the renal and hepatic function is appropriate, this drug can cause hepatomegaly. IV vasoactive drugs are inherently dangerous so should confirm orders with another nurse.)

The client is showing ventricular ectopy, and the HCP orders amiodarone IV. Which interventions should the nurse implement? SATA 1. Monitor telemetry continuously 2. Assess the clients respiratory status 3. Evaluate the clients liver function studies 4. Confirm the original order with another nurse 5 Prepare to defib the client at 200 joules

4 (The most appropriate goal for this client with Hep A is to increase activity tolerance gradually as tolerated. Periods of alternating rest and activity should be included in the plan of care There is no evidence the client is physically immobile, is unable to provide self care or needs to adapt to new energy levels)

The client with Hep A is experiencing fatigue, weakness, and a general feeling of malaise. The client tires rapidly during morning care. The most appropriate goal for this client is to: 1. increase mobility 2. learn new self care skills 3. adapt to new levels of energy 4. gradually increase activity tolerance

2 (Milk thistle has an active ingredient silymarin, which has been used to treat liver disease for more than 2000 years. It is a powerful oxidant and promotes liver cell growth.)

The client with hepatitis asks the nurse "I went to a herbalist who recommended I take milk thistle. What do you think about that herb? Which statement by the nurse is the 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 herb?

3 (The vaccine is given in 3 doses - initially, and then at 1 month, then again at 6 months. The vaccine is administered in a series of 3 injections and is reported to be effective for life, but boosters may be given every 5 years. It is given IM into the deltoid muscle)

The employee health nurse is discussing hepatitis B vaccines with new employees. Which statement best describes the proper administration of the hepatitis B vaccine? 1. The vaccine must be administered once per year 2. Two (2) mL of vaccine should be given each hip 3. The vaccine is given in three (3) doses over a six (6) month period 4. The vaccine is administered intradermally into the deltoid muscle

2 (First clean the needlestick with soap and water and attempt stick bleed to remove any virus injected into the skin. The other interventions will be done, and the infection control nurse/employee health nurse will check the hepatitis status of the client)

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

b (For a client with​ cirrhosis, the nurse assesses recent weight loss during the heath history portion of the nursing assessment. Vital​ signs, mental​ status, and skin color are assessed during the physical examination portion of the nursing assessment.)

The nurse assesses for which item during the health history for a client with​ cirrhosis? a Mental status b Weight loss c Skin color d Vital signs

3 (hypokalemia is a precipitating factor in hepatic encephalopathy. A decrease in creatinine results from muscle atrophy, an increase in creatinine would indicate renal insufficiency. With liver dysfunction, increased aldosterone levels are seen. A decrease in serum protein will decrease colloid osmotic pressure and promote edema)

The nurse assessing the client with 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

d (Rationale: The nurse would expect the client's respiratory rate and oxygen saturation to fall within normal limits, and the client's abdominal girth should decrease by 1-2 cm/day. A decrease in flatulence is unrelated to this procedure.)

The nurse caring for a client recently undergoing abdominal paracentesis for ascites would expect all of the following indicators of successful treatment except: a a respiratory rate within normal range. b improved oxygen saturation. c a reduction in abdominal girth of 1-2 cm/day. d reduction in excess flatulence.

3 (The hep A virus is transmitted via the fecal-oral route. It spreads thru contaminated hands, water and food, especially shellfish growing in contaminated water. Certain animal handlers are at risk for Hep A. particularly those handling primates. Freq hand washing is probably the single most preventative action. Insects do not transmit Hep A. Family members do not need to stay away from the client with hep. It is not necessary to disinfect food or clothing)

The nurse develops a teaching plan for the client about how to prevent the transmission of hepatitis A. Which discharge instruction is appropriate for the client? 1 spray the house to eliminate infected insects 2. tell family members to try to stay away from the client 3. Ask the family members to wash their hands freq 4. Disinfect all clothing and eating utensils

2 (Excess fluid volume could be secondary to portal hypertension. Therefore no increase in abdominal girth would be an appropriate short term goal, indicating excess of fluid volume. 2 kg is more than 4 lbs, which indicates severe fluid retention and is not an appropriate goal. VS are appropriate to monitor, but do not yield specific information on fluid volume status Having the client receive a low sodium diet does not ensure the client will comply with the diet. The short term goal must evaluate if the FV is wnl)

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 2 kg a day 2. The client will have no increase in abdominal girth 3. The clients VS will remain within normal limits 4. The client will receive a low sodium diet

3 (early manifestations of cirrhosis are subtle and usually include GI symptoms, such as anorexia, N/V, and changes in bowel patterns. These changes are caused by the livers altered ability to metabolize carbs, proteins, and fats. Peripheral edema, ascites, and jaundice are LATER signs of liver failure and portal hypertension)

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

1 (A client diagnosed with portal hypertension should be assessed for a tympanic (fluid) wave to check for ascites. High BP is not an etiology of portal hypertension In portal hypertension percussion is difficult and will not provide information about the clients condition Weighing the client should be done daily, not twice a week)

The nurse is assessing the client in end stage liver failure who is diagnosed with portal hypertension. Which intervention should the nurse include in the plan of care? 1. Assess the abdomen for tympanic wave 2. Monitor the clients BP 3. Percuss the liver for size and location 4. WEigh the client twice each week

4 (Tylenol is toxic to the liver and should be avoided. Increased periods of rest allow for liver regeneration. A low fat high carb diet and dry toast to relieve nausea are appropriate)

The nurse is assessing the client with hepatitis A and notices that the AST and ALT lab values have increased. Which statement by the client indicates the need for further instruction by the nurse? 1. I require increased periods of rest 2. I follow a low-fat high carb diet 3. I eat dry toast to relieve my nausea 4. I take acetaminophen for arthritis pain

4 (Although primarily bloodborne, unprotected sex with multiple partners and a Hx of STD's are risk factors for transmission of Hep C virus. Other risk factors include blood transfusions, past Tx with chronic hemodialysis, being a child born to a woman with Hep C, past/current illicit drug IV use, or needlestick injuries to health care workers. It is important the nurse is aware of the clients Hx in order to determine the clients level of understanding of the disease, promote a healthy lifestyle and discuss the role of viral transmission of the disease)

The nurse is caring for a client recently diagnosed with Hep C. In reviewing the clients Hx what info will be most helpful as the nurse develops a teaching plan? The client: 1. has a Hx of exercise induced asthma 2. is a scientist and frequently exposed to multiple chemicals 3. traveled to Central America recently and ate uncooked vegetables 4 has a known Hx of STDs

a,c,e (Rationale Dietary support is essential because dietary needs change as hepatic function fluctuates. Nutrition therapy includes sodium restricted to under 2​ g/day, fluids restricted to​ 1,500 mL/day, vegetable proteins provided with restricted red meat​ consumption, parenteral nutrition as​ needed, and vitamin supplements that include B​ complex, A,​ D, and E. A regular diet or​ high-fiber diet is not appropriate for a client with cirrhosis.)

The nurse is caring for a client with cirrhosis of the liver. Which dietary support does this client​ need? ​(Select all that​ apply.) ​a Fluid-restricted diet ​b High-fiber diet ​c Sodium-restricted diet d Regular diet e Vitamin supplements

b,d,e (Rationale Risk factors for cirrhosis of the liver include excessive alcohol​ use; infection with Hepatitis​ B, C, or​ D; and injection drug use. Biliary atresia​ (poorly formed bile​ ducts) and hepatitis E are not risk factors for cirrhosis of the liver.)

The nurse is caring for a client with cirrhosis of the liver. Which risk factors should the nurse expect to find in the​ client's history? ​(Select all that​ apply.) a Hepatitis E infection b Excessive alcohol use c Biliary atresia d Injection drug use e Hepatitis C infection

a,b,c,e (Rationale Assessment findings that correlate with expected laboratory findings in the client with cirrhosis include bruising​ easily, frequent​ infections, peripheral​ edema, and confusion. Although spider angiomas can be found in clients with​ cirrhosis, their presence is not associated with any laboratory testing.)

