NR 464 - Exam 1 (Saunders) - Liver, Pancreas, Gallbladder

The nurse is reviewing the record of a client admitted to the nursing unit and notes that the client has a history of Laënnec's cirrhosis. Which question related to the client's history would be most important to ask? 1. "Do you abuse alcohol?" 2. "Do you have any known cardiac disease?" 3. "Does your type of employment cause you to have exposure to chemicals?" 4. "Have you ever been told that you have had obstruction to your biliary ducts?"

1. "Do you abuse alcohol?"

The nurse is performing an assessment on a client with acute pancreatitis who was admitted to the hospital. Which assessment question would most specifically elicit information regarding the pain that is associated with acute pancreatitis? 1. "Does the pain in your stomach radiate to your back?" 2. "Does the pain in your lower abdomen radiate to your hip?" 3. "Does the pain in your lower abdomen radiate to your groin?" 4. "Does the pain in your stomach radiate to your lower middle abdomen?"

1. "Does the pain in your stomach radiate to your back?"

The nurse has taught the client with chronic pancreatitis about risk factor modification to reduce the incidence of recurrences. The nurse determines that teaching was effective if the client states that it will be necessary to control which factor? 1. Alcohol intake 2. Duodenal ulcer 3. Crohn's disease 4. Diabetes mellitus

1. Alcohol intake

A client with viral hepatitis states, "I am so yellow." What is the most appropriate nursing action? 1. Assist the client in expressing feelings. 2. Restrict visitors until the jaundice subsides. 3. Perform most of the activities of daily living for the client. 4. Provide information to the client only when he or she requests it.

1. Assist the client in expressing feelings.

The nurse is caring for a client with a low thrombin level as a result of liver dysfunction. Based on this finding it is most important for the nurse to monitor the client for signs and symptoms of which potential complication? 1. Bleeding 2. Infection 3. Dehydration 4. Malnutrition

1. Bleeding

A Penrose drain is in place on the first postoperative day in a client who has undergone a cholecystectomy procedure. Serosanguineous drainage is noted on the dressing covering the drain. Which nursing intervention is most appropriate? 1. Change the dressing. 2. Continue to monitor the drainage. 3. Notify the health care provider (HCP). 4. Use a pen to circle the amount of drainage on the dressing.

1. Change the dressing. Serosanguinous drainage with a small amount of bile is expected from the Penrose drain for the first 24 hours. Drainage then decreases, and the drain is usually removed within 48 hours. A sterile dressing covers the site and should be changed if wet to prevent infection and skin excoriation. Although the nurse would continue to monitor the drainage, the most appropriate intervention is to change the dressing.

The nurse is providing dietary instructions to a client hospitalized for pancreatitis. Which food should the nurse instruct the client to avoid? 1. Chili 2. Bagel 3. Lentil soup 4. Watermelon

1. Chili The client with pancreatitis needs to avoid alcohol, coffee and tea, spicy foods, and heavy meals, which stimulate pancreatic secretions, producing attacks of pancreatitis. The client is instructed in the benefit of eating small, frequent meals that are high in protein, low in fat, and moderate to high in carbohydrates.

The nurse is caring for a client with biliary obstruction. The nurse interprets that obstruction of which passage is related to the client's condition? 1. Cystic duct 2. Liver canaliculi 3. Common bile duct 4. Right hepatic duct

1. Cystic duct The gallbladder receives bile from the liver through the cystic duct. The liver collects bile in the canaliculi, from which bile flows into the right and left hepatic ducts and then into the common hepatic duct. From there, the bile can be transported for storage in the gallbladder through the cystic duct, or it can flow directly into the duodenum by way of the common bile duct.

