221 Mod 1 - All Practice Questions

Which interventions would the nurse expect to be prescribed for a client with acute pancreatitis? Select all that apply. 1) Maintain NPO 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 IV as prescribed for pain 6) Maintain IV fluids at 10 mL/hr to keep the vein open

1, 2, 5.

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 LUQ 5) Pain in the RUQ after a fatty meal 6) Vague RLQ abdominal discomfort

1, 3, 5.

A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which expected assessment finding? A) Malaise B) Dark stools C) Weight gain D) LUQ discomfort

A

Which of the following are risk factors for cholelithiasis? Select all that apply. A) Eating a high-fat diet B) Obesity with a BMI >30 C) Age over 40 D) Female gender E) Male gender

A, B, C, D. High risk factors for developing cholelithiasis may include consuming a high-fat diet, obesity with a BMI > 30, age over 40-years-old, and female clients. The gallbladder, if functioning properly, is required to empty the bile for the client to remain healthy. If it malfunctions and there is an overconcentration of bile, gallstones begin to form. A high-fat high-cholesterol diet places the client at high risk. The client should consume a high-fiber diet instead. Obesity is a predisposing factor especially for clients who lose weight quickly.

A 43-year-old female client underwent a laparoscopic cholecystectomy 8 hours ago. Which of the following actions should be implemented postoperatively? Select all that apply. A) Early ambulation B) Turn, cough, and deep breathing exercises C) Assess the incision sites for redness and swelling D) Assist the client to take a bath in the unit tub E) Consult occupational therapy to assist with ADLs

A, B, C. Postoperatively after a cholecystectomy, the nurse should implement early ambulation. Early ambulation promotes circulation, prevents deep vein thrombosis or blood clots, helps expand lungs, and increases motility of the bowel. Turning, coughing, and breathing exercises helps to expand the lungs fully, clear the client's lungs, and helps prevent pneumonia or atelectasis. The nurse should assess the incision sites for redness, warmth, swelling, or drainage. These are all signs of infection. The client should be monitored for fever as well. This is another sign of infection. The client should shower and never bathe soaking the incisions. Occupational therapy should not be consulted unless the client had trouble with activities of daily living prior to surgery.

A mother brings her teenage son to the clinic, where tests show that he has hepatitis A virus (HAV). They ask the nurse how this could have happened. Which of the following explanations would the nurse correctly identify as possible causes? Select all that apply. A. Sexual activity B. Infection at school C. Ingestion of undercooked beef D. Consumption of sewage-contaminated water or shellfish E. Suboptimal sanitary habits

A, B, D, E. Typically, a child or a young adult acquires the infection at school through poor hygiene, hand-to-mouth contact, or close contact during play. The virus is carried home, where haphazard sanitary habits spread it through the family. An infected food handler can spread the disease, and people can contract it by consuming water or shellfish from sewage-contaminated waters. Outbreaks have occurred in day care centers and institutions as a result of poor hygiene among people with developmental disabilities. Hepatitis A can be transmitted during sexual activity. It is not contracted through the consumption of undercooked beef.

A client asks the nurse, What causes pancreatitis? Which statements can be used to answer the client's question? Select all that apply. A) One of the most common causes is gallstones B) Individuals with multiple sclerosis have a higher risk C) Chronic alcohol use has been linked to pancreatitis D) Pancreatitis can occur after abdominal surgeries E) An ERCP test increases a person's risk of developing pancreatitis

A, C, D, E. A number of factors can cause damage to the pancreas and lead to acute pancreatitis. Primary causes are biliary tract disease and alcoholism. Other factors identified as causing pancreatitis include trauma from abdominal surgeries; viral infections such as mumps or HIV; renal failure; and the use of certain medications like thiazide diuretics, oral contraceptives and corticosteroids. An ERCP (endoscopic retrograde cholangiopancreatography) diagnostic test is used to clear gallstones or place a stent but it carries the risk of initiating acute pancreatitis. Cystic fibrosis is associated with pancreatitis. Mucus blocks the biliary ducts and prevents the transport of digestive enzymes to the intestine, which causes inflammation in the pancreas.

A client with diabetes type 1 is admitted to the emergency room with COVID-19-like symptoms. Which symptoms should the nurse report immediately? Select all that apply. A) BG 475 mg/dL B) Coughing and temperature of 99.8F C) Deep, rapid breathing D) Abdominal cramping E) ABG pH of 7.45

A, C, D. Diabetic ketoacidosis (DKA) is a very serious complication of diabetes mellitus. It occurs when ketones or blood acids increase in the bloodstream in response to elevated blood glucose levels and inadequate insulin. DKA can occur due to illness, infection, or insufficient insulin. The client with DKA has symptoms including extreme thirst, nausea, abdominal cramping, fruity (acetone) breath, deep rapid breaths (Kussmaul breathing), frequent urination, and confusion. The blood glucose is extremely elevated and ketones are found in the blood and urine. The client has to be treated in the hospital and often in the ICU to address the metabolic acidosis associated with DKA. Priority treatments are fluid replacement, insulin therapy, and electrolyte correction.

A nurse is trying to explain to a nursing student the differences between diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar syndrome (HHS). Which symptom(s) is/are associated with HHS? A) Disorientation B) Abdominal pain C) Occurs suddenly D) Extreme dehydration E) Kussmaul respirations F) BG >600 mg/dL

A, D, F. Hyperglycemic hyperosmolar syndrome (HHS) is a serious complication of type 2 diabetes mellitus. It occurs when a client has extremely high blood glucoses (> 600 mg/dl) for an extended time. The interesting characteristics is there are no elevation of ketones in this situation. The condition leads to serious dehydration, excessive thirst, and confusion. It is often caused or triggered by a recent infection of sickness. Treatment (unless airway or breathing is involved) begins with fluid replacement to address the circulation concerns, then insulin therapy to address the elevated blood glucose.

Which is an age-related change of the hepatobiliary system? A. Decreased blood flow B. Enlarged liver C. Decreased prevalence of gallstones D. Increased drug clearance capability

A. Age-related changes of the hepatobiliary system include decreased blood flow, decreased drug clearance capability, increased presence of gall stones, and a steady decrease in the size and weight of the liver.

A client diagnosed with acute pancreatitis is being transferred to another facility. The nurse caring for the client completes the transfer summary, which includes information about the client's drinking history and other assessment findings. Which assessment findings confirm the diagnosis of acute pancreatitis? A. Pain with abdominal distention and hypotension B. Presence of blood in the client's stool and recent hypertension C. Adventitious breath sounds and hypertension D. Presence of easy bruising and bradycardia

A. Assessment findings associated with pancreatitis include pain with abdominal distention and hypotension. Blood in stools and recent hypertension aren't associated with pancreatitis; fatty diarrhea and hypotension are usually present. Presence of easy bruising and bradycardia aren't found with pancreatitis; the client typically experiences tachycardia, not bradycardia. Adventitious breath sounds and hypertension aren't associated with pancreatitis.

The nurse is planning care for a client following an incisional cholecystectomy for cholelithiasis. Which intervention is the highest nursing priority for this client? A. Assisting the client to turn, cough, and deep breathe every 2 hours B. Performing range-of-motion (ROM) leg exercises hourly while the client is awake C. Teaching the client to choose low-fat foods from the menu D. Assisting the client to ambulate the evening of the operative day

A. Assessment should focus on the client's respiratory status. If a traditional surgical approach is planned, the high abdominal incision required during surgery may interfere with full respiratory excursion. The other nursing actions are also important, but are not as high a priority as ensuring adequate ventilation.

A client with liver disease is admitted to the medical surgical unit. The nurse reviews the laboratory values and notices the ammonia level is elevated. The nurse contacts the health care provider and receives a prescription for lactulose 30 mL. After administration of the lactulose, the nurse expects which effect of the drug? A) Increased bowel movements B) Increased urine output C) Nausea and vomiting D) Decreased ascites

A. Cirrhosis is a late stage of scarring (i.e., fibrosis) of the liver caused by many different liver diseases and conditions (e.g., hepatitis, chronic alcoholism). Increased ammonia levels occur in cirrhosis of the liver. Lactulose works by drawing ammonia from the blood into the colon where it is removed from the body. It increases the intestinal motility which aids in trapping and expelling ammonia in the feces. Thus, an increase in bowel movements is expected. Lactulose is sometimes used for treatment of constipation. The other options are incorrect as Lactulose does not usually cause nausea and vomiting, increased urine output or affect ascites.

A patient who suffers from alcoholism is prescribed disulfiram (Antabuse). How does this medication assist the patient in refraining from ingestion of alcohol? A) Allows the accumulation of acetaldehyde B) Increases the level of serotonin C) Increases the level of acetylcholine D) Decreases stimulation of the CNS

A. Disulfiram interferes with hepatic metabolism of alcohol and allows accumulation of acetaldehyde. Disulfiram does not increase the level of serotonin. Disulfiram does not increase the level of acetylcholine. Disulfiram does not decrease the stimulation of the central nervous system.

An older adult client with Type 2 diabetes is brought to the emergency department by his daughter. The client is found to have a blood glucose level of 623 mg/dL. The client's daughter reports that the client recently had a gastrointestinal virus and has been confused for the last 3 hours. The diagnosis of hyperglycemic hyperosmolar syndrome (HHS) is made. What nursing intervention has the highest priority? A) Fluid replacement B) Reversal of altered mental status C) Insulin first, then fluids D) Give sodium bicarbonate

A. Hyperglycemic hyperosmolar syndrome (HHS) is a serious complication of type 2 diabetes mellitus. It occurs when a client has extremely high blood glucoses for an extended time. The interesting characteristics is there are no elevation of ketones in this situation. The condition leads to serious dehydration, excessive thirst, and confusion. It is often caused or triggered by a recent infection or sickness. Treatment (unless airway or breathing is involved) begins with fluid replacement to address the circulation concerns, then insulin therapy to address the elevated blood glucose. Since potassium levels may be elevated due to the insulin deficiency, the potassium levels may begin to lower with insulin treatment, otherwise, decreasing potassium should be addressed. Treating any underlying causes should also be addressed (nausea, vomiting, etc.)