The nurse is caring for a client with cirrhosis. Which assessment findings correlate with expected laboratory findings in the​ client? ​(Select all that​ apply.) a Peripheral edema b Frequent infections c Bruising easily d Spider angiomas e Confusion

3 (An increase in abdominal girth indicates increasing ascites. meaning the clients condition is becoming more serious and should be reported. The normal direct bilirubin level is 0.1-0.4 but a decrease in a value although still elevated would not be reported)

The nurse is caring for the client dx with ascites secondary to hepatic cirrhosis. Which information should the nurse report to the HCP? 1. A decrease in the clients weight by 1 lb 2. An increase in urine after administration of diuretic 3. An increase in abdominal girth of 2 inches 4. A decrease in the serum direct bilirubin to 0.6

2 (The inability to circle food items on the menu may indicate deterioration in the clients cognitive status. The clients neurological status is impaired with hepatic encephalopathy the nurse should investigate this behavior. An increase in ammonia is seen in clients dx with hepatic encephalopathy and coma)

The nurse is caring for the client dx with hepatic encephalopathy Which sign and symptom indicate the disease is progressing? 1. The client has a decrease in serum ammonia 2. The client is not able to circle choices on the menu 3. The client is able to take deep breaths as directed 4. The client is able to eat previously restricted food items

4 (a client with esophageal varices is at an even higher risk of bleeding with elevated PT/INR. The nurse should collaborate with the HCP to prevent bleeding. The other lab findings are not as life threatening. A decreased serum albumin can cause fluid to move into the interstitial tissues. Increased ammonia levels are toxic to the brain. Calcium loss is more common in pancreatitis.)

The nurse is caring for the client with esophageal varices. The nurse should discuss which laboratory report finding with the HCP? 1. normal serum albumin 2. decreased ammonia 3. slightly decreased levels of Calcium 4. elevated PT/INR

1 (Tx of hep consists primarily of bed rest with bathroom privileges. Bed rest is maintained during the acute phase to reduce metabolic demands on the liver, thus increasing its blood supply and promoting liver cell regeneration. When activity is gradually resumed, the client should be taught to rest before becoming overly tired. Although adequate fluid intake is important, it is not necessary to force fluids to tx hep. Antibiotics are not used. Electrolyte imbalances are not typical of hep)

The nurse is developing a plan of care for the client with viral hepatitis. The nurse should instruct the client to : 1. obtain adequate bed rest 2 increase fluid intake 3 take antibiotic therapy as prescribed 4. drink 8 oz of an electrolyte solution every day

1 (immed before a paracentesis, the client should empty the bladder to prevent perforation. The client will be placed High Fowlers position or seated on the side of the bed for the procedure. IV sedatives are not usually administered. The client does not need to be NPO)

The nurse is preparing a client for a paracentesis. The nurse should 1. have the client void immediately before the procedure 2. place the client in a side lying position 3. initiate an IV line to administer sedatives 4. place the client on NPO status for 6 hrs before the procedure

4 (Hep B is spread thru exposure to blood or blood products and through high risk sexual activity. Hep B is considered to be a STD. High risk sex activity includes sex with multiple partners, unprotected sex with an infected individual, male homosexual activity, sex with IV drug users, College students are at high risk for development of Hep B, and are encouraged to be immunized. Alcohol intake by itself does not predispose an individual to hep B, but it can lead to high risk behaviors such as unprotected sex. Good personal hygiene alone will not prevent the transmission of Hep B)

The nurse is preparing a community education program about preventing Hep B infection. Which information should be incorporated into the teaching plan? 1 Hep B is relatively uncommon among college students 2. Freq ingestion of alcohol can predispose an individual to development of Hep B 3. Good personal hygiene habits are most effective at preventing the spread of Hep B 4. The use of a condom is advised for sexual intercourse

3 (Clients with cirrhosis should be instructed to avoid constipation and straining at stool to prevent hemorrhage. The client with cirrhosis has bleeding tendencies because of the livers inability to produce clotting factors. A low protein and high carb diet is recommended. Clients with cirrhosis should not take acetaminophen, which is potentially hepatotoxic. Aspirin also should be avoided if esophageal varices are present Cirrhosis is a CHRONIC disease)

The nurse is providing discharge instructions for a client with cirrhosis. Which statement best indicates the client has understood the teaching? 1. I should eat a high-protein high carb 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 and follow my diet it is possible for my cirrhosis to be cured

1 3 4 2 (Silencing the alarm will eliminate stress to the client and allow the nurse to focus The nurse should then assess the access site to note if the needle is inserted in the vein or if there is tissue trauma, infiltration or inflammation. Next the nurse should check for kinks in the tubing Finally the nurse can plug the pump into the wall to allow the battery to recharge)

The nurse is taking care of a client who has an IV infusion pump. The pump alarm rings. What should the nurse do in order from first to last? 1. silence the pump alarm 2. determine if the pump is plugged into the electrical outlet 3. Assess the clients access site for infiltration or inflammation 4. assess the tubing for hindrances to flow of solution

1 (The main transmission route for Hep A is the oral-fecal route. rarely parental. Good handwashing before eating or preparing food is essential to preventing spread of the disease. PErcutaneous transmission is seen with Hep B,C, and D. Alpha interferon is used for treatment of chronic Hep B and C)

The nurse is teaching the client with hepatitis A about preventing transmission of the disease. The nurse should focus teaching on: 1. proper food handling 2. insulin syringe disposal 3 alpha interferon 4. use of condoms

1 (The client should be monitored closely for changes in mental status. Ammonia has a toxic effect on CNS tissue and produces an altered LOC. Marked by drowsiness, and irritability. If this process is unchecked, the client may lapse into a coma. Increasing ammonia levels are not detected by changes in BP urine output, or respirations)

The nurse monitors a client with cirrhosis for the development of hepatic encephalopathy. Which would be an indication that hepatic encephalopathy is developing? 1. decreased mental status 2. elevated BP 3. decreased urine output 4. labored respiration

b (The client with cirrhosis is at risk for​ ascites; therefore it is important to measure the​ client's abdominal girth while providing care. The nurse should encourage small​ meals, provide a diet low in​ sodium, and use warm water for bathing.)

The nurse observes a distinct change in the Mr.​ Dontay's level of consciousness during a routine assessment during a scheduled physical examination. Mr. Dontay is 55 years​ old, a recovering​ alcoholic, and has a primary diagnosis of cirrhosis. Which intervention is appropriate for Mr. Dontay while providing​ care? a Encouraging large meals b Measuring abdominal girth c Using hot water for bathing d Providing a diet high in sodium

4 (Elevate HOB will allow for increasing lung expansion by decreasing the pressure on the diaphragm. The client requires reassessment. A paracentesis is reserved for symptomatic clients with ascites with impaired respiration or abdominal pain not responding to other measures, such as Na restriction and diuretics. There is no indication for blood cultures. Heart sounds are assessed with routine physical assessment)

The nurse reviewing the chart information for a client with increased ascites. The data include the following: T 98.9 (37.2 C) HR 118, shallow respirations @ 26 min, BP 126/76 and SpO2 89% on room air. The nurse should first: 1. assess heart sounds 2. obtain a prescription for blood cultures 3. prepare for a paracentesis 4 raise the HOB

2 (Hep C is usually transmitted thru blood exposure and needlesticks. A hep C vaccine is currently under development, but is not available. The first line of defecnse against hep B is the hep B vaccine. Hep C is not transmitted thru feces or urine. WEaring a gown and mask will not prevent transmission of the hep C virus if the caregiver comes in contact with infected blood or needles)

The nurse should institute which measures to prevent transmission of the Hep C virus to healthcare personnel? 1. administering the Hep C vaccine to all healthcare personnel 2. decreasing contact with blood and blood contaminated fluids 3. wearing gloves when emptying the bed pan 4. wearing a gown and mask when providing direct care

2 (Low fat, high protein, high carb diet is encouraged for a client with Hep to promote liver rejuvenation. Nutrition intake is important because clients may be anorexic and experience weight loss. Activity should be modified and adequate rest maintained to promote recovery. Social isolation should be avoided, and education on preventing transmission should be provided; the client does not need to sleep in a separate room)