The nurse is caring for a hospitalized client with pancreatitis. Which findings should the nurse look for and expect to note when reviewing the laboratory results? Select all that apply. 1. Elevated lipase level 2. Elevated lactase level 3. Elevated trypsin level 4. Elevated amylase level 5. Elevated sucrase level

1. Elevated lipase level 3. Elevated trypsin level 4. Elevated amylase level

The nurse is reviewing the results of serum laboratory studies for a client admitted for suspected hepatitis. Which laboratory finding is most associated with hepatitis, requiring the nurse to contact the health care provider? 1. Elevated serum bilirubin level 2. Below normal hemoglobin concentration 3. Elevated blood urea nitrogen (BUN) level 4. Elevated erythrocyte sedimentation rate (ESR)

1. Elevated serum bilirubin level Laboratory indicators of hepatitis include elevated liver enzymes, serum bilirubin level, and ESR. However, ESR is a nonspecific test that indicates the presence of inflammation somewhere in the body. The hemoglobin concentration is unrelated to this diagnosis. An elevated BUN level may indicate renal dysfunction.

The nurse is caring for a client with acute pancreatitis. Which finding should the nurse expect to note when reviewing the laboratory results? 1. Elevated serum lipase level 2. Elevated serum bilirubin level 3. Decreased serum trypsin level 4. Decreased serum amylase level

1. Elevated serum lipase level

A client with chronic pancreatitis needs information on dietary modification to manage the health problem. Which item in the diet should the nurse teach the client to limit? 1. Fat 2. Protein 3. Carbohydrate 4. Water-soluble vitamins

1. Fat

A client is admitted to the hospital with acute viral hepatitis. Which sign or symptom should the nurse expect to note based on this diagnosis? 1. Fatigue 2. Pale urine 3. Weight gain 4. Spider angiomas

1. Fatigue

The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Which of these clinical manifestations support this diagnosis? Select all that apply. 1. Fever 2. Positive Cullen's sign 3. Complaints of indigestion 4. Palpable mass in the left upper quadrant 5. Pain in the upper right quadrant after a fatty meal 6. Vague lower right quadrant abdominal discomfort

1. Fever 3. Complaints of indigestion 5. Pain in the upper right quadrant after a fatty meal

The nurse is reviewing the health care provider's prescriptions written for a client admitted to the hospital with acute pancreatitis. Which prescription requires follow-up by the nurse? 1. Full liquid diet 2. Morphine sulfate for pain 3. Nasogastric tube insertion 4. An anticholinergic medication

1. Full liquid diet The client with acute pancreatitis is placed on NPO (nothing by mouth) status to decrease the activity of the pancreas, which occurs with oral intake. Pain management for acute pancreatitis typically begins with the administration of opioids by patient-controlled analgesia. Medications such as morphine or hydromorphone are typically used. Nasogastric tube insertion is done to provide suction of secretions and administer medications as necessary.

The nurse has been caring for a client who required a Sengstaken-Blakemore tube because other treatment measures for esophageal varices were unsuccessful. The health care provider (HCP) arrives on the nursing unit and deflates the esophageal balloon. Which assessment finding by the nurse is the most important and should be reported to the HCP immediately? 1. Hematemesis 2. Bloody diarrhea 3. Swelling of the abdomen 4. An elevated temperature and a rise in blood pressure

1. Hematemesis

The nurse is caring for a client with acute pancreatitis and is monitoring the client for paralytic ileus. Which piece of assessment data should alert the nurse to this occurrence? 1. Inability to pass flatus 2. Loss of anal sphincter control 3. Severe, constant pain with rapid onset 4. Firm, nontender mass palpable at the lower right costal margin

1. Inability to pass flatus

The nurse is teaching the client with viral hepatitis about the stages of the disease. The nurse should explain to the client that the second stage of this disease is characterized by which specific assessment findings? Select all that apply. 1. Jaundice 2. Flulike symptoms 3. Clay-colored stools 4. Elevated bilirubin levels 5. Dark or tea-colored urine