A client is prescribed oral lactulose for the treatment of hepatic encephalopathy. Which of the following products must decrease, resulting in the effectiveness of the medication? A) Ammonia B) Potassium C) Calcium D) Magnesium

A. In clients with cirrhosis, the liver is unable to filter excess ammonia which gets absorbed in the bloodstream causing hepatic encephalopathy. Ammonia in the bloodstream is toxic and can travel to the brain affecting cognition. Lactulose increases gastrointestinal (GI) motility and draws ammonia from the bloodstream and into the colon where it is removed from the body by stool only, not by renal excretion. The presence of stools is not an indication of the effectiveness of lactulose on mental status. Nurses must evaluate the effectiveness of lactulose for the treatment of hepatic encephalopathy, which is seen as an improved mental status in the client.

A patient is diagnosed with mild acute pancreatitis. What does the nurse understand is characteristic of this disorder? A. Edema and inflammation B. Sepsis C. Disseminated intravascular coagulopathy D. Pleural effusion

A. Mild acute pancreatitis is characterized by edema and inflammation confined to the pancreas. Minimal organ dysfunction is present, and return to normal function usually occurs within 6 months.

A nurse is caring for a client newly diagnosed with hepatitis A. Which statement by the client indicates the need for further teaching? A. How did this happen? I've been faithful my entire marriage. B. I'll wash my hands often. C. I'll be very careful when preparing food for my family. D. I'll take all my medications as ordered.

A. The client requires further teaching if he suggests that he acquired the virus through sexual contact. Hepatitis A is transmitted by the oral-fecal route or through ingested food or liquid that's contaminated with the virus. Hepatitis A is rarely transmitted through sexual contact. Clients with hepatitis A need to take every effort to avoid spreading the virus to other members of their family with precautions such as preparing food carefully, washing hands often, and taking medications as ordered.

Which is the best nursing explanation for the symptom of polyuria in a client with diabetes mellitus? A. High sugar pulls fluid into the bloodstream, which results in more urine production. B. Increased ketones in the urine promote the manufacturing of more urine. C. With diabetes, drinking more results in more urine production. D. The body's requirement for fuel drives the production of urine.

A. The hypertonicity from concentrated amounts of glucose in the blood pulls fluid into the vascular system, resulting in polyuria. The urinary frequency triggers the thirst response, which then results in polydipsia. Ketones in the urine and body requirements do not affect the production of urine.

A 42-year-old female client arrives in the emergency department exhibiting RUQ pain radiating to the right shoulder, chills, tachycardia, and vomiting. The nurse suspects the client will be diagnosed with which condition? A) Cholecystitis B) Pancreatitis C) Ulcerative colitis D) Crohn's disease

A. The symptoms of cholecystitis may include RUQ pain radiating to the right shoulder, chills, fever, tachycardia, and vomiting. Cholecystitis is inflammation of the gallbladder. The inflammation is typically caused by stones that block the ducts that lead out of the gallbladder resulting in bile backup which causes inflammation. Backup of bile causes gallstones to form. With acute flare-ups, the priority intervention is to make the client NPO. Treatment may include a lithotripsy for small stones or a laparoscopic cholecystectomy or an open cholecystectomy.

A client with liver cirrhosis develops ascites. Which medication will the nurse prepare teaching for this client? A. Spironolactone B. Furosemide C. Acetazolamide D. Ammonium chloride

A. The use of diuretic agents along with sodium restriction is successful in 90% of clients with ascites. Spironolactone, an aldosterone-blocking agent, is most often the first-line therapy in clients with ascites from cirrhosis. When used with other diuretic agents, spironolactone helps prevent potassium loss. Oral diuretic agents such as furosemide may be added but should be used cautiously because long-term use may induce severe hyponatremia (sodium depletion). Acetazolamide and ammonium chloride are contraindicated because of the possibility of precipitating hepatic encephalopathy and coma.

A nurse cares for a client with interstitial pancreatitis. What client teaching will the nurse include when planning care for the client? A. Inflammation is confined to only the pancreas. B. Inflammation spreads to the surrounding glands. C. Normal function returns after about 2 weeks. D. Tissue necrosis occurs within the pancreas.

A. There are two forms of pancreatitis-inflammatory and necrotizing. Interstitial pancreatitis is characterized by diffuse enlargement of the pancreas due to inflammatory edema confined only to the pancreas itself; normal function returns after about 6 months. Necrotizing pancreatitis is life-threatening and tissue necrosis occurs within the pancreas as well as the surrounding glands.

A client with cholelithiasis has a gallstone lodged in the common bile duct. When assessing this client, the nurse expects to note: A. yellow sclera. B. black, tarry stools. C. circumoral pallor. D. light amber urine.

A. Yellow sclerae are an early sign of jaundice, which occurs when the common bile duct is obstructed. Urine normally is light amber. Circumoral pallor and black, tarry stools don't occur in common bile duct obstruction; they are signs of hypoxia and GI bleeding, respectively.

A client is admitted to the hospital with a diagnosis of DKA. The initial BG level iis 950 mg/dL. A continuous IV infusion of short-acting insulin is initiated, along with IV rehydrration with NS. The BG level is now decreased to 240 mg/dL. The nurse would prepare to administer which medication next? 1) An ampule of 50% dextrose 2) NPH insulin subcutaneously 3) IV fluids containing dextrose 4) Phenytoin for the prevention of seizures

ANS: 3

A diabetes nurse educator is teaching a group of clients with type 1 diabetes about sick day rules. What guideline applies to periods of illness in a diabetic client? A. Do not eliminate insulin when nauseated and vomiting. B. Report elevated glucose levels greater than 150 mg/dL (8.3 mmol/L). C. Eat three substantial meals a day, if possible. D. Reduce food intake and insulin doses in times of illness.

ANS: A Rationale: The most important issue to teach clients with diabetes who become ill is not to eliminate insulin doses when nausea and vomiting occur. Rather, they should take their usual insulin or oral hypoglycemic agent dose, and then attempt to consume frequent, small portions of carbohydrates. In general, blood sugar levels will rise but should be reported if they are greater than 300 mg/dL (16.6 mmol/L).

A diabetic educator is discussing sick day rules with a newly diagnosed type 1 diabetic. The educator is aware that the client will require further teaching when the client states what? A. I will not take my insulin on the days when I am sick, but I will certainly check my blood sugar every 2 hours. B. If I cannot eat a meal, I will eat a soft food such as soup, gelatin, or pudding six to eight times a day. C. I will call the doctor if I am not able to keep liquids in my body due to vomiting or diarrhea. D. I will call the doctor if my blood sugar is over 300 mg/dL (16.6 mmol/L) or if I have ketones in my urine.

ANS: A Rationale: The nurse must explain the sick day rules again to the client who plans to stop taking insulin when sick. The nurse should emphasize that the client should take insulin agents as usual and test the blood sugar and urine ketones every 3 to 4 hours. In fact, insulin-requiring clients may need supplemental doses of regular insulin every 3 to 4 hours. The client should report elevated glucose levels (greater than 300 mg/dL or 16.6 mmol/L, or as otherwise instructed) or urine ketones to the health care provider. If the client is not able to eat normally, the client should be instructed to substitute with soft foods such a gelatin, soup, and pudding. If vomiting, diarrhea, or fever persists, the client should have an intake of liquids every 30 to 60 minutes to prevent dehydration.

A client has a recent diagnosis of chronic pancreatitis and is undergoing diagnostic testing to determine pancreatic islet cell function. The nurse should anticipate what diagnostic test? A. Glucose tolerance test B. ERCP C. Pancreatic biopsy D. Abdominal ultrasonography

ANS: A Rationale: A glucose tolerance test evaluates pancreatic islet cell function and provides necessary information for making decisions about surgical resection of the pancreas. This specific clinical information is not provided by ERCP, biopsy, or ultrasound.

A client has been scheduled for an ultrasound of the gallbladder the following morning. What should the nurse do in preparation for this diagnostic study? A. Have the client refrain from food and fluids after midnight. B. Administer the contrast agent orally 10 to 12 hours before the study. C. Administer the radioactive agent intravenously the evening before the study. D. Encourage the intake of 64 ounces of water 8 hours before the study.

ANS: A Rationale: An ultrasound of the gallbladder is most accurate if the client fasts overnight, so that the gallbladder is distended. Contrast and radioactive agents are not used when performing ultrasonography of the gallbladder, as an ultrasound is based on reflected sound waves.

During a health education session, a participant has asked about the hepatitis E virus. What prevention measure should the nurse recommend for preventing infection with this virus? A. Following proper hand-washing techniques B. Avoiding chemicals that are toxic to the liver C. Wearing a condom during sexual contact D. Limiting alcohol intake

ANS: A Rationale: Avoiding contact with the hepatitis E virus through good hygiene, including hand-washing, is the major method of prevention. Hepatitis E is transmitted by the fecal- oral route, principally through contaminated water in areas with poor sanitation. Consequently, none of the other listed preventative measures is indicated.

A group of nurses have attended an in-service on the prevention of occupationally acquired diseases that affect health care providers. What action has the greatest potential to reduce a nurse's risk of acquiring hepatitis C in the workplace? A. Disposing of sharps appropriately and not recapping needles B. Performing meticulous hand hygiene at the appropriate moments in care C. Adhering to the recommended schedule of immunizations D. Wearing an N95 mask when providing care for clients on airborne precautions

ANS: A Rationale: HCV is bloodborne. Consequently, prevention of needlestick injuries is paramount. Hand hygiene, immunizations and appropriate use of masks are important aspects of overall infection control, but these actions do not directly mitigate the risk of HCV.

A client's abdominal ultrasound indicates cholelithiasis. When the nurse is reviewing the client's laboratory studies, what finding is most closely associated with this diagnosis? A. Increased bilirubin B. Decreased serum cholesterol C. Increased blood urea nitrogen (BUN) D. Decreased serum alkaline phosphatase level

ANS: A Rationale: If the flow of blood is impeded, bilirubin, a pigment derived from the breakdown of red blood cells, does not enter the intestines. As a result, bilirubin levels in the blood increase. Cholesterol, BUN, and alkaline phosphatase levels are not typically affected.

A nurse on a solid organ transplant unit is planning the care of a client who will soon be admitted upon immediate recovery following liver transplantation. What aspect of nursing care is the nurse's priority? A. Implementation of infection-control measures B. Close monitoring of skin integrity and color C. Frequent assessment of the client's psychosocial status D. Administration of antiretroviral medications

ANS: A Rationale: Infection control is paramount following liver transplantation. This is a priority over skin integrity and psychosocial status, even though these are valid areas of assessment and intervention. Antiretrovirals are not indicated.