The nurse should teach the client with hepatitis A to: 1. limit caloric intake and reduce weight 2. increase carbs and protein in the diet 3. avoid contact with others and sleep in a separate room 4. intensify routine exercise and increase strength

a (Rationale: The client with chronic viral hepatitis resulting in cirrhosis should avoid alcohol and medications like acetaminophen that will further damage the liver. Because the liver becomes fibrotic and there is an extensive loss of liver cells, treatments will not cure or reverse the disease, but they can help to slow the progression to liver failure. Use of medications to regulate protein metabolism is one form of supportive therapy that can help to reduce complications and delay liver failure but these, of course, do not guarantee a long life. )

The nurse would evaluate teaching as effective when a client with chronic viral hepatitis progressing to cirrhosis states which of the following? a "The medications that help to regulate how my body handles protein will help me have a pretty normal lifespan." b "I know I should only use acetaminophen for pain relief." c "I understand that the fibrosis and loss of liver cells can be reversed if I'm really careful with my diet and avoid alcohol and drugs." d "Since this is caused by an infection, not lifestyle, I'm glad to hear that I won't need to reduce my alcohol intake."

1 (sufficient energy is required for healing. Adequate carb intake can spare protein. The client should eat approx. 16 carb kilocalories for each kilogram of ideal body weight daily TPN is not routinely prescribed for the client with hepatitis. The client must lose a large amt of weight and be unable to eat anything for TPN to be ordered.)

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

1 3 2 4 (The nurse should first assess the client with cirrhosis to ensure the clients safety and assess the client for onset of hepatic encephalopathy. The nurse should then assess the client with acute pancreatitis who is requesting pain med, and deliver the needed med. The nurse should then assess the client who underwent a cholecystectomy and is 1 day post op to make sure the T tube is draining and the client is performing post op breathing exercises. The nurse can speak last with the client with Hep B who has questions about discharge instructions because this is not urgent)

The nurses assignment consists of 4 clients. From highest to lowest priority, in which order should the nurse assess the clients after receiving the morning report? 1. The client with cirrhosis who became confused and disoriented last night 2. The client who is 1 day post op following a cholecystectomy and has a T tube inserted 3. The client with acute pancreatitis who is requesting pain medication 4. The client with Hep B who has questions about discharge instructions

1,2,3 (Hep B can be transmitted by sharing any type of needles, especially those who use drugs. Hep B can be transmitted thru sexual activity, therefore recommend abstinence, mutual monogomy and barrier protection. Three does of Hep B vaccine provide immunity in 90% of healthy adults. Immune globulin shots are administered as postexposure prophylaxis, but encouraging these injections is not a health promotion activity. Hepatoxic meds should be avoided in clients who have Hep or who have had it. )

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? SATA 1.. Do not share needles or equipment 2. Use barrier protection during sex 3. Get the Hep 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 weeks before symptoms develop. Hep B is spread thru contact with body fluids and blood Hep C is transmitted thru infected blood and body fluids Hep D only causes infection in people also infected with Hep B or C)

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

4 (Hep A is transmitted by the fecal-oral route. Good handwashing helps to prevent its spread. Singing the happy birthday song takes approx. 30 secs. which is how long an individual should wash their hands Eating after each other should be discouraged, but it is not the most important intervention. Only bottled water should be consumed in 3rd world countries, but not necessary in american schools. Hep B and C are transmitted by sexual activity)

The school nurse is discussing methods to prevent an outbreak of hep 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

1 (Clients with cirrhosis, without complications, a high calorie, high carb diet is preferred to provide adequate supply of nutrients. In the early stages of cirrhosis, there is no need to restrict protein, fat or sodium.)

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

a (The purpose of liver functions tests in diagnosing cirrhosis is to determine the degree of elevation of liver enzymes. A CBC is used to determine the presence of anemia. Coagulation studies are used to determine the prothrombin time. Serum glucose and cholesterol levels are used to determine the effect cirrhosis is having on glucose and lipid metabolism)

What is the purpose of liver functions tests in diagnosing​ cirrhosis? a To determine the degree of elevation of liver enzymes b To determine the presence of anemia c To determine the prothrombin time d To determine glucose and lipid metabolism

1 (The prothrombin time may be prolonged because of decreased absorption of Vit K and decreased production of prothrombin by the liver. The client should be assessed carefully for bleeding tendencies. Blood glucose, serum calcium and potassium are not affected by hep)

When planning care for a client with hepatitis A, the nurse should review lab reports for which lab values? 1 prolonged prothrombin time (PT) 2. decreased blood glucose 3. elevated potassium level 4. decreased serum calcium level

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. It really doesnt matter how long the client has been drinking, the dx of alcoholic cirrhosis indicates the client probably has been drinking many years. An advance directive is important for the client that is terminally ill, but is not priority question. And unless the client is very malnourished this is not a typical nursing question)

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 advanced directive? 3. When did you have your last alcoholic drink? 4. What foods did you eat at your last meal?

a,b,c,e (Complications associated with cirrhosis include esophageal​ varices, splenomegaly,​ ascites, and hepatic encephalopathy. Hypertension is not a complication associated with cirrhosis.)

Which complications are associated with​ cirrhosis? ​(Select all that​ apply.) a Hepatic encephalopathy b Splenomegaly c Esophageal varices d Hypertension e Ascites

a (Excessive alcohol use is the leading cause of cirrhosis. Injection drug use increases the risk for contracting bloodborne hepatitis​ (B, C, or​ D), which leads to chronic hepatitis and then cirrhosis. Unprotected sex and hepatitis E infection are not causes of cirrhosis.)

Which factor is the leading cause of​ cirrhosis? a Excessive alcohol use b Injection drug use c Unprotected sex d Hepatitis E

2 (LIver inflammation and obstruction block the normal flow of bile, excess bilirubin turns the skin and sclerae yellow and the urine dark and frothy. Profound anorexia is also common. Tarry stools are indicative of GI bleeding and would not be expected in hepatitis. Light or clay colored stools may occur related to bile duct obstruction. SOB would be unexpected.)

Which finding is normal for a client during the icteric phase of hep A? 1. tarry stools 2. yellowed sclerae 3. sob 4. light, frothy urine

3 (clay colored stools and hemorrhoids are GI effects of liver failure. Hypoalbuminemia (decreased albumin) and muscle wasting are METABOLIC effects not GI effects. Oligomenorrhea is no menses, which is a reproductive effect, and decreased body hair is integumentary effect Dyspnea is a RESP effect, and caput medusae (dilated veins around the umbilicus) is an integumentary effect although it is on the abdomen)

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

2 (The client should be able to verbalize the importance of reporting any bleeding tendencies that could be the result of prolonged prothrombin time. Ascites is not typically a clinical manifestation of hep, it is associated with cirrhosis. Alcohol should be eliminated for at least 1 year after the dx of hepatitis to allow the liver time to fully recover. There is no need for the client to be restricted to the home because hepatitis is not spread thru casual contact between individuals)

Which goal is appropriate for a client with Hep A? The client will: 1. demonstrate a decrease in fluid retention related to ascites 2. Verbalize the importance of reporting bleeding gums or bloody stools 3. limit use of alcohol to 2-3 drinks per week 4. restrict activity to within the home to prevent disease transmission

2 (General health promotion measures include maintaining good nutrition, avoiding infection, and abstaining from alcohol. It is not necessary to take multivitamins if the client is obtaining adequate nutrition. Rest and sleep are essential, but an impaired liver may not be able to detoxify sedatives and barbiturates. Such drugs must be used cautiously if at all, by clients with cirrhosis. The client does not need to limit contact with others but should exercise caution to stay away from ill people)

Which health promotion activity should the nurse suggest that the client with cirrhosis add to the daily routine at home? 1. supplement diet with multivitamins 2. abstain from drinking alcohol 3. take a sleeping pill at bedtime 4. limit contact with other people whenever possible

2 (Adequate rest ins needed for maintaining optimal immune function The client must avoid all alcohol. Clients are usually anorexic and nauseated in the afternoon and evening, therefore the main meal should be in the morning. Diet drinks and juices provide few calories, and the client needs an increased calorie diet for healing)

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

1 (The increased serum ammonia level associated with liver failure causes the hepatic encephalopathy, which in turn leads to neurological deficit. Administering a loop diuretic is appropriate for ascites and portal hypertension Checking the stool for bleeding is an appropriate intervention for esophageal varices and decreased Vit K Assessing the abdominal fluid wave ius an appropriate intervention for ascites and portal hypertension)

Which intervention should the nurse implement specifically for the client in end stage liver failure who is experiencing hepatic encephalopathy? 1. Assess the clients neurological status 2. Prepare to administer a loop diuretic 3. Check the clients stool for blood 4. Assess for an abdominal fluid wave

b (Rationale Liver biopsy helps distinguish cirrhosis from other forms of liver disease. The O2 ​level, CO2 ​level, and WBC count are not relevant to establishing the diagnosis of cirrhosis.)