1. Jaundice 3. Clay-colored stools 4. Elevated bilirubin levels 5. Dark or tea-colored urine

The nurse is caring for an older client. The nurse should anticipate that medication dosages will be further adjusted if the client has dysfunction of which organ? 1. Liver 2. Stomach 3. Pancreas 4. Gallbladder

1. Liver

The nurse is caring for a client with common bile duct obstruction. The nurse should anticipate that the health care provider (HCP) will prescribe which diet for this client? 1. Low fat 2. High protein 3. High carbohydrate 4. Low in water-soluble vitamins

1. Low fat

A client is diagnosed with viral hepatitis, complaining of "no appetite" and "losing my taste for food." What instruction should the nurse give the client to provide adequate nutrition? 1. Select foods high in fat. 2. Increase intake of fluids, including juices. 3. Eat a good supper when anorexia is not as severe. 4. Eat less often, preferably only 3 large meals daily.

2. Increase intake of fluids, including juices. Although no special diet is required to treat viral hepatitis, it is generally recommended that clients consume a low-fat diet, as fat may be tolerated poorly because of decreased bile production. Small, frequent meals are preferable and may even prevent nausea. Frequently, appetite is better in the morning, so it is easier to eat a good breakfast. An adequate fluid intake of 2500 to 3000 mL/day that includes nutritional juices is also important.

A client with acute pancreatitis is experiencing severe pain from the disorder. The nurse determines that education about positioning to reduce pain was effective if the client avoids which action? 1. Sitting up 2. Lying flat 3. Leaning forward 4. Drawing the legs to the chest

2. Lying flat

The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client? Select all that apply. 1. Maintain NPO (nothing by mouth) status. 2. Encourage coughing and deep breathing. 3. Give small, frequent high-calorie feedings. 4. Maintain the client in a supine and flat position. 5. Give hydromorphone intravenously as prescribed for pain. 6. Maintain intravenous fluids at 10 mL/hour to keep the vein open.

1. Maintain NPO (nothing by mouth) status. 2. Encourage coughing and deep breathing. 5. Give hydromorphone intravenously as prescribed for pain. The client with acute pancreatitis normally is placed on NPO status to rest the pancreas and suppress gastrointestinal secretions, so adequate intravenous hydration is necessary. Because abdominal pain is a prominent symptom of pancreatitis, pain medications such as morphine or hydromorphone are prescribed. Meperidine is avoided, as it may cause seizures. Some clients experience lessened pain by assuming positions that flex the trunk, with the knees drawn up to the chest. A side-lying position with the head elevated 45 degrees decreases tension on the abdomen and may help to ease the pain. The client is susceptible to respiratory infections because the retroperitoneal fluid raises the diaphragm, which causes the client to take shallow, guarded abdominal breaths. Therefore, measures such as turning, coughing, and deep breathing are instituted.

A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which expected assessment finding? 1. Malaise 2. Dark stools 3. Weight gain 4. Left upper quadrant discomfort

1. Malaise

The nurse is creating a plan of care for a client with cirrhosis and ascites. Which nursing actions should be included in the care plan for this client? Select all that apply. 1. Monitor daily weight. 2. Measure abdominal girth. 3. Monitor respiratory status. 4. Place the client in a supine position. 5. Assist the client with care as needed.

1. Monitor daily weight. 2. Measure abdominal girth. 3. Monitor respiratory status. 5. Assist the client with care as needed.

A client with cirrhosis has ascites and excess fluid volume. Which assessment findings does the nurse anticipate to note as a result of increased abdominal pressure? Select all that apply. 1. Orthopnea and dyspnea 2. Petechiae and ecchymosis 3. Inguinal or umbilical hernia 4. Poor body posture and balance 5. Abdominal distention and tenderness

1. Orthopnea and dyspnea 2. Petechiae and ecchymosis 3. Inguinal or umbilical hernia 5. Abdominal distention and tenderness

The nurse is caring for a client with cirrhosis. As part of dietary teaching to minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the material if the client states to increase intake of which food? 1. Pork 2. Milk 3. Chicken 4. Broccoli

1. Pork Thiamine is present in a variety of foods of plant and animal origin. Pork products are especially rich in the vitamin. Other good sources include peanuts, asparagus, and whole-grain and enriched cereals.