A client is being discharged after a liver transplant and the nurse is performing discharge education. When planning this client's continuing care, the nurse should prioritize what risk diagnosis? A. Risk for infection related to immunosuppressant use B. Risk for injury related to decreased hemostasis C. Risk for unstable blood glucose related to impaired gluconeogenesis D. Risk for contamination related to accumulation of ammonia

ANS: A Rationale: Infection is the leading cause of death after liver transplantation. Pulmonary and fungal infections are common; susceptibility to infection is increased by the immunosuppressive therapy that is needed to prevent rejection. This risk exceeds the threats of injury and unstable blood glucose. The diagnosis of Risk for Contamination relates to environmental toxin exposure.

The nurse's review of a client's most recent laboratory results indicates a bilirubin level of 3.0 mg/dL (high). The nurse assesses the client for: A. jaundice. B. bleeding. C. malnutrition. D. hypokalemia.

ANS: A Rationale: Jaundice becomes clinically evident when the serum bilirubin level exceeds 2.0 mg/dL (34 mmol/L). Elevated bilirubin levels are not associated with hypokalemia, malnutrition or bleeding, though these complications may result from the underlying liver disorder.

A client with ongoing back pain, nausea, and abdominal bloating has been diagnosed with cholecystitis secondary to gallstones. The nurse should anticipate that the client will undergo what intervention? A. Laparoscopic cholecystectomy B. Methyl tertiary butyl ether (MTBE) infusion C. Intracorporeal lithotripsy D. Extracorporeal shock wave therapy (ESWL)

ANS: A Rationale: Most of the nonsurgical approaches, including lithotripsy and dissolution of gallstones, provide only temporary solutions to gallstone problems and are infrequently used. Cholecystectomy is the preferred treatment.

A 37-year-old client presents at the emergency department (ED) reporting nausea and vomiting and severe abdominal pain. The client's abdomen is rigid, and there is bruising to the client's flank. The client's spouse states that the client was on a drinking binge for the past 2 days. The ED nurse should assist in assessing the client for what health problem? A. Severe pancreatitis with possible peritonitis B. Acute cholecystitis C. Chronic pancreatitis D. Acute appendicitis with possible perforation

ANS: A Rationale: Severe abdominal pain is the major symptom of pancreatitis that causes the client to seek medical care. Pain in pancreatitis is accompanied by nausea and vomiting that does not relieve the pain or nausea. Abdominal guarding is present and a rigid or board-like abdomen may be a sign of peritonitis. Ecchymosis (bruising) to the flank or around the umbilicus may indicate severe peritonitis. Pain generally occurs 24 to 48 hours after a heavy meal or alcohol ingestion. The link with alcohol intake makes pancreatitis a more likely possibility than appendicitis or cholecystitis.

A triage nurse in the emergency department is assessing a client who presented with reports of general malaise. Assessment reveals the presence of jaundice and increased abdominal girth. What assessment question best addresses the possible etiology of this client's presentation? A. How many alcoholic drinks do you typically consume in a week? B. To the best of your knowledge, are your immunizations up to date? C. Have you ever worked in an occupation where you might have been exposed to toxins? D. Has anyone in your family ever experienced symptoms similar to yours?

ANS: A Rationale: Signs or symptoms of hepatic dysfunction indicate a need to assess for alcohol use. Immunization status, occupational risks, and family history are also relevant considerations, but alcohol use is a more common etiologic factor in liver disease.

A nurse is assisting with serving dinner trays on the unit. Upon receiving the dinner tray for a client admitted with acute gallbladder inflammation, the nurse will question which of the following foods on the tray? A. Fried chicken B. Mashed potatoes C. Dinner roll D. Tapioca pudding

ANS: A Rationale: The diet immediately after an episode of acute cholecystitis is initially limited to low-fat liquids. Cooked fruits, rice or tapioca, lean meats, mashed potatoes, bread, and coffee or tea may be added as tolerated. The client should avoid fried foods such as fried chicken, as fatty foods may bring on an episode of cholecystitis.

A nurse is caring for a client with hepatic encephalopathy. While making the initial shift assessment, the nurse notes that the client has a flapping tremor of the hands. The nurse should document the presence of what sign of liver disease? A. Asterixis B. Constructional apraxia C. Fetor hepaticus D. Palmar erythema

ANS: A Rationale: The nurse will document that a client exhibiting a flapping tremor of the hands is demonstrating asterixis. While constructional apraxia is a motor disturbance, it is the inability to reproduce a simple figure. Fetor hepaticus is a sweet, slightly fecal odor to the breath and not associated with a motor disturbance. Skin changes associated with liver dysfunction may include palmar erythema, which is a reddening of the palms, but is not a flapping tremor.

A nurse educator is teaching a group of recent nursing graduates about their occupational risks for contracting hepatitis B. What preventative measures should the educator promote? Select all that apply. A. Immunization B. Use of standard precautions C. Consumption of a vitamin-rich diet D. Annual vitamin K injections E. Annual vitamin B12 injections

ANS: A, B Rationale: People who are at high occupational risk for contracting hepatitis B, including nurses and other health care personnel exposed to blood or blood products, should receive active immunization. The consistent use of standard precautions is also highly beneficial. Vitamin supplementation is unrelated to an individual's risk of HBV.

A client's assessment and diagnostic testing are suggestive of acute pancreatitis. When the nurse is performing the health interview, what assessment question(s) addresses likely etiologic factors? Select all that apply. A. How many alcoholic drinks do you typically consume in a week? B. Have you ever been tested for diabetes? C. Have you ever been diagnosed with gallstones? D. Would you say that you eat a particularly high-fat diet? E. Does anyone in your family have cystic fibrosis?

ANS: A, B, C, D Rationale: Eighty percent of clients with acute pancreatitis have biliary tract disease such as gallstones or a history of long-term alcohol abuse. Diabetes and high-fat consumption are also associated with pancreatitis. Cystic fibrosis is not a noted etiologic factor for pancreatitis.

A client's health care provider has ordered a liver panel in response to the client's development of jaundice. When reviewing the results of this laboratory testing, the nurse should expect to review what blood tests? Select all that apply. A. Alanine aminotransferase (ALT) B. C-reactive protein (CRP) C. Gamma-glutamyl transferase (GGT) D. Aspartate aminotransferase (AST) E. B-type natriuretic peptide (BNP)

ANS: A, C, D Rationale: Liver function testing includes GGT, ALT, and AST. CRP addresses the presence of generalized inflammation and BNP is relevant to heart failure; neither is included in a liver panel.

A client with end-stage liver disease has developed hypervolemia. What nursing interventions would be most appropriate when addressing the client's fluid volume excess? Select all that apply. A. Administering diuretics B. Administering calcium channel blockers C. Implementing fluid restrictions D. Implementing a 1500 kcal/day restriction E. Enhancing client positioning

ANS: A, C, E Rationale: Administering diuretics, implementing fluid restrictions, and enhancing client positioning can optimize the management of fluid volume excess. Calcium channel blockers and calorie restriction do not address this problem.

A client with type 2 diabetes normally achieves adequate glycemic control through diet and exercise. Upon being admitted to the hospital for a cholecystectomy, however, the client has required insulin injections on two occasions. The nurse would identify what factor most likely caused this short-term change in treatment? A. Alterations in bile metabolism and release have likely caused hyperglycemia. B. Stress has likely caused an increase in the client's blood sugar levels. C. The client's efforts did not control the diabetes using nonpharmacologic measures. D. The client's volatile fluid balance surrounding surgery has likely caused unstable blood sugars.

ANS: B Rationale: During periods of physiologic stress, such as surgery, blood glucose levels tend to increase because levels of stress hormones (epinephrine, norepinephrine, glucagon, cortisol, and growth hormone) increase. The client's need for insulin is unrelated to the action of bile. The client's normal routine of nonpharmacological strategies of diet and exercise have been changed due to the client's admission to the hospital. Therefore, the client cannot overestimate what they cannot control. Electrolyte/ fluid balances may have some bearing on glucose levels, but stress is the most impactful cause of the change happening to this client.

A client with a history of type 1 diabetes has just been admitted to the critical care unit (CCU) for diabetic ketoacidosis. The CCU nurse should prioritize what assessment during the client's initial phase of treatment? A. Monitoring the client for dysrhythmias B. Maintaining and monitoring the client's fluid balance C. Assessing the client's level of consciousness D. Assessing the client for signs and symptoms of venous thromboembolism

ANS: B Rationale: In addition to treating hyperglycemia, management of DKA is aimed at correcting dehydration, electrolyte loss, and acidosis before correcting the hyperglycemia with insulin. The nurse should monitor the client for dysrhythmias, decreased LOC and VTE, but restoration and maintenance of fluid balance is the highest priority.

A client with diabetes is asking the nurse what causes diabetic ketoacidosis (DKA). Which of the following is a correct statement by the nurse? A. DKA can be caused by taking too much insulin. B. DKA can be caused by taking too little insulin. C. DKA can happen without a cause. D. DKA will not happen with type 1 diabetes.

ANS: B Rationale: Three main causes of DKA are decreased or missed dose of insulin, illness or infection, and undiagnosed and untreated diabetes. DKA may be the initial manifestation of type 1 diabetes. For prevention of DKA related to illness, the client should attempt to consume frequent small portions of carbohydrates. Drinking fluid every hour is important to prevent dehydration. Blood glucose and urine ketones must be assessed every 3 to 4 hours, and the client should take the usual dose of insulin.

A client with a diagnosis of esophageal varices has undergone endoscopy to gauge the progression of this complication of liver disease. Following the completion of this diagnostic test, what nursing intervention should the nurse perform? A. Keep client NPO until the results of test are known. B. Keep client NPO until the client's gag reflex returns. C. Administer analgesia until post-procedure tenderness is relieved. D. Give the client a cold beverage to promote swallowing ability.

ANS: B Rationale: After the examination, fluids are not given until the client's gag reflex returns. Lozenges and gargles may be used to relieve throat discomfort if the client's physical condition and mental status permit. The result of the test is known immediately. Food and fluids are contraindicated until the gag reflex returns.