Which laboratory test is prescribed for a client with suspected​ cirrhosis? a O2 level b Liver biopsy c CO2 level d WBC count

d (Appropriate nursing diagnoses for a client with cirrhosis include impaired skin​ integrity, diminished protection and impaired nutrition.​ Increased, not​ decreased, fluid volume is appropriate for a client with cirrhosis.)

Which nursing diagnosis is not appropriate for a client with​ cirrhosis? a Diminished protection b Impaired skin integrity c Impaired nutrition d Decreased fluid volume

a (Rationale Clients with cirrhosis deal with a variety of​ problems, but​ fatigue, activity​ intolerance, and anxiety are not among them. A few nursing diagnoses that are appropriate include impaired skin​ integrity, increased risk for acute​ confusion, diminished​ protection, increased fluid​ volume, and reduced​ nutrition, less than body requirements.)

Which nursing diagnosis supports a medical diagnosis of​ cirrhosis? a Increased risk for acute confusion b Fatigue c Activity intolerance d Anxiety

1 (Ascites can compromise the action of the diaphragm and increase the clients risk of respiratory problems. Ascites also greatly increases the risk of skin breakdown. Freq position changes are important but the preferred position is Fowlers. )

Which position would be appropriate for a client with severe ascites? 1. Fowlers 2. Side lying 3. reverse Trendelenburg 4. Sims

4 (contact precautions are recommended for clients with Hep A. This includes wearing gloves for direct care. A gown is not required unless substantial contact with the client is anticipated. It is not necessary to wear a mask. The client does not need a private room unless incont of stool)

Which precautions should the healthcare team observe when caring for clients with Hep A? 1. gowning when entering the clients room 2. wearing a mask when providing care 3. assigning the client to a private room 4. wearing gloves when giving direct care

2 (The Hepatitis B vaccine will prevent the client from contracting the disease. 1. This intervention appropriate for preventing Hep A 3. This appropriate for preventing Hep A 4. The nurse uses standard precautions, not the client)

Which priority teaching information should the nurse discuss with the client to help prevent contracting hepatitis B? 1. Explain the importance of good handwashing 2. Recommend the client take the Hep B vaccine 3. Tell the client to not ingest unsanitary food or water 4. Discuss the importance of standard precautions

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 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 dont get exhausted 3. I had a big hearty breakfast this morning 4. I took some cough syrup for a nasty head cold

3

Which task is most appropriate to delegate to the UAP? 1. Draw the serum liver function test 2. Evaluate the clients intake and output 3. Perform the bedside glucometer check 4. Help the ward clerk transcribe orders

a (Nutritional support for cirrhosis includes restricting sodium intake to 2 g per day. Administering vitamin K and recommending antacids is pharmacologic therapy. Decreasing fluid​ intake, not increasing​ it, is considered a nutritional therapy for cirrhosis. )

Which therapy for cirrhosis is considered nutritional​ therapy? a Restricting sodium intake b Recommending antacids c Administering vitamin K d Increasing fluid intake

2 (standard precautions apply to blood, body fluids, secretions, excretions except sweat, regardless of whether they contain visible blood)

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

3 (This client has experienced a physiological problem and the nurse must assess the client and the emesis to decide on possible interventions.)

1. The nurse is caring for clients on a medical unit. Which task should the nurse implement first? 1. change the abd surgical dressing for a client who ambulated in the hall 2. discuss the correct method of placing Montgomery straps on the client with the UAP 3. Assess the male client who called the desk to say he is nauseated and just vomited 4. Place a call to the extended care facility to give the report on a discharged client

1 ( Nausea and vomiting are common adverse effects of interferon alfa-2a, but continued vomiting should be reported to the physician, because dehydration may occur. The medication may be given by either the subcutaneous or intramuscular route. Flulike symptoms such as a mild temperature elevation, headache, muscle aches, and anorexia are common after initiation of therapy but tend to decrease over time. Focus: Prioritization)

10. A patient with chronic hepatitis C has been receiving interferon alfa-2a (Roferon-A) injections for the last month. Which information gathered during a home visit is most important to communicate to the physician? 1. The patient has persistent nausea and vomiting. 2. The patient injects the medication into the thigh by the intramuscular route. 3. The patient's temperature is 99.7° F (37.6° C) orally. 4. The patient reports chronic fatigue, muscle aches, and anorexia.

4 (The client has a urinary output of less than 30 mL/hr, therefore this client may be going into renal failure and should be assessed first. : definitions: tenesmus: straining to empty bowels, Jaundice and ascites are expected in client with liver failure, so that client is not first. Barretts esophagus is expected to have dysphagia and pyroisis aka heartburn.)

10. Which client should the nurse assess first after receiving the pm shift assessment? 1. The client with Barretts esophagus who has dysphagia and pyrosis 2. The client with proctitis who has tenesmus and passage of mucus through the rectum 3. the client with liver failure who is jaundiced and has ascites 4. The client with abd pain who has an 8 hr urinary output of 150 mL

3 ( Patients taking immunosuppressive medications are at increased risk for development of cancer. A nontender swelling or lump may signify that the patient has lymphoma. The other data indicate that the patient is experiencing common side effects of the immunosuppressive medications. Focus: Prioritization)

11. A patient with a history of liver transplantation is receiving cyclosporine (Sandimmune), prednisone (Deltasone), and mycophenolate (CellCept). Which finding is of most concern? 1. Gums that appear very pink and swollen 2. A blood glucose level that is increased to 162 mg/dL 3. A nontender lump above the clavicle 4. Grade 1+ pitting edema in the feet and ankles

3 (mucosal barrier agent must be administered before the client eats in order to coat the gastric mucosa. Administer this first.)

12. The nurse is preparing to administer morning medications to client on a medical unit. Which medication should then nurse administer first? 1. Methylprenisolon (Solu-Medrol), a steroid to a client with Crohns disease 2. Donepezil (Aricept) an acetylcholinesterase inhibitor, to a client with dementia 3. Sucralfate (Carafate) a mucosal barrier agent to a client dx with ulcer disease 4. Enoxaparin (Lovenox) an anticoagulant to a client on bed rest after abdominal surgery

3 (HARD RIGID ABD)

13. The nurse has received morning shift report on a surgical unit in a community hospital. Which client should the nurse assess first? 1. The client 6 hrs post op small bowel resection who has hypoactive bowel sounds x4 quads 2. The client who is scheduled for abdominal-peritoneal resection this morning who is crying and upset 3. The client who is 1 day post op for abd surgery and has a hard rigid abdomen 4. The client who is 2 days postop for emergency appendectomy and is complaining of abd pain rating 8 on scale 1-10

3 (The location of the incision for a cholecystectomy the general anesthesia needed, and a heavy smoking history make this client high risk for pulmonary complications. WRONG: #2 The clients high BP should be monitored closely and meds administered but would not cause to have a higher risk for complications.)

