Liver/Biliary NCLEX Questions

The nurse has an order to administer 1.5 ounces of lactulose to a client that has cirrhosis. How many milliliters of lactulose should the nurse administer? (Record your answer using a whole number)

45mLs

A client with an esophagogastric tamponade tube has a sudden drop in SpO2 and an increase in respiratory rate to 40 breaths/min. What should the nurse do in order form first to last? (All options must be used) a. Affirm airway obstruction by the tube b. Remove the tube c. Apply oxygen by face mask d. Deflate the tube by cutting with bedside scissors

a. Affirm airway obstruction by the tube d. Deflate the tube by cutting with bedside scissors b. Remove the tube c. Apply oxygen by face mask

A client with cirrhosis is receiving lactulose. The nurse notes the client is more confused and has asterixis. The nurse should: a. Assess for gastrointestinal (GI) bleeding b. Withhold the lactulose c. Increase protein in the diet d. Monitor serum bilirubin levels

a. Assess for gastrointestinal (GI) bleeding

The patient had a liver biopsy one hour ago. The nurse should first: a. Auscultate lung sounds b. Check for fever c. Obtain a CBC d. Apply packing to the biopsy site

a. Auscultate lung sounds

The nurse monitors a client with cirrhosis for the development of hepatic encephalopathy. Which would be an indication that hepatic encephalopathy is developing? a. Decreased mental status b. Elevated blood pressure c. Decreased urine output d. Labored respirations

a. Decreased mental status

The nurse is preparing a client for a paracentesis. The nurse should: a. Have the client void immediately before the procedure b. Place the client in a side-lying position c. Initiate an IV line to administer sedatives d. Place the client on nothing by mouth (NPO) status 6 hours before the procedure

a. Have the client void immediately before the procedure

What diet should be implemented for a client who is in the early stages of cirrhosis? a. High-calorie, high- CHO b. Low-protein, low-CHO c. Low-fat, low-protein d. High-CHO, low-sodium

a. High-calorie, high- CHO

A nurse is developing a care plan for a client with hepatic encephalopathy. Which are goals for the care for this client? (Select all that apply) a. Prevent constipation b. Administer lactulose to reduce blood ammonia levels c. Monitor coordination when walking d. Check the pupil reaction e. Provide food and fluids high in carbohydrate f. Encourage physical activity

a. Prevent constipation b. Administer lactulose to reduce blood ammonia levels c. Monitor coordination when walking d. Check the pupil reaction e. Provide food and fluids high in carbohydrate

A client with cirrhosis who has ascites receives 100ml of 25% serum albumin IV. Which finding would best indicate that the albumin is having its desired effect? a. Reduced ascites b. Increased serum albumin level c. Decreased anorexia d. Increased ease of breathing

a. Reduced ascites

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. (All options must be used) a. Silence the pump alarm b. Assess the clients access site for infiltration or inflammation c. Asses the tubing for hindrances to flow of solution d. Determine if the infusion pump is plugged into an electrical outlet

a. Silence the pump alarm b. Assess the clients access site for infiltration or inflammation c. Asses the tubing for hindrances to flow of solution d. Determine if the infusion pump is plugged into an electrical outlet

The nurse's assignment consists of four clients. From highest to lowest priority, in which order should the nurse assess the clients after receiving report? (All options must be used) a. The client with cirrhosis who became confused and disoriented during the night b. The client with acute pancreatitis who is requesting pain medication c. The client who is 1 day postoperative following a cholecystectomy and has a T-tube inserted d. The client with hepatitis B who has questions about discharge instructions

a. The client with cirrhosis who became confused and disoriented during the night b. The client with acute pancreatitis who is requesting pain medication c. The client who is 1 day postoperative following a cholecystectomy and has a T-tube inserted d. The client with hepatitis B who has questions about discharge instructions

A client is to be discharged with a prescription for lactulose. The nurse teaches the client and the client's spouse how to administer this medication. Which statement would indicate that the client has understood the information? a. "I will take it with an antacid" b. " I will mix it with apple juice" c. " I will take it with a laxative" d. " I will mix the crushed tablets in some gelatin"

b. " I will mix it with apple juice"