What health promotion teaching should the nurse prioritize to prevent drug-induced hepatitis? A. Finish all prescribed courses of antibiotics, regardless of symptom resolution. B. Adhere to dosing recommendations of over-the-counter analgesics. C. Ensure that expired medications are disposed of safely. D. Ensure that pharmacists regularly review drug regimens for potential interactions.

ANS: B Rationale: Although any medication can affect liver function, use of acetaminophen (found in many over-the-counter medications used to treat fever and pain) has been identified as the leading cause of acute liver failure. Finishing prescribed antibiotics and avoiding expired medications are unrelated to this disease. Drug interactions are rarely the cause of drug-induced hepatitis.

The nurse is caring for a client who has just returned from the ERCP removal of gallstones. The nurse should monitor the client for signs of what complications? A. Pain and peritonitis B. Bleeding and perforation C. Acidosis and hypoglycemia D. Gangrene of the gallbladder and hyperglycemia

ANS: B Rationale: Following ERCP removal of gallstones, the client is observed closely for bleeding, perforation, and the development of pancreatitis or sepsis. Blood sugar alterations, gangrene, peritonitis, and acidosis are less likely complications.

A client has had a laparoscopic cholecystectomy. The client is now reporting right shoulder pain. What should the nurse suggest to relieve the pain? A. Aspirin every 4 to 6 hours as prescribed B. Application of heat 15 to 20 minutes each hour C. Application of an ice pack for no more than 15 minutes D. Application of liniment rub to affected area

ANS: B Rationale: If pain occurs in the right shoulder or scapular area (from migration of the CO2 used to insufflate the abdominal cavity during the procedure), the nurse may recommend use of a heating pad for 15 to 20 minutes hourly, walking, and sitting up when in bed. Aspirin would constitute a risk for bleeding.

A nurse is caring for a client with a blocked bile duct from a tumor. What manifestation of obstructive jaundice should the nurse anticipate? A. Watery, blood-streaked diarrhea B. Orange and foamy urine C. Increased abdominal girth D. Decreased cognition

ANS: B Rationale: If the bile duct is obstructed, the bile will be reabsorbed into the blood and carried throughout the entire body. It is excreted in the urine, which becomes deep orange and foamy. Bloody diarrhea, ascites, and cognitive changes are not associated with obstructive jaundice.

A nurse is caring for a client who has been scheduled for endoscopic retrograde cholangiopancreatography (ERCP) the following day. When providing anticipatory guidance for this client, the nurse should describe what aspect of this diagnostic procedure? A. The need to protect the incision post procedure B. The use of moderate sedation C. The need to infuse 50% dextrose during the procedure D. The use of general anesthesia

ANS: B Rationale: Moderate sedation, not general anesthesia, is used during ERCP. D50 is not given and the procedure does not involve the creation of an incision.

A nurse is caring for a client with cirrhosis secondary to heavy alcohol use. The nurse's most recent assessment reveals subtle changes in the client's cognition and behavior. What is the nurse's most appropriate response? A. Ensure that the client's sodium intake does not exceed recommended levels. B. Report this finding to the primary provider due to the possibility of hepatic encephalopathy. C. Inform the primary provider that the client should be assessed for alcoholic hepatitis. D. Implement interventions aimed at ensuring a calm and therapeutic care environment.

ANS: B Rationale: Monitoring is an essential nursing function to identify early deterioration in mental status. The nurse monitors the client's mental status closely and reports changes so that treatment of encephalopathy can be initiated promptly. This change in status is likely unrelated to sodium intake and would not signal the onset of hepatitis. A supportive care environment is beneficial, but does not address the client's physiologic deterioration.

A client with cirrhosis has experienced a progressive decline in his health; and liver transplantation is being considered by the interdisciplinary team. How will the client's prioritization for receiving a donor liver be determined? A. By considering the client's age and prognosis B. By objectively determining the client's medical need C. By objectively assessing the client's willingness to adhere to post-transplantation care D. By systematically ruling out alternative treatment options

ANS: B Rationale: The client would undergo a classification of the degree of medical need through an objective determination known as the Model of End-Stage Liver Disease (MELD) classification, which stratifies the level of illness of those awaiting a liver transplant. This algorithm considers multiple variables, not solely age, prognosis, potential for adherence, and the rejection of alternative options.

A client with a history of injection drug use has been diagnosed with hepatitis C. When collaborating with the care team to plan this client's treatment, the nurse should anticipate what intervention? A. Administration of immune globulins B. A regimen of antiviral medications C. Rest and watchful waiting D. Administration of fresh-frozen plasma (FFP)

ANS: B Rationale: There is no benefit from rest, diet, or vitamin supplements in HCV treatment. Studies have demonstrated that antiviral agents are most effective. Immune globulins and FFP are not indicated.

A client is brought to the emergency department. The client is a type 2 diabetic and is experiencing hyperglycemic hyperosmolar syndrome (HHS). The nurse should identify what components of HHS? Select all that apply. A. Leukocytosis B. Glycosuria C. Dehydration D. Hypernatremia E. Hyperglycemia

ANS: B, C, E Rationale: In HHS, persistent hyperglycemia causes osmotic diuresis, which results in losses of water and electrolytes. To maintain osmotic equilibrium, water shifts from the intracellular fluid space to the extracellular fluid space. With glycosuria and dehydration, hyponatremia and increased osmolarity occur. Leukocytosis does not take place.

A client with type 1 diabetes has told the nurse that the client's most recent urine test for ketones was positive. What is the nurse's most plausible conclusion based on this assessment finding? A. The client should withhold the next scheduled dose of insulin. B. The client should promptly eat some protein and carbohydrates. C. The client's insulin levels are inadequate. D. The client would benefit from a dose of metformin.

ANS: C Rationale: Ketones in the urine signal that there is a deficiency of insulin and that control of type 1 diabetes is deteriorating. Withholding insulin or eating food would exacerbate the client's ketonuria. Metformin will not cause short-term resolution of hyperglycemia.

Which of the following clients with type 1 diabetes is most likely to experience adequate glucose control? A. A client who skips breakfast when the glucose reading is greater than 220 mg/dL (12.3 mmol/L) B. A client who never deviates from the prescribed dose of insulin C. A client who adheres closely to a meal plan and meal schedule D. A client who eliminates carbohydrates from the daily intake

ANS: C Rationale: The therapeutic goal for diabetes management is to achieve normal blood glucose levels without hypoglycemia. Therefore, diabetes management involves constant assessment and modification of the treatment plan by health professionals and daily adjustments in therapy (possibly including insulin) by clients. For clients who require insulin to help control blood glucose levels, maintaining consistency in the amount of calories and carbohydrates ingested at meals is essential. In addition, consistency in the approximate time intervals between meals, and the snacks, helps maintain overall glucose control. Skipping meals is never advisable for person with type 1 diabetes.

A nurse has entered the room of a client with cirrhosis and found the client on the floor. The client reports falling when transferring to the commode. The client's vital signs are within reference ranges and the nurse observes no apparent injuries. What is the nurse's most appropriate action? A. Remove the client's commode and supply a bedpan. B. Complete an incident report and submit it to the unit supervisor. C. Have the client assessed by the primary provider due to the risk of internal bleeding. D. Perform a focused abdominal assessment in order to rule out injury.

ANS: C Rationale: A fall would necessitate thorough medical assessment due to the client's risk of bleeding. The nurse's abdominal assessment is an appropriate action, but is not wholly sufficient to rule out internal injury. Medical assessment is a priority over removing the commode or filling out an incident report, even though these actions are appropriate.

A client has undergone a laparoscopic cholecystectomy and is being prepared for discharge home. When providing health education, the nurse should prioritize what topic? A. Management of fluid balance in the home setting B. The need for blood glucose monitoring for the next week C. Signs and symptoms of intra-abdominal complications D. Appropriate use of prescribed pancreatic enzymes

ANS: C Rationale: Because of the early discharge following laparoscopic cholecystectomy, the client needs thorough education in the signs and symptoms of complications. Fluid balance is not typically a problem in the recovery period after laparoscopic cholecystectomy. There is no need for blood glucose monitoring or pancreatic enzymes.

A client has just been diagnosed with chronic pancreatitis. The client is underweight and in severe pain and diagnostic testing indicates that over 80% of the client's pancreas has been destroyed. The client asks the nurse why the diagnosis was not made earlier in the disease process. What would be the nurse's best response? A. The symptoms of pancreatitis mimic those of much less serious illnesses. B. Your body doesn't require pancreatic function until it is under great stress, so it is easy to go unnoticed. C. Chronic pancreatitis often goes undetected until a large majority of pancreatic function is lost. D. It's likely that your other organs were compensating for your decreased pancreatic function.

ANS: C Rationale: By the time symptoms occur in chronic pancreatitis, approximately 90% of normal acinar cell function (exocrine function) has been lost. Late detection is not usually attributable to the vagueness of symptoms. The pancreas contributes continually to homeostasis and other organs are unable to perform its physiologic functions.

A community health nurse is caring for a client whose multiple health problems include chronic pancreatitis. During the most recent home visit, the nurse learns that the client is experiencing severe abdominal pain and has vomited 3 times in the past several hours. What is the nurse's most appropriate action? A. Administer a PRN dose of pancreatic enzymes as prescribed. B. Teach the client about the importance of abstaining from alcohol. C. Arrange for the client to be transported to the hospital. D. Insert an NG tube, if available, and stay with the client.

ANS: C Rationale: Chronic pancreatitis is characterized by recurring attacks of severe upper abdominal and back pain, accompanied by vomiting. The onset of these acute symptoms warrants hospital treatment. Pancreatic enzymes are not indicated and an NG tube would not be inserted in the home setting. Client education is a later priority that may or may not be relevant.

A nurse is caring for a client with hepatic encephalopathy. The nurse's assessment reveals that the client exhibits episodes of confusion, is difficult to arouse from sleep and has rigid extremities. Based on these clinical findings, the nurse should document what stage of hepatic encephalopathy? A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4

ANS: C Rationale: Clients in the third stage of hepatic encephalopathy exhibit the following symptoms: stuporous, difficult to arouse, sleep most of the time, exhibits marked confusion, incoherent in speech, asterixis, increased deep tendon reflexes, rigidity of extremities, marked EEG abnormalities. Clients in stages 1 and 2 exhibit clinical symptoms that are not as advanced as found in stage 3, and clients in stage 4 are comatose. In stage 4, there is an absence of asterixis, absence of deep tendon reflexes, flaccidity of extremities, and EEG abnormalities.