15 The nurse is preparing clients for surgery. which client has the greatest potential for experiencing complications? 1. The client scheduled for removal of an abdominal mass who is overweight 2. The client scheduled for a gastrectomy who has arterial hypertension 3. The client scheduled for an open cholecystectomy who smokes two packs of cigs a day 4. The client scheduled for an emergency appendectomy who smoke marijuana on a daily basis

3 (Wound dehiscence is the premature bursting open of a wound along surgical suture and is an emergency that would require first assessment.)

19 The med surg nurse has just received the am shift report. Which client should the nurse assess first? 1. The client who has a parlytic ileus and absent bowel sounds 2. The client who is 2 days post op abdominal surgery and has a soft tender abdomen 3. The client who is 6 hrs postop and has an abdominal wound dehiscence 4. The client who had a liver transplant and is being transferred to the rehab unit

1 ( The UAP should use infection control precautions for the protection of self, employees, and other clients. Monitoring is an RN responsibility. UAPs can report valuable information; however, they are not responsible for detecting signs and symptoms that can be subtle or hard to detect, such as skin changes. While playing games with the client may be ideal, it is rarely possible on a medical-surgical unit. Focus: Delegation)

19. In the care of a client with acute viral hepatitis, which task should be delegated to the UAP? 1. Emptying the bedpan while wearing gloves 2. Playing games or engaging the client in diversional activities 3. Monitoring dietary preferences 4. Reporting signs and symptoms of jaundice

1 ( There is a potential for sudden rupture of fragile blood vessels with massive hemorrhage from straining that increases thoracic or abdominal pressure. The client could have fluid accumulation in the abdomen (ascites) that can be mild and hard to detect or severe enough to cause orthopnea. Dependent peripheral edema can also be observed but is less urgent. Focus: Prioritization)

20. You are caring for a client with cirrhosis and portal hypertension. Which statement by the client concerns you the most? 1. "I'm very constipated and have been straining during bowel movements." 2. "I can't button my pants anymore because my belly is so swollen." 3. "I have a tight sensation in my lower legs when I forget to put my feet up." 4. "When I sleep, I have to sit in a recliner so that I can breathe more easily."

2 (Pain is priority because the nurse must first determine if this is expected pain or complication of surgery. Assess this client first. #1 the ABGs reflect metabolic alkalosis which is expected with excessive vomiting)

21 The nurse is caring for clients on a surgical unit. Which client should the nurse assess first? 1. The client who has been vomiting for 2 days and has an ABG of pH 7.47, PaO2 95, PacO2 44, HCO3 30 2. The client who is 8 hrs postop for splenectomy and who is complaining of abdominal pain, rating it as a 9 on a scale of 1-10 3. The client who is 12 hrs postop abd surgery and has dark green bile draining in the NG tube 4. The client who is 2 days post op for hiatal hernia repair and is complaining of feeling constipated

2, 3 ( Both clients will need frequent pain assessments and medications. Clients with copious diarrhea or vomiting will frequently need enteric isolation. Cancer clients receiving chemotherapy are at risk for immunosuppression and are likely to need protective isolation. Focus: Assignment)

23. You must rearrange the room assignments for several clients. Which two clients would be best to put in the same room? 1. 35-year-old woman with copious intractable diarrhea and vomiting 2. 43-year-old woman who underwent cholecystectomy 2 days ago 3. 53-year-old woman with pain related to alcohol-associated pancreatitis 4. 62-year-old woman with colon cancer receiving chemotherapy and radiation _____, _____

3 (The clients apical pulse is above normal and the BP is low which are signs of hypovolemic shock, which warrants immed intervention. #1 Hemoglobin 9 think tranfusion time, this H/H is ok #4 coffee ground indicates old blood which would not be unexpected in the client with esophageal bleeding)

25 The client is dx with esophageal bleeding.. Which of the following assessment data warrants immediate intervention by the nurse? 1. The clients H/H is 11.4/32 2. The clients abdomen is soft to touch and non-tender 3. The clients VS are T 99, AP 114, RR 18, BP 88/60 4. The clients nasogastric tube has coffee ground drainage

3 ( The UAP can take vital signs and report all of the values to the RN. In this case, all of the values are needed in order to detect trends. In other cases, you may decide to give parameters for reporting. The RN should assess skin temperature and pain, and closely monitor the urine because quantity is an indicator of perfusion and red/pink urine can signal damage to the urinary system, transfusion reaction, or rhabdomyolysis. Focus: Delegation)

25. You are caring for a client who was admitted to your medical-surgical unit for observation after being evaluated in the emergency department for blunt trauma to the abdomen. Which instructions are appropriate to give to the UAP? 1. Check the client's skin temperature and report if the skin feels cool. 2. Check the urine in the urometer every hour and observe for red- or pink-tinged urine. 3. Check vital signs every hour and report all of the values. 4. Check the client's pain and report worsening of pain or discomfort.

1 ( Refeeding syndrome occurs when aggressive and rapid feeding results in fluid retention and heart failure. Electrolytes, especially phosphorus, should be monitored, and the client should be observed for signs of fluid overload. Changes in bowel sounds, nausea, and distention may occur but are also appropriate for any client with nutritional issues or for clients receiving enteral feedings. Observing for purging and water ingestion would be appropriate for a client with an eating disorder. Change in stool patterns may occur, but are not related to refeeding syndrome. Focus: Prioritization)

27. Clients who are undernourished or starved for prolonged periods are at risk for refeeding syndrome when nourishment is first given. What is the priority nursing assessment to prevent complications associated with this syndrome? 1. Monitor for peripheral edema, crackles in the lungs, and jugular vein distention. 2. Monitor for decreased bowel sounds, nausea, bloating, and abdominal distention. 3. Observe for signs of secret purging and ingestion of water to increase weight. 4. Assess for alternating constipation and diarrhea and pale clay-colored stools.

3 ( All of these measures should be performed for total care of the client; however weighing the client every day is considered the single best indicator of fluid volume. Focus: Prioritization)

28. You are caring for a client who was admitted for advanced cirrhosis. The client has massive ascites, peripheral dependent edema in the lower extremities, nausea and vomiting, and dyspnea related to pressure on the diaphragm. For the nursing diagnosis of Excess Fluid Volume, which indicator is the most reliable for tracking fluid retention? 1. Auscultating the lung fields for crackles every day 2. Measuring the abdominal girth every morning 3. Performing daily weights with the same amount of clothing 4. Checking the extremities for pitting edema and comparing to baseline

3 ( Substance abuse may exclude a person from the transplant list, so the nurse should conduct additional assessment about this comment. The comment about difficulty in taking prescription medications should also be investigated because a true inability to follow the treatment regimen would also exclude the client from the list. Focus: Prioritization)

29. A client with end-stage liver disease is talking to you about being on the transplant list. Which statement by the client concerns you the most? 1. "I have a family history of diabetes." 2. "I had symptoms of asthma when I was a kid." 3. "I am going to cut down on my drinking very soon." 4. "I am not very good about taking prescribed medication."

4 (The client with Crohns disease should be asymptomatic, so pain and diarrhea warrant intervention by the nurse, pain could indicate a complication. WRONG: The other answers all have expected symptoms for the condition/diagnoses definitions: stretorrhea=fat frothy stools, pyrexia=fever, dyspepsia=upset stomach, eructation=belching)

3. Which client warrants immediate intervention from the nurse on the medical unit? 1. The client diagnosed with dyspepsia who has eructation and bloating 2. The client diagnosed with pancreatitis who has steatorrhea and pyrexia 3. The client with diverticulitis who has LLQ pain and fever 4. The client with Crohns disease who has right lower abd pain and diarrhea

1 (The nurse should first assess the clients neurological status to determine the status of the client.)

30 The LPN tells the nurse the client dx with liver failure is getting more confused. Which intervention should the nurse implement first? 1. Assess the clients neurological status 2. Notify the clients healthcare provider 3. Request a stat ammonia serum level 4. Tell the LPN to obtain the clients VS

3 ( T-tubes should not be irrigated, aspirated, or clamped without a specific order from the physician. All of the other actions are appropriate in the care of this client. Focus: Supervision)

30. You are supervising a nursing student who is caring for a client who had a cholecystectomy. There is a T-tube in place. You would intervene if the student performs which action? 1. Maintains the client in a semi-Fowler position 2. Checks the amount, color, and consistency of the drainage 3. Gently aspirates the drainage from the tube 4. Inspects the skin around the tube for redness or irritation

1 (The nurse should not delegate to the UAP feeding a client who is not stable and at risk for complications during feeding, as a result of dysphagia. This requires judgement the UAP is not expected to possess.)