Which health promotion activity should the nurse suggest that the client with cirrhosis add to the daily routine at home? a. Supplement the diet with daily multivitamins b. Abstain from drinking alcohol c. Take a sleeping pill at bedtime d. Limit contact with other people whenever possible

b. Abstain from drinking alcohol

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. (Select all that apply) a. Avoid lotions containing calamine b. Add baking soda to the water in a tub bath c. Keep nails short and clean d. Rub the skin when it itches with knuckles instead of nails e. Massage skin with alcohol f. Increase sodium intake in the diet

b. Add baking soda to the water in a tub bath c. Keep nails short and clean d. Rub the skin when it itches with knuckles instead of nails

The nurse should institute which measures to prevent transmission of the hepatitis C virus to healthcare personnel? a. Administer the hepatitis C vaccine to all healthcare personnel b. Decreasing contact with blood and blood- contaminated fluids c. Wearing gloves when emptying the bedpan d. Wearing a gown and mask when providing direct care

b. Decreasing contact with blood and blood- contaminated fluids

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? a. Constipation b. Hyperkalemia c. Irregular pulse d. Dysuria

b. Hyperkalemia

The nurse is providing discharge instructions for a client with cirrhosis. Which statement best indicates that the client has understood the teaching? a. "I should eat a high- protein, high- carbohydrate diet to provide energy" b. "It is safer for me to take acetaminophen for pain instead of aspirin" c. "I should avoid constipation to decrease chances of bleeding" d. "If I get enough rest and follow my diet, it is possible for my cirrhosis to be cured"

c. "I should avoid constipation to decrease chances of bleeding"

The nurse is assessing a client who is in the early stages of cirrhosis of the liver. Which focused assessment is appropriate? a. Peripheral edema b. Ascites c. Anorexia d. Jaundice

c. Anorexia

A client's serum ammonia level is elevated and the HCP prescribes 30ml of lactulose. Which effect is common for this drug? a. Increased urine output b. Improved level of consciousness c. Increased bowel movements d. Nausea and vomiting

c. Increased bowel movements

The nurse is assessing a client with cirrhosis who has developed hepatic encephalopathy. The nurse should notify the healthcare provider (HCP) of a decrease in which serum lab value that is a potential precipitating factor for hepatic encephalopathy? a. Aldosterone b. Creatinine c. Potassium d. Protein

c. Potassium

A client with ascites and peripheral edema is at risk for impaired skin integrity. To prevent skin breakdown, the nurse should: a. Institute range- of- motion (ROM) exercises every 4 hours b. Massage the abdomen once per shift c. Use an alternating air pressure mattress d. Elevate the lower extremities

c. Use an alternating air pressure mattress

A client has advanced cirrhosis of the liver. The client's spouse asks the nurse why his abdomen is swollen, making it very difficult for him to fasten his pants. How should the nurse respond to provide the most accurate explanation of the disease process? a. "He must have eaten too many foods with salt in them. Salt pulls water with it." b. "The swelling in his ankles must have moved up closer to his heart so the fluid circulates better." c. "He must have forgotten to take his daily water pill." d. "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. "Blood is not able to flow readily through the liver now, and the liver cannot make protein to keep fluid inside the blood vessels."

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

d. A client with hepatitis whose pulse was 84 bpm and is now 118bpm and is irregular

The nurse is caring for a client with esophageal varices. The nurse should discuss which laboratory finding with the HCP? a. Normal serum albumin b. Decreased ammonia c. Slightly decreased levels of calcium d. Elevated PT/INR

d. Elevated PT/INR

The nurse is reviewing the chart information for a client with increased ascites. The data include the following: - temperature 98.9F (37.2C) - heart rate 118, shallow respirations 26/min - BP 128/76 mmHg - SpO2 89% on room air The nurse should first: a. Assess heart sounds b. Obtain a prescription for blood cultures c. Prepare for a paracentesis d. Raise the bed of the bed

d. Raise the bed of the bed

Which precautions should the healthcare team observe when caring for patients with Hepatitis A? a. Gowning when entering the client's room b. Wearing a mask when providing care c. Assigning the client to a private room d. Wearing gloves when giving direct care

d. Wearing gloves when giving direct care