A client with liver disease has developed ascites; the nurse is collaborating with the client to develop a nutritional plan. The nurse should prioritize which of the following in the client's plan? A. Increased potassium intake B. Fluid restriction to 2 L per day C. Reduction in sodium intake D. High-protein, low-fat diet

ANS: C Rationale: Clients with ascites require a sharp reduction in sodium intake. Potassium intake should not be correspondingly increased. There is no need for fluid restriction or increased protein intake.

A client is admitted to the ICU with acute pancreatitis. The client's family asks what causes acute pancreatitis. The critical care nurse knows that a majority of clients with acute pancreatitis have what health issue? A. Type 1 diabetes B. An impaired immune system C. Undiagnosed chronic pancreatitis D. An amylase deficiency

ANS: C Rationale: Eighty percent of clients with acute pancreatitis have biliary tract disease or a history of long-term alcohol abuse. These clients usually have had undiagnosed chronic pancreatitis before their first episode of acute pancreatitis. Diabetes, an impaired immune function, and amylase deficiency are not specific precursors to acute pancreatitis.

A nurse who provides care in a community clinic assesses a wide range of individuals. The nurse should identify which client as having the highest risk for chronic pancreatitis? A. A 45-year-old obese woman with a high-fat diet B. An 18-year-old man who is a weekend binge drinker C. A 39-year-old man with chronic alcoholism D. A 51-year-old woman who smokes one-and-a-half packs of cigarettes per day

ANS: C Rationale: Excessive and prolonged consumption of alcohol accounts for most cases of chronic pancreatitis in Western societies.

A student nurse is caring for a client who has a diagnosis of acute pancreatitis and who is receiving parenteral nutrition. The student should prioritize which of the following assessments? A. Fluid output B. Oral intake C. Blood glucose levels D. BUN and creatinine levels

ANS: C Rationale: In addition to administering enteral or parenteral nutrition, the nurse monitors serum glucose levels every 4 to 6 hours. Output should be monitored but in most cases it is not more important than serum glucose levels. A client on parenteral nutrition would have no oral intake to monitor. Blood sugar levels are more likely to be unstable than indicators of renal function.

A client with portal hypertension has been admitted to the medical floor. The nurse should prioritize what assessments? A. Assessment of blood pressure and assessment for headaches and visual changes B. Assessments for signs and symptoms of venous thromboembolism C. Daily weights and abdominal girth measurement D. Blood glucose monitoring q4h

ANS: C Rationale: Obstruction to blood flow through the damaged liver results in increased blood pressure (portal hypertension) throughout the portal venous system. This can result in varices and ascites in the abdominal cavity. Assessments related to ascites are daily weights and abdominal girths. Portal hypertension is not synonymous with cardiovascular hypertension and does not create a risk for unstable blood glucose or VTE.

A client is receiving care in the intensive care unit for acute pancreatitis. The nurse is aware that pancreatic necrosis is a major cause of morbidity and mortality in clients with acute pancreatitis. Consequently, the nurse should assess for what signs or symptoms of this complication? A. Sudden increase in random blood glucose readings B. Increased abdominal girth accompanied by decreased level of consciousness C. Fever, increased heart rate and decreased blood pressure D. Abdominal pain unresponsive to analgesics

ANS: C Rationale: Pancreatic necrosis is a major cause of morbidity and mortality in clients with acute pancreatitis because of resulting hemorrhage, septic shock, and multiple organ dysfunction syndrome (MODS). Signs of shock would include hypotension, tachycardia and fever. Each of the other listed changes in status warrants intervention, but none is clearly suggestive of an onset of pancreatic necrosis.

A nurse is creating a care plan for a client with acute pancreatitis. The care plan includes reduced activity. What rationale for this intervention should be cited in the care plan? A. Bed rest reduces the client's metabolism and reduces the risk of metabolic acidosis. B. Reduced activity protects the physical integrity of pancreatic cells. C. Bed rest lowers the metabolic rate and reduces enzyme production. D. Inactivity reduces caloric need and gastrointestinal motility.

ANS: C Rationale: The acutely ill client is maintained on bed rest to decrease the metabolic rate and reduce the secretion of pancreatic and gastric enzymes. Staying in bed does not release energy from the body to fight the disease.

A client who has undergone liver transplantation is ready to be discharged home. Which outcome of health education should the nurse prioritize? A. The client will obtain measurement of drainage from the T-tube. B. The client will exercise three times a week. C. The client will take immunosuppressive agents as required. D. The client will monitor for signs of liver dysfunction.

ANS: C Rationale: The client is given written and verbal instructions about immunosuppressive agent doses and dosing schedules. The client is also instructed on steps to follow to ensure that an adequate supply of medication is available so that there is no chance of running out of the medication or skipping a dose. Failure to take medications as instructed may precipitate rejection. The nurse would not teach the client to measure drainage from a T-tube as the client wouldn't go home with a T-tube. The nurse may teach the client about the need to exercise or what the signs of liver dysfunction are, but the nurse would not stress these topics over the immunosuppressive drug regimen.

A client has been admitted to the hospital for the treatment of chronic pancreatitis. The client has been stabilized and the nurse is now planning health promotion and educational interventions. Which of the following should the nurse prioritize? A. Educating the client about expectations and care following surgery B. Educating the client about the management of blood glucose after discharge C. Educating the client about postdischarge lifestyle modifications D. Educating the client about the potential benefits of pancreatic transplantation

ANS: C Rationale: The client's lifestyle (especially regarding alcohol use) is a major determinant of the course of chronic pancreatitis. The disease is not often managed by surgery, and blood sugar monitoring is not necessarily indicated for every client after hospital treatment. Transplantation is not an option.

A client who had surgery for gallbladder disease has just returned to the postsurgical unit from postanesthetic recovery. The nurse caring for this client knows to immediately report what assessment finding to the health care provider? A. Decreased breath sounds B. Drainage of bile-colored fluid onto the abdominal dressing C. Rigidity of the abdomen D. Acute pain with movement

ANS: C Rationale: The location of the subcostal incision will likely cause the client to take shallow breaths to prevent pain, which may result in decreased breath sounds. The nurse should remind clients to take deep breaths and cough to expand the lungs fully and prevent atelectasis. Acute pain is an expected assessment finding following surgery; analgesics should be given for pain relief. Abdominal splinting or application of an abdominal binder may assist in reducing the pain. Bile may continue to drain from the drainage tract after surgery, which will require frequent changes of the abdominal dressing. Increased abdominal tenderness and rigidity should be reported immediately to the health care provider, as it may indicate bleeding from an inadvertent puncture or nicking of a major blood vessel during the surgical procedure.

A nurse is providing discharge education to a client who has undergone a laparoscopic cholecystectomy. During the immediate recovery period, the nurse should recommend what foods? A. High-fiber foods B. Low-purine, nutrient-dense foods C. Low-fat foods high in proteins and carbohydrates D. Foods that are low-residue and low in fat

ANS: C Rationale: The nurse encourages the client to eat a diet that is low in fats and high in carbohydrates and proteins immediately after surgery. There is no specific need to increase fiber or avoid purines. A low-residue diet is not indicated.

A medical nurse is aware of the need to screen specific clients for their risk of hyperglycemic hyperosmolar syndrome (HHS). In what client population does this syndrome most often occur? A. Clients who are obese and who have no known history of diabetes B. Clients with type 1 diabetes and poor dietary control C. Adolescents with type 2 diabetes and sporadic use of antihyperglycemics D. Middle-aged or older people with either type 2 diabetes or no known history of diabetes

ANS: D Rationale: HHS occurs most often in older clients (50 to 70 years of age) who have no known history of diabetes or who have type 2 diabetes. HHS is a serious metabolic disorder resulting from a relative insulin deficiency initiated by an illness that raises the demand for insulin. Obesity does play a role in HHS but clients usually have a history of type 2 diabetes. Clients with type 1 diabetes usually present with DKA (diabetic ketoacidosis). Adolescents with type 2 have a low incidence of this condition.

An older adult client with type 2 diabetes is brought to the emergency department by the client's daughter. The client is found to have a blood glucose level of 600 mg/dL (33.3 mmol/L). The client's daughter reports that the client recently had a gastrointestinal virus and has been confused for the last 3 hours. The diagnosis of hyperglycemic hyperosmolar syndrome (HHS) is made. What nursing action would be a priority? A. Administration of antihypertensive medications B. Administering sodium bicarbonate intravenously C. Reversing acidosis by administering insulin D. Fluid and electrolyte replacement

ANS: D Rationale: The overall approach to HHS includes fluid replacement, correction of electrolyte imbalances, and insulin administration. Antihypertensive medications are not indicated, as hypotension generally accompanies HHS due to dehydration. Sodium bicarbonate is not given to clients with HHS, as their plasma bicarbonate level is usually normal. Insulin administration plays a less important role in the treatment of HHS because it is not needed for reversal of acidosis, as in diabetic ketoacidosis (DKA).

A client has been newly diagnosed with acute pancreatitis and admitted to the acute medical unit. How should the nurse explain the pathophysiology of this client's health problem? A. Toxins have accumulated and inflamed your pancreas. B. Bacteria likely migrated from your intestines and became lodged in your pancreas. C. A virus that was likely already present in your body has begun to attack your pancreatic cells. D. The enzymes that your pancreas produces have damaged the pancreas itself.

ANS: D Rationale: Although the mechanisms causing pancreatitis are unknown, pancreatitis is commonly described as the autodigestion of the pancreas. Less commonly, toxic substances and microorganisms are implicated as the cause of pancreatitis.

A nurse is caring for a client with liver failure and is performing an assessment of the client's increased risk of bleeding. The nurse recognizes that this risk is related to the client's inability to synthesize prothrombin in the liver. What factor most likely contributes to this loss of function? A. Alterations in glucose metabolism B. Retention of bile salts C. Inadequate production of albumin by hepatocytes D. Inability of the liver to use vitamin K

ANS: D Rationale: Decreased production of several clotting factors may be partially due to deficient absorption of vitamin K from the GI tract. This probably is caused by the inability of liver cells to use vitamin K to make prothrombin. This bleeding risk is unrelated to the roles of glucose, bile salts, or albumin.