A client with cirrhosis is beginning to show signs of hepatic encephalopathy. The nurse should plan a dietary consultation to limit the amount of which ingredient in the client's diet? 1. Protein 2. Calories 3. Minerals 4. Carbohydrates

1. Protein

The health care provider has determined that a client has contracted hepatitis A based on flulike symptoms and jaundice. Which statement made by the client supports this medical diagnosis? 1. "I have had unprotected sex with multiple partners." 2. "I ate shellfish about 2 weeks ago at a local restaurant." 3. "I was an intravenous drug abuser in the past and shared needles." 4. "I had a blood transfusion 30 years ago after major abdominal surgery."

2. "I ate shellfish about 2 weeks ago at a local restaurant." **Oral-fecal route

A sexually active young adult client has developed viral hepatitis. Which client statement indicates the need for further teaching? 1. "I should avoid drinking alcohol." 2. "I can go back to work right away." 3. "My partner should get the vaccine." 4. "A condom should be used for sexual intercourse."

2. "I can go back to work right away."

A home care nurse visits a client who was recently diagnosed with cirrhosis. The nurse provides home care management instructions to the client. Which client statement indicates a need for further instruction? 1. "I will obtain adequate rest." 2. "I will take acetaminophen if I get a headache." 3. "I should monitor my weight on a regular basis." 4. "I need to include sufficient amounts of carbohydrates in my diet."

2. "I will take acetaminophen if I get a headache."

The nurse who is caring for a client with a diagnosis of cirrhosis is monitoring the client for signs of portal hypertension. Which finding should the nurse interpret as a sign or symptom of portal hypertension? 1. Flat neck veins 2. Abdominal distention 3. Hemoglobin of 14.2 g/dL (142 mmol/L) 4. Platelet count of 600,000 mm3 (600 × 109/L)

2. Abdominal distention

The nurse is performing discharge teaching for a client with chronic pancreatitis. Which information should the nurse include? 1. Alcohol should be consumed in moderation. 2. Avoid caffeine because it may aggravate symptoms. 3. Diet should be high in carbohydrates, fats, and proteins. 4. Frothy, fatty stools indicate that enzyme replacement is working.

2. Avoid caffeine because it may aggravate symptoms.

The nurse is giving instructions to a client with cholecystitis about food to exclude from the diet. Which food item identified by the client indicates that the educational session was successful? 1. Fresh fruit 2. Brown gravy 3. Fresh vegetables 4. Poultry without skin

2. Brown gravy

The nurse should incorporate which in the dietary plan to ensure optimal nutrition for the client during the acute phase of hepatitis? Select all that apply. 1. Select foods high in protein content. 2. Consume multiple small meals throughout the day. 3. Select foods low in carbohydrates to prevent nausea. 4. Allow the client to select foods that are most appealing. 5. Eliminate fatty foods from the meal trays until nausea subsides. 6. Eat a nutritious dinner because it is typically the best tolerated meal of the day.

2. Consume multiple small meals throughout the day. 4. Allow the client to select foods that are most appealing. 5. Eliminate fatty foods from the meal trays until nausea subsides.

A hospitalized client with liver disease has a dietary protein restriction. The nurse encourages intake of which source of complete proteins to maximize the availability of essential amino acids? 1. Nuts 2. Meats 3. Cereals 4. Vegetables

2. Meats

A client with viral hepatitis has no appetite, and food makes the client nauseated. Which nursing intervention is appropriate? 1. Encourage foods that are high in protein. 2. Monitor for fluid and electrolyte imbalance. 3. Explain that high-fat diets usually are better tolerated. 4. Explain that most daily calories need to be consumed in the evening hours.