4. The nurse and the UAP are caring for clients on a med-surg unit. Which task should not be assigned to the UAP? 1. Instruct the UAP to feed the 69 year old who is experiencing dysphagia 2 REquest the UAP change the linens for the 89 year old client with fecal incontinence 3. Tell the UAP to assist the 54 year old client with a bowel management program 4. Ask the UAP to obtain VS on the 72 year old client diagnosed with cirrhosis

2

40 The significant other of a client dx with liver cancer and who is dying asks the nurse, what is bereavement counseling? Which statement is the nurses best response? 1. Bereavement counseling helps the client accept the terminal illness 2. It provides support to you and your family in the transition to a life without your loved one 3. We provide counseling to you and your loved one during the dying process 4. It is a group counseling for family members whose loved ones have died

3

41 The nurse is working in a digestive disease disorder clinic. Which nursing action is an example of evidence-based practice? 1. Turn on the tap water to help a client urinat 2. Use two identifiers to identify a client before a procedure 3. Educate a client based on current published information 4. Read nursing journals about the latest procedures

2

43 The administrative supervisor is staffing the hospitals med surg units during an icestorm and has received many calls from staff who are unable to get to the hospital. Which action should the supervisor implement first? 1. inform the cheif nursing officer 2. notify the on duty staff to stay 3. call staff members who live close to the facility 4. implement the emergency disaster protocol

3 (This client is exhibiting symptoms asthma a complication of GERD therefore the client should be assigned to the most experienced nurse. #4 PAin is expected with a surgical procedure and a less experienced nurse could admin pain meds #1 regurgitation is a common manifestation of gerd, so not the most experienced nurse #2 Barretts esophagitis is a complication of gerd, new grads can prepare the client for a diagnostic procedure)

46 The charge nurse is making assignments on a med surg unit. Which client should be assigned to the most experienced nurse? 1 the client with lower esophageal dysfunction who is experiencing regurgitation 2. The client dx with Barretts esophagitis who is scheduled for an endoscopy 3. The client dx with gastroesophageal reflux disease who has bilateral wheezed 4. The client dx with 1 day post op hiatal hernia who has pain rated a 4 on a scale of 0-10

3 (high risk due to hypokalemia. Assess the cardiac status and then implement other interventions)

47 The client is experiencing severe diarrhea and has a serum potassium level of 3.3 Which intervention should the nurse implement first? 1. Notify the HCP 2. Assess for leg cramps 3. Place on telemetry 4. Prepare to admin IV potassium

3 (A client with a continuous feeding tube should be in the Fowlers or high Fowlers position to prevent aspiration pneumonia. This action requires immediate intervention)

5. Which behavior by the UAP requires immediate intervention by the nurse? 1 The UAP is refusing to feed the client Dx with acute diverticulitis 2 The UAP would not place the client on the bedside commode who was on bed rest 3. The UAP placed the client with continuous feeding tube in supine position 4. The UAP placed sequential compression devices on the client who is on strict bed rest.

3 (Direct pressure is applied to the site and the client is placed on the right side to maintain site pressure for at least 2 hours. Turning the client to the left side warrants intervention by the nurse so the client will not hemorrhage. #1 The client should stay on his or her right side for at least 2 hrs post procedure so giving a urinal to void is ok. #2 the client is NOT NPO after, so they can have water)

58 The male client is 30 mins post procedure liver biopsy. Which action by the UAP requires the nurse to intervene? 1. The UAP offered the client a urinal to void 2. The UAP gave the client a glass of water 3. The UAP turned the client on the left side 4. The UAP took the clients VS

3 (Mittens will help prevent the client from scratching the skin and causing skin breakdown, which is a priority for the client with liver failure. The client has decreased Vitamin K, which will lead to bleeding. The client is also immunosuppressed which will lead to infection. WRONG: #1 Hot water increases pruritis and soap will cause dry skin, #2 this will help dry skin but this is not the first intervention to protect #4 benedryl will help decrease pruritis but will take 30 mins to work, protection is the priority)

59 The client dx with liver failure is experiencing pruritus secondary to sever jaundice and is scratching the upper extremities. Which intervention should the nurse implement first? 1. Request the UAP to assist the client to take a hot soapy shower 2. Apply emollient to the clients upper extremities 3. Place mittens on both hands of the client 4. Administer benedryl 25 mg PO to the client

2 (Milk thistle has an active ingredient silymarin, which has been used to treat liver disease for more than 2000 years. It is a powerful oxidant and promotes liver cell growth. This response gives the client factual information)

60 The client with hepatitis asks the nurse "Is there any herb I can take to help my liver get better?" Which statement is the nurses best response? 1. You should ask your HCP about taking herbs 2. Milk thistle is a powerful oxidant and promotes liver cell growth 3. You should not take any medication that is not prescribed 4. Why would you want to take any herbs?

1 (Pain should be assessed even if it is expected for the clients dx if other clients are stable)

64 The nurse has received the am shift report. Which client should the nurse assess first? 1. the client with peptic ulcer disease who is complaining of acute epigastric pain 2. The client with acute gastroenteritis who is upset and wants to go home 3. The client with inflammatory bowel disease who is receiving TPN 4. The client with hep B who is complaining and who is jaundiced and anorexic

2 (The client was just transferred from the PACU therefore the nurse should assess this client first to perform a baseline assessment to ensure the client is stable)

67 The nurse is caring for the following clients on a surgical unit. Which client should the nurse assess first? 1. The client with an inguinal hernia repair who has a urine output of 160 mL in 4 hrs 2. The client with an emergency appendectomy who was transferred from PACU 3. The client who is 4 hours post op abd surgery who has flatulence 4. The client who is 6 hrs post procedure colonoscopy and is being discharged

2 (This client is being prepared for a test in the morning and is the least acute of the clients listed. The new grad should be assigned to this client.)

8. The charge nurse is making assignments on a medical unit. Which client should the nurse assign to the graduate nurse? 1. The client who has received 3 units of PRBCs 2. The client scheduled for an esophagogastroduodenoscopy in the morning 3. The client with short bowel syndrome who has diarrhea and a K+ level of 3.3 4. The client who has just returned from surgery for a sigmoid colostomy

a,e (Rationale: Edematous tissue must receive meticulous care to prevent tissue breakdown. When jaundice is present, bile salts can deposit on the skin, causing pruritus and scratching by the client to relive itching, which promotes skin breakdown. Warm water should be used for bathing rather than hot water as the latter increases itching. An air pressure mattress and careful repositioning can prevent skin breakdown, and having the client in different positions, such as chair-sitting, can relieve pressure on the skin. However, having the client sit in a chair for 30 minutes each shift may be too disruptive to rest and sleep and may not be possible for the severely ill bedridden individual. Range of motion exercises preserve joint function but do not prevent skin breakdown. )

A client diagnosed with chronic cirrhosis has jaundice, ascites, and pitting peripheral edema as well as hepatic encephalopathy. Which nursing interventions are most appropriate to prevent skin breakdown? (Select all that apply.) a Turning and repositioning every 2 hours b Using hot water to bathe to relieve pruritus c Asking client to sit in a chair for 30 minutes each shift d Range of motion every 4 hours e Alternating air pressure mattress

c (Rationale Hepatic encephalopathy may be aggravated by sepsis secondary to​ infection, due to increased buildup of toxic​ substances, in clients with cirrhosis. Portal​ hypertension, esophageal​ varices, and Wilson disease are not caused or aggravated by infection.)