A local public health nurse is informed that a cook in a local restaurant has been diagnosed with hepatitis A. What should the nurse advise individuals to obtain who ate at this restaurant and have never received the hepatitis A vaccine? A. The hepatitis A vaccine B. Albumin infusion C. The hepatitis A and B vaccines D. An immune globulin injection

ANS: D Rationale: For people who have not been previously vaccinated, hepatitis A can be prevented by the intramuscular administration of immune globulin during the incubation period, if given within 2 weeks of exposure. Administration of the hepatitis A vaccine will not protect the client exposed to hepatitis A, as protection will take a few weeks to develop after the first dose of the vaccine. The hepatitis B vaccine provides protection against the hepatitis B virus, but plays no role in protection for the client exposed to hepatitis A. Albumin confers no therapeutic benefit.

A client presents to the emergency department (ED) reporting severe right upper quadrant pain. The client states that the family doctor said the pain was caused by gallstones. The ED nurse should recognize what possible complication of gallstones? A. Acute pancreatitis B. Atrophy of the gallbladder C. Gallbladder cancer D. Gangrene of the gallbladder

ANS: D Rationale: In calculous cholecystitis, a gallbladder stone obstructs bile outflow. Bile remaining in the gallbladder initiates a chemical reaction; autolysis and edema occur; and the blood vessels in the gallbladder are compressed, compromising its vascular supply. Gangrene of the gallbladder with perforation may result. Pancreatitis, atrophy, and cancer of the gallbladder are not plausible complications.

A client is being treated for acute pain from an episode of pancreatitis. The nurse has identified a nursing diagnosis of Ineffective Breathing Pattern related to pain secondary to effects of surgery. Which intervention should the nurse perform in order to best address this diagnosis? A. Position the client supine to facilitate diaphragm movement. B. Administer corticosteroids by nebulizer as prescribed. C. Perform oral suctioning as needed to remove secretions. D. Administer analgesic per orders.

ANS: D Rationale: The client has ineffective breathing patterns due to pain. To increase the likelihood of the client being able to perform interventions for his/her respiratory status, it would be important to treat acute pain first. A supine position will result in increased pressure on the diaphragm and potentially decreased respiratory expansion. Steroids and oral suctioning are not indicated.

A nurse is assessing a client who has been diagnosed with cholecystitis, and is experiencing localized abdominal pain. When assessing the characteristics of the client's pain, the nurse should anticipate that it may radiate to what region? A. Left upper chest B. Inguinal region C. Neck or jaw D. Right shoulder

ANS: D Rationale: The client may have biliary colic with excruciating upper-right abdominal pain that radiates to the back or right shoulder. Pain from cholecystitis does not typically radiate to the left upper chest, inguinal area, neck, or jaw.

A nurse is performing an admission assessment for an 81-year-old client who generally enjoys good health. When considering normal, age-related changes to hepatic function, the nurse should anticipate what finding? A. Similar liver size and texture as in younger adults B. A nonpalpable liver C. A slightly enlarged liver with palpably hard edges D. A slightly decreased size of the liver

ANS: D Rationale: The most common age-related change in the liver is a decrease in size and weight. The liver is usually still palpable, however, and is not expected to have hardened edges.

A client returns to the floor after a laparoscopic cholecystectomy. The nurse should assess the client for signs and symptoms of what serious potential complication of this surgery? A. Diabetic coma B. Decubitus ulcer C. Wound evisceration D. Bile duct injury

ANS: D Rationale: The most serious complication after laparoscopic cholecystectomy is a bile duct injury. Clients do not face a risk of diabetic coma. A decubitus ulcer is unlikely because immobility is not expected. Evisceration is highly unlikely, due to the laparoscopic approach.

A home health nurse is caring for a client discharged home after pancreatic surgery. The nurse documents the nursing diagnosis Risk for Imbalanced Nutrition: Less than Body Requirements on the care plan based on the potential complications that may occur after surgery. What are the most likely complications for the client who has had pancreatic surgery? A. Proteinuria and hyperkalemia B. Hemorrhage and hypercalcemia C. Weight loss and hypoglycemia D. Malabsorption and hyperglycemia

ANS: D Rationale: The nurse arrives at this diagnosis based on the complications of malabsorption and hyperglycemia. These complications often lead to the need for dietary modifications. Pancreatic enzyme replacement, a low-fat diet, and vitamin supplementation often are also required to meet the client's nutritional needs and restrictions. Electrolyte imbalances often accompany pancreatic disorders and surgery, but the electrolyte levels are more often deficient than excessive. Hemorrhage is a complication related to surgery, but not specific to the nutritionally based nursing diagnosis. Weight loss is a common complication, but hypoglycemia is less likely.

A nurse is amending a client's plan of care in light of the fact that the client has recently developed ascites. What should the nurse include in this client's care plan? A. Mobilization with assistance at least 4 times daily B. Administration of beta-adrenergic blockers as prescribed C. Vitamin B12 injections as prescribed D. Administration of diuretics as prescribed

ANS: D Rationale: Use of diuretics along with sodium restriction is successful in 90% of clients with ascites. Beta-blockers are not used to treat ascites and bed rest is often more beneficial than increased mobility. Vitamin B12 injections are not necessary.

A patient has begun taking cholestyramine. Which of the following are noted as the most common adverse effects? A) Nausea, flatulence, and constipation B) Increased appetite and blood pressure C) Fatigue and mental disorientation D) Hiccups, nasal congestion, and dizziness

Ans: A Feedback: Cholestyramine is not absorbed systemically, so the main adverse effects are gastrointestinal (GI) ones (abdominal fullness,flatulence, diarrhea, and constipation). Constipation is especially common, and a bowel program may be necessary to control this problem.

A 59-year-old male patient has a long history of heavy alcohol use and was diagnosed with liver cirrhosis several months earlier. The patient's medical history includes numerous other health problems, including angina. When considering the use of nifedipine in the management of this patient's angina, what consideration should the nurse be aware of? A) The patient is likely to experience an increased effect of the medication. B) This patient will require a higher dose than a patient without this medical history. C) Nifedipine is contraindicated because it is highly hepatotoxic. D) The patient's increased albumin levels

Ans: A Feedback: In patients with cirrhosis, bioavailability of oral drugs is greatly increased and metabolism (of both oral and parenteral drugs) is greatly decreased. Both of these effects increase plasma levels of drug from a given dose (essentially an overdose).

A patient has been placed on tacrolimus, andthe route will be changed from IV to oral prior to discharge home from the hospital. How will this change in administration route affect the patient's plan of care? A) The patient's dose of tacrolimus will have to be increased. B) The patient will receive the drug QID rather than BID C) The patient will have to be monitored more closely for adverse effects. D) The patient will have to take tacrolimus concurrently with an antiemetic.

Ans: A Feedback: Tacrolimus, like cyclosporine, is not well absorbed orally, so it is necessary to give higher oral doses than IV doses to obtain similar blood levels. Increased frequency is not necessarily required. Concurrent dosing with an antiemetic is not required. Regardless of the route by which the drug is provided, the patient needs to be closely monitored for adverse effects.

A young woman is seen in the physician's office and wants to ensure that she is vaccinated against hepatitis. Vaccines are available for which of the following types of hepatitis? Select all that apply. A) Hepatitis A virus B) Hepatitis B virus C) Hepatitis C virus D) Hepatitis D virus E) Hepatitis G virus

Ans: A, B Feedback: Vaccines are available for hepatitis A and B.

A patient was admitted with a diagnosis of a gastrointestinal bleed, the latest of several hospital admissions that have been attributed to his alcohol abuse. The addictions medicine specialist has prescribed disulfiram, which will A) prevent the patient from experiencing euphoria if he drinks alcohol. B) produce unpleasant reactions if the patient drinks alcohol. C) intensify the patient's CNS depression if he drinks alcohol. D) result in a depressed mood if he drinks alcohol.

Ans: B Feedback: Disulfiram inhibits the enzyme aldehyde dehydrogenase to block the oxidation of alcohol. The resulting accumulation of acetaldehyde produces an unpleasant reaction when disulfiram is consumed with alcohol. The effects do not include prevention of euphoria, increased CNS depression, or depressed mood, however.

A patient with alcoholism and chronic liver failure is admitted to the medical unit. He is confused and has an elevated serum ammonia level. What laxative will the nurse administer to lower the serum ammonia level? A) Docusate sodium (Colace) B) Polyethylene glycol-electrolyte solution (NuLYTELY) C) Lactulose (Cephulac) D) Sorbitol

Ans: C Feedback: Lactulose decreases production of ammonia in the intestine. Lactulose is a disaccharide that is not absorbed from the GI tract. It is used to treat hepatic encephalopathy. Docusate sodium only provides stool softening and has no effect on serum ammonia levels. Polyethylene glycol- electrolyte solution (NuLYTELY) is not used to decrease serum ammonia. Sorbitol is not used to decrease serum ammonia.

A hospital patient with a diagnosis of liver failure has been prescribed a low dose of spironolactone in order to treat ascites. The nurse who is providing this patient's care should prioritize assessments for the signs and symptoms of what health problem? A) Peritonitis B) Liver cancer C) Cirrhosis D) Hepatic encephalopathy

Ans: D Feedback: Spironolactone is used in the treatment of ascites. However, it should be used cautiously and carefully monitored in patients with significant hepatic impairment because a rapid change in fluid and electrolyte balance may lead to hepatic coma. It is important to monitor susceptible patients carefully for signs and symptoms of hepatic encephalopathy. There is no risk for liver cancer, cirrhosis, or peritonitis that results directly from the use of spironolactone.

A patient is diagnosed with acute pancreatitis. Which education about the basic mechanism of this disease would the nurse provide? 1. The chemicals being produced by your pancreas are going to work too early and they are damaging the pancreatic tissues. 2. Your pancreas has lost the ability to produce insulin. 3. A major part of your inflammatory system is inhibited. 4. Your blood pressure is elevated because of increased blood flow to your pancreas.

Answer: 1 Explanation: 1. Acute pancreatitis develops when pancreatic enzymes become prematurely activated, resulting in autodigestion of the pancreas and surrounding tissues. 2. Acute pancreatitis is not caused by the pancreas inability to produce insulin. 3. The activation of kallikrein, a major part of the inflammatory system, and not the inhibition of kallikrein, causes systemic hypotension. 4. The multisystem effects of acute pancreatitis generally result in hypotension, not hypertension.