2. Monitor for fluid and electrolyte imbalance. If nausea occurs and persists, the client will need to be assessed for fluid and electrolyte imbalance. It is important to explain to the client that most calories should be eaten in the morning hours because nausea is most common in the afternoon and evening. Clients should select a diet high in calories because energy is required for healing. Protein increases the workload on the liver. Changes in bilirubin interfere with fat absorption, so low-fat diets are better tolerated.

The nurse is caring for a client with acute pancreatitis. Which medications should the nurse expect to be prescribed for treatment of this problem? Select all that apply. 1. Insulin 2. Morphine 3. Dicyclomine 4. Pancrelipase 5. Pantoprazole 6. Acetazolamide

2. Morphine 3. Dicyclomine 5. Pantoprazole 6. Acetazolamide Medications used to treat acute pancreatitis include pain medications such as morphine, antispasmodics such as dicyclomine, proton pump inhibitors such as pantoprazole, and acetazolamide to decrease the volume and bicarbonate concentration of pancreatic secretions. Insulin is used in chronic pancreatitis to treat diabetes mellitus or hyperglycemia if needed, and pancreatic enzyme products are used for replacement of pancreatic enzymes.

The nurse is assessing a client with liver disease for signs and symptoms of low albumin. Which sign or symptom should the nurse expect to note? 1. Weight loss 2. Peripheral edema 3. Capillary refill of 5 seconds 4. Bleeding from previous puncture sites

2. Peripheral edema

The nurse is monitoring a client with cirrhosis of the liver for signs of hepatic encephalopathy. Which assessment finding would the nurse note as an early sign of hepatic encephalopathy? 1. Restlessness 2. Presence of asterixis 3. Complaints of fatigue 4. Decreased serum ammonia levels

2. Presence of asterixis

Lactulose is prescribed for a hospitalized client with a diagnosis of hepatic encephalopathy. Which assessment finding indicates that the client is responding to this medication therapy as anticipated? 1. Vomiting occurs. 2. The fecal pH is acidic. 3. The client experiences diarrhea. 4. The client is able to tolerate a full diet.

2. The fecal pH is acidic. Lactulose is an osmotic laxative used to decrease ammonia levels, which are elevated in hepatic encephalopathy. The desired effect is 2 or 3 soft stools per day with an acid fecal pH.

A client is admitted to the hospital with a diagnosis of acute pancreatitis. Which would the nurse expect the client to report about the pain? 1. Eating helps to decrease the pain. 2. The pain usually increases after vomiting. 3. The pain is mostly around the umbilicus and comes and goes. 4. The pain increases when the client sits up and bends forward.

2. The pain usually increases after vomiting.

The nurse is obtaining a health history for a client with chronic pancreatitis. The health history is most likely to include which as a most common causative factor in this client's disorder? 1. Weight gain 2. Use of alcohol 3. Exposure to occupational chemicals 4. Abdominal pain relieved with food or antacids

2. Use of alcohol

A client is experiencing blockage of the common bile duct. Which food selection made by the client indicates the need for further teaching? 1. Rice 2. Whole milk 3. Broiled fish 4. Baked chicken

2. Whole milk Bile acids or bile salts are produced by the liver to emulsify or break down fats. Blockage of the common bile duct impedes the flow of bile from the gallbladder to the duodenum, thus preventing breakdown of fatty intake. Knowledge of this should direct you to the option of whole milk. Dairy products, such as whole milk, ice cream, butter, and cheese, are high in cholesterol and fat and should be avoided.

A client with viral hepatitis is having difficulty coping with the disorder. Which question by the nurse is the most appropriate in identifying the client's coping problem? 1. "Do you have a fever?" 2. "Are you losing weight?" 3. "Have you enjoyed having visitors?" 4. "Do you rest sometime during the day?"

3. "Have you enjoyed having visitors?"