A client diagnosed with liver cirrhosis is being treated for an infection. For which complication should the nurse monitor the​ client? a Esophageal varices b Wilson disease c Hepatic encephalopathy d Portal hypertension

1 (because the biopsy needles insertion site is close to the lung, there is a risk of lung puncture and pneumothorax; therefore immed after the procedure the nurse should determine diminished or absent lung sounds in the right lung. Although fever indicates infection, a rise in temp is not seen immed. A CBC is warranted if the VS and client symptoms indicate potential hemorrhage. The needle insertion site is covered with a pressure dressing there is no need for a dressing requiring packing.)

A client had a liver biopsy 1 hr ago. The nurse should first: 1. auscultate lung sounds 2 check for fever 3. obtain CBC 4. apply packing to the biopsy site

3 (Clients with Hep C should receive geno-type testing to determine the most effective treatment approach. and it must be done prior to starting drug treatment with alph-interferon. There are six types of hep C genotypes and clients have different responses to drugs depending on their genotype. The recommended course of treatment depends on the genotype)

A client has a positive serologic test for anti-HCV (hep C virus). The nurse should instruct the client: 1. how to self administer alpha interferon 2. that the HCV will resolve in approximately 3 months 3. That a follow up appt for HCV genotype testing is required 4. to take alpha-interferon as prescribed

4 (Portal Hypertension and hypoalbuminemia is a result of cirrhosis cause a fluid shift into the peritoneal space causing ascites. In a cardiac or kidney problem, NOT CIRRHOSIS, sodium can promote edema formation and subsequent decreased urine output. Edema does not migrate upward toward the heart to enhance circ. Although diuretics promote the excretion of excess fluid, occasionally forgetting or omitting a dose will not yield the ascites found in cirrhosis of the liver)

A client has advanced cirrhosis of the liver. The clients 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 provide the most accurate explanation of the disease process? 1. He must have been eating too many foods with salt in them. Salt pulls water with 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, and the liver cannot make protein to keep fluid inside the blood vessels

d (Rationale: The highest priority is protecting the airway so if the client develops respiratory distress, the nurse would deflate the esophageal balloon to avoid compression on the airway. The physician would be notified following this action. The nurse would not remove the NG tube, and the client would not be placed in a supine position. An appropriate syringe should be kept at the bedside to deflate the esophageal balloon in case respiratory distress occurs.)

A client hospitalized with cirrhosis and bleeding varices is being treated with esophageal balloon and gastric balloons using a multiple-lumen nasogastric tube to apply pressure to the varices. An endotracheal tube has already been inserted/is being treated. Which of the following is the priority action by the nurse if the client develops respiratory distress? a Contact the physician. b Place the client supine. c Remove the nasogastric tube. d Deflate the esophageal balloon.

c (Rationale: The nurse should assess bowel sounds and palpate for tenderness since spontaneous bacterial infection (spontaneous bacterial peritonitis) can develop with ascites, producing abdominal discomfort, fever, and worsening encephalopathy. Headache and nuchal rigidity are symptoms of meningitis. Neck vein distention is associated with right-sided heart failure. Abdominal girth and shifting dullness are important in monitoring progress of ascites, not infection. )

A client hospitalized with severe ascites due to cirrhosis develops abdominal pain, fever, and confusion. As part of the initial plan for care, the nurse should first: a Inquire about headache and check for nuchal rigidity. b Measure abdominal girth and percuss for shifting dullness. c Auscultate bowel sounds and palpate the abdomen for tenderness. d Observe for neck vein distention and auscultate lung sounds.

a,c,d,e (Portals of entry for infection that may lead to sepsis​ include, but are not limited​ to, intravenous​ catheters, surgical​ wounds, sexually transmitted​ infections, and peptic ulcerations. Pulse oximetry is not an invasive procedure and is not a portal of entry for infectious sepsis)

A client is at risk for infectious sepsis through which portals of​ entry? ​(Select all that​ apply.) a Surgical wounds b Pulse oximetry monitoring c Sexually transmitted infections d Intravenous catheters e Peptic ulcerations

2 (The taste of lactulose is a problem for some clients. Mixing it with fruit juice, water or milk can make it more palatable. Lactulose should NOT be given with antacids which would inhibit action. Lactulose should not be taken with a laxative because increased stooling is an adverse effect of the drug and would be potentiated by using a laxative. Lactulose comes in the form of syrup for oral and rectal administration)

A client is to be discharged with a prescription for lactulose. The nurse teaches the client and the clients souse how to administer this medication. Which statement would indicate the client has understood the information? 1. I will take it with an antacid 2. I will mix it with apple juice 3. I will take it with a laxative 4 I will mix the crushed tablets in some gelatin

1 (Current therapy includes a combination of IV interferon and ribavirin that often includes unpleasant side effects and requires frequent monitoring. The recent approval of oral, directly acting antiviral agents (telaprevir, boceprevir, sofosbuvir, simeprevir) is expected to decrease monitoring rates and increase cure rates, though these drugs are currently very expensive. Though answers 3 and 4 may be true, it is not appropriate to make judgements about a clients health insurance and lifestyle choices)

A client recently dx with Hep C states: Now that you know what is wrong with me, you can just get me the new drugs to take care of it right? The nurse tells the client: 1. The Tx is complex. There are new antiviral drugs available that may make Tx more effective and help you tolerate it better 2. There are drugs to help with the symptoms, but once you have Hep C you will never be cured 3. The medicine currently used to treat Hep C is very expensive, and your insurance probably will not pay for it 4. If you continue to make the same lifestyle choices the medicine will not make any difference

4 (during the convalescent or posticteric stage of hepatitis fatigue and malaise are the most common problems. These symptoms usually disappear within 2-4 months. Fatigue and malaise are not evidence of a secondary infection. Hep A is not treated by drug therapy. It is important that the client continue to balance activity with periods of rest)

A client who is recovering from Hep A has fatigue and malaise. The client asks the nurse, When will my strength return? Which response by the nurse is most appropriate? 1 Your fatigue should be gone by now. We will evaluate you for a secondary infection 2. Your fatigue is an adverse effect of your drug therapy and will disappear when your treatment regimen is complete 3. It is important for you to increase your activity level That will help decrease your fatigue 4. It is normal for you to feel fatigued. The fatigue should go away in the next 2-4 months

1 3 2 4 (The nurse should first assess the client to determine if the tube is obstructing the airway; assessment is done by assessing the airflow. Once obstruction is established, the tube should be deflated and then quickly removed. A set of scissors should always be at bedside to allow for emergency deflation of the ballon. Oxygen via face mask should then be applied once the tube is removed)

A client with a Sengstaken-Blakemore tube has a sudden drop in SpO2 and an increase in respiratory rate to 40 breaths a 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 with bedside scissors 4. apply oxygen via face mask

b (Rationale: Hepatic encephalopathy results from cerebral edema, the accumulation of neurotoxins in the blood; therefore, the nurse wants to assess for signs of neurological involvement. Tremoring or flapping of the hands (asterixis) when the arms are extended and wrists dorsiflexed, agitation, confusion, and changes in mentation are common. These clients typically have ascites and edema, so they also experience weight gain, although they may actually be malnourished due to compromised liver functioning and nutrient absorption. Urinary urgency and stomatitis are not related to hepatic encephalopathy. )

A client with advanced cirrhosis has been diagnosed with hepatic encephalopathy. The nurse expects to assess for: a Weight loss b Hand tremors c Urinary urgency d Stomatitis

3 (Edematous tissue is easily traumatized. An alternating air pressure mattress will help decrease pressure on the edematous tissue. ROM exercise is for joint function. When abdominal skin is stretched taut due to ascites, it must be cleaned very carefully, it should not be massaged. Elevation of the LE extremities promotes venous return and decreases swlling)

A client with ascites and peripheral edema is at risk for impaired skin integrity. To prevent skin breakdown the nurse should: 1. institute ROM exercise q4h 2. massage the abd once a shift 3. use an alternating air pressure mattress 4. elevate the LE