A patient with acute hepatic dysfunction is having difficulty completing his menu and can't seem to remember how to use the bed controls. The nurse realizes these changes might indicate which stage of hepatic encephalopathy? 1. I 2. II 3. III 4. IV

Answer: 1 Explanation: 1. Manifestations of stage I hepatic encephalopathy are subtle and include impaired handwriting and intellectual function changes. 2. Manifestations of stage II hepatic encephalopathy include a decreased level of consciousness and disorientation to time and place. 3. In stage III hepatic encephalopathy, the nurse would assess stupor and abnormal posturing. 4. Stage IV hepatic encephalopathy is manifested by coma, seizures, and severe electroencephalogram abnormalities.

The nurse is participating in the use of Ranson's criteria to assess a patient with pancreatitis. Which statement reflects a disadvantage of using these criteria? 1. It takes 48 hours for complete assessment. 2. Ranson's criteria are not valid for patients over 55. 3. This scoring system is not useful for persons with renal disease. 4. Invasive testing is necessary as part of Ranson's criteria.

Answer: 1 Explanation: 1. The complete assessment of Ranson's criteria requires 48 hours after initial symptoms appear. 2. Ranson's criteria are valid for older patients. Age over 55 increases risk. 3. There is no indication that these criteria are not valid for those with renal disease. 4. No invasive testing is necessary for this scoring.

A patient is demonstrating hepatic encephalopathy due to buildup of ammonia. The nurse anticipates intervention to support which function of the liver? 1. Protein metabolism 2. Vitamin synthesis 3. Fat metabolism 4. Carbohydrate metabolism

Answer: 1 Explanation: 1. The liver is responsible for synthesis of the majority of the body's proteins and for degrading amino acids for energy use through the process of deamination. The major by-product of deamination is ammonia, which is toxic to tissues. The liver is responsible for converting ammonia into urea, a nontoxic substance. Urea diffuses from the liver into the circulation for urinary excretion. When liver failure occurs, ammonia cannot be converted to urea and levels rapidly build in the blood. 2. If the liver is not synthesizing vitamins, the patient would demonstrate findings related to vitamin A, D, E, and K deficiency. 3. Fat metabolism is not related to the development of hepatic encephalopathy or a buildup of ammonia. 4. Alterations in ability to metabolize carbohydrates would not result in hepatic encephalopathy, but rather in changes such as serum glucose levels.

A patient with long-standing type 2 diabetes may be developing diabetic ketoacidosis (DKA). Which assessment findings would the nurse evaluate as supporting that diagnosis? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. A sweet smell to the breath 2. Ketonuria 3. Blood pH of 7.48 4. WBC of 28,000 5. Potassium of 3.4 mEq/L

Answer: 1, 2, 4, 5 Explanation: 1. Acetone is excreted through the lungs due to production of acidic ketone bodies. This causes ketone breath. 2. Presence of ketones in the urine, or ketonuria, is associated with diabetic ketoacidosis. 3. Blood pH of 7.48 would indicate the patient is alkalotic, not acidotic. 4. A WBC this high indicates infection, but this level would also occur with DKA. DKA is often caused by infection. 5. Low potassium occurs in DKA.

A patient is diagnosed with hyperglycemic hyperosmolar state (HHS). Which interventions would the nurse anticipate? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Potassium supplementation 2. Testing for sources of infection 3. Increasing amount of NPH insulin administered 4. Increasing IV fluid administration 5. Monitoring arterial blood gases

Answer: 1, 2, 4, 5 Explanation: 1. HHS can cause either potassium deficit or excess. Potassium supplementation may be necessary. 2. Infection can cause HHS. Identification and management of causative factors is important. 3. HHS management requires administration of IV insulin. 4. HHS results in dehydration that is managed with IV fluids. 5. Monitoring arterial blood gases may help guide treatment decisions.

A patient diagnosed with acute pancreatitis is demonstrating signs of respiratory distress. What physiologic rationale would the nurse explain for this change in respiratory assessment? Select all that apply. 1. Pancreatic enzymes can destroy a component of surfactant. 2. Increase in the size of the abdomen may cause atelectasis. 3. Increased intracranial pressure from pancreatic damage reduces neurological control of respiratory rate and depth. 4. Inflammation of the diaphragm may result in pleural effusion. 5. Lung damage may occur from factors released systemically.

Answer: 1, 2, 4, 5 Explanation: 1. Respiratory insufficiency and failure are common complications of acute pancreatitis and are attributed to the release of pancreatic enzyme phospholipase A, which destroys the phospholipid component of surfactant. 2. The increase in abdominal size resulting from inflammation of tissues may reduce respiratory excursion sufficiently to cause pressure on the lung and atelectasis. 3. A decreased level of consciousness may change respiratory pattern, but this change is not due to increased intracranial pressure. 4. Enzyme irritation of the diaphragm may result in pleural effusion, which will cause respiratory distress. 5. Factors such as trypsin, cytokines, and free-fatty acids are released during pancreatitis and can result in lung damage.

A patient is brought to the emergency department by his son who reports that his father was recently diagnosed with diabetes and is not acting like himself today. Which additional findings would the nurse consider as suggesting hyperglycemic hyperosmolar state (HHS)? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The son reports his father's diabetes is type 2. 2. The patient's plasma glucose reading is 638 mg/dL. 3. The patient's bicarbonate level is 14. 4. The patient's blood pH is 7.28. 5. The patient is 60 years of age.

Answer: 1, 2, 5 Explanation: 1. HHS is more common in patients with type 2 diabetes. 2. Very high serum glucose levels are associated with HHS. 3. Low bicarbonate levels are associated with DKA. 4. Acidosis is often not present in HHS. 5. HHS is seen in older patients, while DKA typically occurs in those younger than 44.

Just after being admitted to the emergency department for symptoms of influenza, the patient loses consciousness. His wife reports that he is diabetic but has not taken his oral medications for a couple of days. Which nursing interventions are indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Check the patient's blood glucose using a fingerstick monitor. 2. Place 1.5 tubes of 40% glucose gel under the patient's tongue. 3. Obtain intravenous access. 4. Administer 50% dextrose subcutaneously. 5. Administer regular insulin subcutaneously.

Answer: 1, 3 Explanation: 1. There are a number of reasons this patient may have lost consciousness including hypoglycemia. Checking the patient's glucose is indicated. 2. This patient is not conscious, so this is not an acceptable intervention. 3. Since this patient is not conscious, it is important to secure intravenous access for administration of medications. 4. 50% dextrose injected subcutaneously would severely damage tissues. 50% dextrose is given by intravenous infusion. 5. This patient is more likely to have hypoglycemia due to illness even though he has not been taking his medications. Additional insulin is not indicated.

A patient has been admitted to the intensive care unit with the diagnosis of hyperacute liver failure. Which assessment findings would the nurse anticipate in this patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. INR (international normalized ratio) greater than 1.5 2. History of alcohol abuse 3. Jaundice 4. Mental status changes 5. Serum glucose greater than 125 mg/dL

Answer: 1, 3, 4 Explanation: 1. By definition, acute liver failure results in an INR greater than 1.5. 2. Acute liver failure has many etiologies. The nurse should not assume this patient has abused alcohol. 3. The designation of hyperacute liver failure is based on the amount of time between onset of jaundice and another finding. Therefore, jaundice exists in this patient. 4. The designation of hyperacute liver failure is based on the amount of time between onset of an assessment finding and the development of hepatic encephalopathy. Mental status changes are found in hepatic encephalopathy. 5. Serum glucose is not a factor in determining the classification of acute liver failure.

The nurse has identified that a patient with acute pancreatitis has impairment of respiratory gas exchange. What interventions will the nurse include in this patient's plan of care? Select all that apply. 1. Administer analgesics as prescribed. 2. Monitor for ileus development. 3. Treat inflammatory response. 4. Ambulate as tolerated. 5. Avoid opioid medications.

Answer: 1, 3, 4 Explanation: 1. Treating pain may allow for deeper and more regular respirations. 2. Development of ileus is not directly related to gas exchange. 3. Inflammatory changes can result in thickening of the alveolar membrane. 4. Ambulation will help the patient mobilize fluids and will help to open airways. 5. Opioid medications are necessary for the control of pain. They do have depressant effects but should be used as needed for comfort.

A patient with acute pancreatitis begins to demonstrate confusion and agitation. How will the nurse evaluate this finding? Select all that apply. 1. Neurological changes are a common finding in acute pancreatitis. 2. Confusion is due to the increases of serum ammonia common in pancreatitis. 3. An acute cerebral vascular accident is imminent and the healthcare provider should be contacted. 4. The patient's intracranial pressure is rising sharply. 5. The patient's mental status should be documented using the Glasgow Coma Scale

Answer: 1, 5 Explanation: 1. The patient with acute pancreatitis frequently develops an alteration in level of consciousness. 2. Increased serum ammonia levels are not associated with pancreatic dysfunction but rather hepatic dysfunction. 3. Confusion and agitation in this patient are not related to an impending acute cerebral vascular accident. 4. Confusion and agitation in this patient do not indicate increasing intracranial pressure but are probably related to pain and anxiety. 5. The nurse should use the Glasgow Coma Scale to document current neurological status so that changes can be trended.\

A patient with type 2 diabetes mellitus, lethargy, and a blood glucose level of 650 mg/dL has been diagnosed with hyperglycemic hyperosmolar syndrome (HHS). The nurse monitors this patient for the development of which complication? 1. Hyperkalemia 2. Seizures 3. Metabolic acidosis 4. Fluid volume overload

Answer: 2 Explanation: 1. HHS results in a substantial loss of electrolytes. 2. HHS is associated with severe neurological changes secondary to profound dehydration. 3. Acidosis is usually not seen with this type of diabetes because sufficient insulin is produced to prevent lipolysis and ketogenesis. 4. HHS results in osmotic diuresis and resultant dehydration.

