NCLEX The client with Cirrhosis

4. raise the head of the bed.

57. The nurse is reviewing the chart information for a client with increased ascites. The data include the following: temperature 98.9°F (37.2°C), heart rate 118 bpm, shallow respirations 26/min, blood pressure 128/76 mm Hg, 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 head of the bed.

1. Fowler's

58. Which position would be appropriate for a client with severe ascites? 1. Fowler's 2. side-lying 3. reverse Trendelenburg 4. Sims

4. elevated PT/INR

59. The nurse is caring for a client with esophageal varices. The nurse should discuss which laboratory report finding with the healthcare provider (HCP)? 1. normal serum albumin 2. Decreased ammonia 3. Slightly decreased levels of calcium 4. Elevated PT/INR

1. reduced ascites

60. 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

1, 3, 2, 4

61. A client with a Sengstaken-Blakemore tube has a sudden drop in SpO2 and an increase in respiratory rate to 40 breaths/min. What should the nurse do in order from first to last? All options must be used. 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.

1. auscultate lung sounds.

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

Image

47. The nurse is assessing a client for ascites. Where does the nurse place the hands to percuss for the presence of fluid?

1. assess for gastrointestinal (GI) bleeding.

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

3. potassium

49. 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? 1. aldosterone 2. creatinine 3. potassium 4. protein

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."

50. 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? 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."

1. Prevent constipation. 2. Administer lactulose to reduce blood ammonia levels. 3. Monitor coordination while walking 4. Check the pupil reaction. 5. Provide food and fluids high in carbohydrate.

51. A nurse is develòping with a care plan for a client with hepatic encephalopathy. Which are goals for the care for this client? Select all that Apply. 1. Prevent constipation. 2. Administer lactulose to reduce blood ammonia levels. 3. Monitor coordination while walking 4. Check the pupil reaction. 5. Provide food and fluids high in carbohydrate. 6. Encourage physical activity.

3. anorexia

52. 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

2. hyperkalemia

53. 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

1. high-calorie, high-carbohydrate

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

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.

55. 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. 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.

2. Abstain from drinking alcohol.

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

3. improved liver function.

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

1. decreased mental status

63. 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 blood pressure 3. decreased urine output 4. labored respirations

3. increased bowel movements

64 A client's serum ammonia level is elevated, and the healthcare provider (HCP) prescribes 30 mL of lactulose. Which effect is common for this drug? 1. increased urine output 2. improved level of consciousness 3. Increased bowel movements 4. nausea and vomiting

60 mL

65. The nurse has a prescription to administer 2 oz of lactulose to a client who has cirrhosis. How many milliliters of lactulose should the nurse administer? Record your answer using a whole number.

2. "I will mix it with apple juice."

66. 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? 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."

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

67. The nurse is providing discharge instructions for a client with cirrhosis. Which statement best indicates that the client has understood the teaching? 1. "I should eat a high protein, high carbohydrate diet to provide energy." 2. "It is safer for me to take acetaminophen for pain instead of aspirin." 3. "I should avoid constipation to decrease chances of bleeding." 4. "If I get enough rest and follow my diet, it is possible for my cirrhosis to be cured."

1. have the client void immediately before the procedure.

68. 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 nothing by mouth (NPO) status 6 hours before the procedure

3. use an alternating air pressure mattress.

69. A client with ascites and peripheral edema is at risk for impaired skin integrity. To prevent skin breakdown, the nurse should: 1. institute range-of-motion (ROM) exercise every 4 hours. 2. massage the abdomen once a shift. 3. use an alternating air pressure mattress. 4. elevate the lower extremities.