The nurse has given instructions to a client with hepatitis about postdischarge management during convalescence. The nurse determines that further teaching is needed if the client makes which statement? 1. "I need to avoid alcohol and aspirin." 2. "I should eat a high-carbohydrate, low-fat diet." 3. "I can resume a full activity level within 1 week." 4. "I need to take the prescribed amounts of vitamin K."

3. "I can resume a full activity level within 1 week."

A client with viral hepatitis is discussing with the nurse the need to avoid alcohol and states, "I'm not sure I can avoid alcohol." What is the most appropriate nursing response? 1. "I don't believe that." 2. "Everything will be all right." 3. "I'm not sure that I understand. Would you please explain?" 4. "I think you should talk more with the health care provider about this."

3. "I'm not sure that I understand. Would you please explain?"

A client seen in the ambulatory care clinic has ascites and slight jaundice. The nurse should assess the client for a history of chronic use of which medication? 1. Ibuprofen 2. Ranitidine 3. Acetaminophen 4. Acetylsalicylic acid

3. Acetaminophen

The nurse is developing a teaching plan for a client with viral hepatitis. The nurse should plan to include which information in the teaching session? 1. The diet should be low in calories. 2. Meals should be large to conserve energy. 3. Activity should be limited to prevent fatigue. 4. Alcohol intake should be limited to 2 ounces per day.

3. Activity should be limited to prevent fatigue.

The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence? 1. Dorsiflex the client's foot. 2. Measure the abdominal girth. 3. Ask the client to extend the arms. 4. Instruct the client to lean forward.

3. Ask the client to extend the arms.

The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention is most appropriate? 1. Clamp the T-tube. 2. Irrigate the T-tube. 3. Document the findings. 4. Notify the health care provider.

3. Document the findings. Following cholecystectomy, drainage from the T-tube is initially bloody and then turns a greenish-brown color. The drainage is measured as output. The amount of expected drainage will range from 500 to 1000 mL/day. The nurse would document the output.

The nurse is caring for a client with pancreatitis. Which finding should the nurse expect to note when reviewing the client's laboratory results? 1. Elevated level of pepsin 2. Decreased level of lactase 3. Elevated level of amylase 4. Decreased level of enterokinase

3. Elevated level of amylase

The nurse manager is providing an educational session to nursing staff members about the phases of viral hepatitis. The nurse manager tells the staff that which clinical manifestation(s) are primary characteristics of the preicteric phase? 1. Pruritus 2. Right upper quadrant pain 3. Fatigue, anorexia, and nausea 4. Jaundice, dark-colored urine, and clay-colored stools

3. Fatigue, anorexia, and nausea

The nurse is caring for a client admitted with severe weight loss due to dieting. Based on the data provided, which condition should the nurse suspect is occurring in this client? 1. Lactic acidosis 2. Glycogenolysis 3. Gluconeogenesis 4. Glucose metabolism

3. Gluconeogenesis Gluconeogenesis is the production of glucose for energy from protein and fat stores in the body. This can occur with extreme dieting and also with diabetes mellitus. Glycogenolysis is the production of glucose from glycogen stores in the liver. Lactic acidosis occurs with excess production of lactic acid resulting from anaerobic metabolism. The body normally burns glucose for energy.

The nurse is assigned to care for a client with a Sengstaken-Blakemore tube. Which laboratory result is most focused on evaluating the effectiveness of this tube? 1. Sodium 2. Creatinine 3. Hemoglobin 4. Ammonia

3. Hemoglobin A Sengstaken-Blakemore tube may be used in a client with a diagnosis of cirrhosis with ruptured esophageal varices if other treatment measures are unsuccessful. The tube has an esophageal and a gastric balloon. The esophageal balloon exerts pressure on the ruptured esophageal varices and stops the bleeding. The gastric balloon holds the tube in the correct position and prevents migration of the esophageal balloon, which could harm the client. Evaluation of the client's hemoglobin level trends will determine if the tube is effective. Sodium, creatinine, and ammonia levels are not related to monitoring for blood loss.