2,4,5 (Clients with Chronic C should abstain from alcohol as it can spread cirrhosis and end stage liver disease. Clients should also check with their HCPs before taking any non prescription medications, or herbal supplements. It is also important that clients who are infected with HCV be tested for HIV as clients who have both HIV and HCV have a more rapid disease progression than those with HCV alone. Clients with HCV and N should be instructed to eat 4-5 times a day to help reduce anorexia and N. The client should obtain sufficient rest to manage fatigue)

A client with chronic hepatitis C is experiencing N/V anorexia, and fatigue During the health history, the client states that he is homosexual drinks one to two glasses of wine with dinner, is taking St Johns wort for a bit of depression, and takes acetaminophen for frequent headaches. What should the nurse do? SATA 1. Instruct the client that the wine with meals can be beneficial for cardiovascular health 2. Instruct the client to ask the HCP about taking any other medications as they may interact with medications the client is currently taking 3. Instruct the client to increase the protein in the diet and eat less freq 4. Advise the client of the need for additional testing for HIV 5. Encourage the client to obtain sufficient rest

2 (Spronolactone spares K. therefore the client should be watched for hyperkalemia. Other common adverse effects include abd cramping, D, dizziness, headache and rash. Constipation and dysuria are not common adverse effects. An irreg pulse is not an adverse effect of spironolactone but could develop if serum potassium levels are not closely watched)

A client with 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

d (Rationale For the client with cirrhosis who successfully achieves identified goals and​ outcomes, the nurse should observe improved coagulation studies. Slight​ bruising, disorientation, and elevated liver function tests do not indicate successful achievement of goals.)

A client with cirrhosis is being evaluated for discharge. Which outcome and nursing observation indicate the client is ready for discharge​ home? a Only slightly elevated liver function tests b Easily reoriented to person c Only slight bruising d Improved coagulation studies

1 (The client with cirrhosis can develop hepatic encephalopathy caused by increasing ammonia levels Asterixis, a flapping tremor is a characteristic symptom of increasing ammonia levels. Bacterial action on increased protein in the bowel will increase ammonia levels and cause the encephalopathy to worsen. GI bleeding and protein consumed in the diet increase protein in the intestine and can elevate ammonia levels. Lactulose is given to reduce ammonia formation in the intestine and should not be held since neurological symptoms are worsening. Bilirubin is assoc with jaundice)

A client with cirrhosis is receiving lactulose. The nurse notes the client is more confused and has asterixis. The nurse should: 1. assess for GI bleeding 2. withhold the lactulose 3. increase protein in the diet 4. monitor serum bilirubin levels

1 (Normal serum albumin is administered to reduce ascites. Hypoalbuminemia, a mechanism underlying ascites formation results in decreased colloid osmotic pressure. Administering serum albumin increases the plasma colloid osmotic pressure, which causes fluid to flow from the tissue space into the plasma. Increased urine output is the best indication the albumin is having the desired effect. An increased serum albumin level and increased ease of breathing may indirectly imply that the administration of albumin is effective in relieving the ascites, However it is not as direct an indication as increased urine output and reduced ascites. Anorexia is not affected by the administration of albumin)

A client with cirrhosis who has ascites receives 100 mL of 25% serum albumin IV. Which finding would best indicate that the albumin is having its desired effect? 1. reduced ascites 2. increased serum albumin level 3. decreased anorexia 4. increased ease of breathing

2,3,4 (Baking soda baths can decrease pruritus, keeping nails short and rubbing the area with knuckles can decrease breakdown when scratching. Calamine lotions help relieve itching. Alcohol will increase skin dryness. Sodium in the diet will increase edema and weaken skin integrity)

A client with jaundice has pruritus and areas of irritation from scratching. What measures can the nurse suggest the client use to prevent skin breakdown? SATA 1. Avoid lotions containing calamine 2. Add baking soda to the water in a tub bath 3. keep nails short and clean 4. Rub the skin when it itches with knuckles instead of nails 5. massage skin with alcohol 6. Increase sodium intake in diet

d (Rationale Use of the transjugular intrahepatic portosystemic shunt​ (TIPS) relieves portal hypertension and reduces the onset of esophageal varices and ascites. The​ Sengstaken-Blakemore and Minnesota tubes are used for bleeding​ varices, and paracentesis is done to relieve severe ascites that does not respond to diuretic therapy.)

A client with​ end-stage cirrhosis is brought to the emergency department with declining functional status. Which treatment will relieve the client​'s symptoms of portal hypertension and reduce the onset of esophageal varices and​ ascites? ​a Sengstaken-Blakemore tube b Paracentesis c Minnesota tube d Transjugular intrahepatic portosystemic shunt​ (TIPS)

3 (LActulose increases intestinal motility thereby trapping and expelling ammonia in the feces. An increase in the number of bowel movements is expected as an adverse effect. Lactulose does not affect urine output. Any improvements in mental status would be the result of increased ammonia elimination, not an adverse effect of the drug. N/V are not common adverse effects of lactulose)

A clients serum ammonia level is elevated and the HCP prescribes 30 mL of lactulose. Which effect is common for this drug? 1. Increase urine output 2. improved LOC 3 increase bowel movements 4. N/V

b,c,d (Rationale: In the United States, the greatest risk factors for developing cirrhosis and chronic liver disease include high rates of alcohol use and abuse and being of Native American or Hispanic/Latino origin. Rather than higher triglycerides causing cirrhosis, excessive alcohol consumption causes metabolic changes in the liver, which leads to higher triglyceride synthesis. While hepatitis can be contracted from food handlers with the disease, this is not a primary risk factor for developing cirrhosis/chronic liver disease. )

A nurse invited to present to high school adolescents in a biology class about health issues would identify which factors as having the greatest risk for developing cirrhosis and chronic liver disease? (Select all that apply.) a Exposure to food handlers who may or may not be immunized against hepatitis b Being of Native American descent c Being of Hispanic/Latino descent d Excessive alcohol consumption e Having high triglyceride levels

a (Rationale Diuretics are used to reduce fluid retention and ascites. While furosemide​ (Lasix) may be​ used, the drug of choice is spironolactone​ (Aldactone). Neomycin sulfate reduces the number of​ ammonia-forming bacteria in the​ bowel, and oxazepam​ (Serax) is used for acute agitation.)

A nurse is caring for a client with ascites secondary to cirrhosis. Which medication is the treatment of​ choice? a Spironolactone​ (Aldactone) b Oxazepam​ (Serax) c Furosemide​ (Lasix) d Neomycin sulfate

d (Rationale Abdominal​ distention, which is an imbalance of fluid within the portal​ system, might mean ascites in a client with cirrhosis. The vital signs are all within normal limits.)

A nurse is caring for a client with cirrhosis. Which assessment finding warrants immediate​ attention? a Pulse of 60 bpm b Oxygen saturation of​ 92% c Blood pressure of​ 110/72 mmHg d Abdominal distention

1,2,3,4,5 (Constipation leads to increased ammonia production, Lactulose is a hyperosmotic laxative that reduces blood ammonia by acidifying the colon contents, which retards diffusion of nonionic ammonia from the colon to the blood while promoting its migration from the blood to the colon. Hepatic encephalopathy is considered a toxic or metabolic condition that causes cerebral edema, it affects a persons coordination and pupil reaction to light and accommodation. Food and fluids high in carbs should be given because the liver is not synthesizing and storing glucose. Because exercise produces ammonia as a by product of metabolism, activity should be limited, not encouraged)

A nurse is developing a care plan for a client with hepatic encephalopathy. Which are goals for the care of this client? SATA 1. PRevent constipation 2. administer lactulose to reduce blood ammonia 3. monitor coordination while walking 4. check the pupil reaction 5. provide food and fluids high in carbs 6. encourage physical activity

4 (Change in baseline. May need ECG, This one first)

After completing assessment rounds, which client should the nurse discuss with the HCP first? 1. A client with cirrhosis who is depressed and has refused to eat for the past 2 days 2. A client with stable VS that has been receiving IV ciprofloxacin following a cholecystectomy for 1 day and has developed a rash on the chest and arms 3. A client with pancreatitis whose family requests to speak with the HCP regarding the treatment plan 4 A client with hepatitis whose pulse was 84 bpm and regular and is now 118 and irregular