The nurse is caring for a client with altered protein metabolism as a result of liver dysfunction. Which finding should the nurse expect to note when reviewing the client's laboratory results? 1. Increased lactase level 2. Decreased albumin level 3. Increased ammonia level 4. Decreased lactic acid level

3. Increased ammonia level

The nurse is reviewing laboratory test results for the client with liver disease and notes that the client's albumin level is low. Which nursing action is focused on the consequence of low albumin levels? 1. Evaluating for asterixis 2. Inspecting for petechiae 3. Palpating for peripheral edema 4. Evaluating for decreased level of consciousness

3. Palpating for peripheral edema

The nurse is reviewing the laboratory results for a client with cirrhosis and notes that the ammonia level is 85 mcg/dL (51 mcmol/L). Which dietary selection does the nurse suggest to the client? 1. Roast pork 2. Cheese omelet 3. Pasta with sauce 4. Tuna fish sandwich

3. Pasta with sauce

The nurse is performing an assessment on a client with suspected acute pancreatitis. Which complaint made by the client supports the diagnosis? 1. "I have epigastric pain radiating to my neck." 2. "I have severe abdominal pain that is relieved after vomiting." 3. "My temperature has been running between 96°F (35.5°C) and 97°F (36.1°C)." 4. "I've been experiencing constant, severe abdominal pain that is unrelieved by vomiting."

4. "I've been experiencing constant, severe abdominal pain that is unrelieved by vomiting."

A client has undergone esophagogastroduodenoscopy (EGD). The nurse should place highest priority on which item as part of the client's care plan? 1. Monitoring the temperature 2. Monitoring complaints of heartburn 3. Giving warm gargles for a sore throat 4. Assessing for the return of the gag reflex

4. Assessing for the return of the gag reflex **Except with esophageal varices

A client with cirrhosis complicated by ascites is admitted to the hospital. The client reports a 10-lb weight gain over the past 1½ weeks. The client has edema of the feet and ankles, and his abdomen is distended, taut, and shiny with striae. Which client problem is most appropriate at this time? 1. Difficulty with sleeping 2. Risk for skin breakdown 3. Difficulty with breathing 4. Excessive body fluid volume

4. Excessive body fluid volume

A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis? Select all that apply. 1. Diarrhea 2. Black, tarry stools 3. Hyperactive bowel sounds 4. Gray-blue color at the flank 5. Abdominal guarding and tenderness 6. Left upper quadrant pain with radiation to the back

4. Gray-blue color at the flank 5. Abdominal guarding and tenderness 6. Left upper quadrant pain with radiation to the back Grayish-blue discoloration at the flank is known as Grey-Turner's sign and occurs as a result of pancreatic enzyme leakage to cutaneous tissue from the peritoneal cavity. The client may demonstrate abdominal guarding and may complain of tenderness with palpation. The pain associated with acute pancreatitis is often sudden in onset and is located in the epigastric region or left upper quadrant with radiation to the back. The other options are incorrect.

A client with liver dysfunction has low serum levels of fibrinogen and a prolonged prothrombin time (PT). Based on these findings, which actions should the nurse plan to promote client safety? Select all that apply. 1. Monitor serum potassium levels. 2. Weigh client daily, and monitor trends. 3. Monitor for symptoms of fluid retention. 4. Provide the client with a soft toothbrush. 5. Instruct the client to use an electric razor. 6. Monitor all secretions for frank or occult blood.

4. Provide the client with a soft toothbrush. 5. Instruct the client to use an electric razor. 6. Monitor all secretions for frank or occult blood.

The nurse assists a health care provider in performing a liver biopsy. After the procedure, the nurse should place the client in which position? 1. Prone 2. Supine 3. Left side 4. Right side

4. Right side