A patient who has required an insulin drip is being transitioned to subcutaneous insulin. Which intervention would the nurse anticipate? 1. Administering NPH insulin subcutaneously every 2 hours according to fingerstick blood sugar. 2. Administering the prescribed dose of NPH insulin 2 hours before discontinuing the insulin drip. 3. Tapering the insulin drip administration rate over the next several days. 4. Plan to administer twice the number of units of NPH insulin that the patient has been receiving per hour in regular insulin.

Answer: 2 Explanation: 1. The insulin administered according to fingerstick blood sugar should be regular insulin. 2. In order to maintain blood glucose levels, the nurse should plan to administer the ordered NPH insulin 2 hours before the rapidly acting regular insulin being administered by IV is discontinued. 3. Transition to NPH insulin is generally done by discontinuing the regular insulin drip without tapering. 4. The total daily dose of NPH insulin will be half the total regular insulin dose administered over the last 24 hours. This NPH insulin will be administered in two divided doses.

The nurse is planning the care for a patient admitted with diabetic ketoacidosis. How does the nurse anticipate this condition will be medically managed? 1. BID dosing of NPH insulin and PRN coverage with regular insulin 2. A continuous low-dose intravenous infusion of regular insulin 3. Once-per-evening dose of Lantus insulin with daytime coverage with regular insulin 4. Sliding scale coverage with regular insulin

Answer: 2 Explanation: 1. Twice a day dosing of NPH insulin and as needed coverage with regular insulin is frequently used to regulate patients with type 1 diabetes experiencing blood sugar fluctuations secondary to physiological stressors. 2. A low-dose continuous source of insulin provides for stricter regulation and control of the blood sugar because dosing can be regulated hourly. 3. Once-per-evening dose of Lantus insulin with daytime coverage of regular insulin is frequently used to regulate patients with type 1 diabetes experiencing blood sugar fluctuations secondary to physiological stressors. 4. Sliding scale coverage with regular insulin is frequently used to regulate blood sugars in a patient with type 2 diabetes who does need a daily insulin dose but is experiencing elevated blood sugars.

The nurse is caring for a patient with a history of type 2 diabetes who has recently experienced a myocardial infarction. The nurse would increase monitoring for findings of diabetic ketoacidosis (DKA) when which medication is added to the patient's drug regimen? 1. Warfarin sodium 2. Hydrochlorothiazide diuretic 3. Aspirin 4. Calcium channel blocker

Answer: 2 Explanation: 1. Warfarin sodium will not have any significant effect on blood glucose level. 2. Thiazide diuretics along with the stress of the myocardial infarction may increase insulin deficit sufficiently to precipitate a hyperglycemic crisis such as DKA. 3. Aspirin therapy should not have a significant effect on blood glucose level. 4. Calcium channel blockers do not have any significant effects on the blood glucose level.

A patient is diagnosed with acute interstitial pancreatitis. The nurse would reinforce which information about this patient's prognosis? 1. This disorder often progresses to multiple organ dysfunction with a poor outcome. 2. This disorder often causes pancreatic edema, which will resolve with good results. 3. Extensive fat and tissue necrosis occurs with this type of pancreatitis. 4. The patient will most likely have irreversible damage to the pancreas.

Answer: 2 Explanation: 1. A patient with hemorrhagic pancreatitis has a poor prognosis with the potential to develop multiple organ dysfunction. 2. Nonhemorrhagic or interstitial acute pancreatitis is a short-term illness characterized by pancreatic edema and little to no necrosis. Inflammation is localized, and the condition is reversible with a good prognosis. 3. Hemorrhagic acute pancreatitis is characterized by extensive fat and tissue necrosis with severe damage to the pancreas. 4. Hemorrhagic acute pancreatitis results in irreversible damage to the pancreas.

A patient with symptoms of acute pancreatitis is scheduled for an abdominal ultrasound and a CT scan. The ultrasound department is very busy, so the patient is asked to wait. What rationale would the nurse provide for not doing the CT scan first? 1. The ultrasound is the only way to assess the severity of damage to the pancreas. 2. The ultrasound can assess for gallstones as the cause of the pain. 3. Once the patient has had a CT scan, the ultrasound must be delayed for at least 72 hours. 4. The CT scan will be done only after the ultrasound has demonstrated that complications such as hemorrhage do not exist.

Answer: 2 Explanation: 1. An ultrasound cannot determine the severity of the damage to the pancreas. 2. An ultrasound on admission can assess for gallstones as the etiology of the pain rather than establishing a diagnosis of acute pancreatitis. If this is the case, the CT scan may not be necessary. 3. There is no reason why the ultrasound should be delayed if a CT scan has already been done. 4. The ultrasound cannot diagnose these complications. The CT scan is more specific.

A patient with acute hepatic dysfunction demonstrates slow slurred speech and cold clammy skin. The nurse would collaborate with the primary care provider for treatment of which condition? 1. Cerebral embolism 2. Hypoglycemia 3. Bleeding esophageal varices 4. Increased ammonia level

Answer: 2 Explanation: 1. Cerebral embolism is not a common occurrence in acute hepatic dysfunction and is not supported by these assessment findings. 2. Since liver failure interferes with normal carbohydrate metabolism, the patient may develop hypoglycemia secondary to decreased gluconeogenesis. The patient should be closely monitored for the development of hypoglycemic symptoms, which include slow thinking, slurred speech, nervousness, tachycardia, and cold clammy skin. 3. If esophageal varices exist and begin bleeding, the patient will experience hematemesis. 4. Liver failure can result in increased serum ammonia levels, which will cloud mentation. It will not result in cold clammy skin at the level in which the patient will still be able to speak.

A patient with a history of chronic liver disease is admitted with acute hemorrhage from esophageal varices. The nurse would expect treatment interventions for which causative condition? 1. The patient has developed gallstones as a result of poor liver function. 2. The patient has portal hypertension with shunting of blood. 3. The nonsteroidal anti-inflammatory drug (NSAID) use that caused the patient's chronic liver failure has also resulted in gastritis. 4. The abdominal distention caused by ascites has resulted in reflux esophagitis.

Answer: 2 Explanation: 1. Esophageal varices are not associated with gallstones. 2. Esophageal varices are a complication of portal hypertension. Since the esophageal veins in the lower part of the esophagus are a common collateral flow diversion, any rapid increase in pressure of the engorged veins will lead to an acute hemorrhage. 3. Gastritis is not associated with esophageal varices. 4. Esophageal varices are not caused by reflux esophagitis.

A patient with acute pancreatitis is diagnosed with a pseudocyst. Which nursing intervention should be added to this patient's plan of care? 1. Monitor urine output. 2. Increase assessment for signs and symptoms of infection. 3. Limit protein intake. 4. Reduce fluid intake.

Answer: 2 Explanation: 1. Monitoring urine output is not specific to the care of this patient. 2. A pancreatic pseudocyst is composed of pancreatic enzymes, necrotic tissue, and possibly blood. Some pseudocysts resolve on their own; however, while they are present, they may become infected or rupture into the peritoneal cavity, which can precipitate chemical peritonitis. Because of this, the nurse should increase assessment for signs and symptoms of infection. 3. There is no reason to limit the amount of protein this patient is consuming. 4. There is no reason to limit the amount of fluids this patient is consuming.

A patient with acute pancreatitis has been treated to minimize pancreatic stimulation, but vomiting continues. The nurse would anticipate which intervention? 1. NPO (nothing by mouth) status 2. Placement of a nasogastric tube to intermittent suction 3. Administration of morphine 4. Increased ambulation

Answer: 2 Explanation: 1. NPO status is part of resting the GI tract and would already be part of minimizing pancreatic stimulation. 2. Vomiting should stop when the patient is placed on GI tract rest. If this does not occur, placement of a nasogastric tube to intermittent suction is considered. 3. Drug therapy will include antacids, proton pump inhibitors, or anticholinergics. 4. Increasing ambulation is not indicated when the patient is vomiting.

A patient reports taking two 500-mg acetaminophen tablets at least 3 or 4 times a day to treat muscle pain in his back. What nursing assessment question is priority? 1. Do you drink plenty of water when you take these pills? 2. What other medications do you take? 3. Have you had your back reassessed lately? 4. What other measures do you take to relieve your back pain?

Answer: 2 Explanation: 1. The patient should drink a full glass of water with these pills, but this is not the priority assessment question. 2. The nurse should assess this patient for unintended acetaminophen overdose by asking about other medications the patient takes. If these other medications also contain acetaminophen, the patient may be in danger of overdose. 3. The nurse would ask questions to follow up on chronic back pain, but this is not the highest priority. 4. The nurse should ask about additional pain relief measures and may discover problems such as alcohol use. This question is a priority, but it is not the highest priority.

The nurse is assessing a patient admitted with acute liver failure of unknown etiology. Which statement made by the family requires additional investigation? 1. I thought her skin color change was due to going to the indoor tanning booth. 2. She has been exercising by gathering wild berries and greens for salads. 3. We went to the mall last week and she got pretty tired while shopping. 4. She was exposed to influenza last week when she went to visit her sister.

Answer: 2 Explanation: 1. There is no association with indoor tanning booths and acute liver failure. 2. This statement may reveal that the patient has ingested mushrooms that can cause liver toxicity. The nurse should ask additional assessment questions. 3. Being tired and intolerant of exercise would be expected if the patient was in acute liver failure. 4. Exposure to influenza is not a significant risk factor for development of acute liver failure.

While assessing a patient admitted with acute hepatic dysfunction, the nurse notes abnormal involuntary movements of the patient's hands. How should the nurse document this finding? 1. As seizure activity 2. As asterixis 3. As decorticate posturing 4. As hyperreflexia

Answer: 2 Explanation: 1. This abnormal movement does not represent a seizure. 2. Asterixis, or liver flap, refers to an involuntary tremor that is particularly noted in the hands but may also be seen in the feet and tongue. 3. Abnormal posturing would affect all four extremities. 4. This finding represents a tremor, not a reflex.

The nurse comes to the cardiac patient's room to administer subcutaneous insulin. The patient says, I have always taken pills for my diabetes. Am I getting worse? What should the nurse consider when formulating a response to this question? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Some cardiac diseases cause oral antidiabetic medications to be less effective. 2. The stress of illness makes it difficult to control glucose with oral medications. 3. The changes associated with hospitalization make it difficult to control glucose with oral medications. 4. The patient will likely need to take insulin to control glucose even after release from the hospital. 5. Once discharged the patient can use urine dipstick measurements to guide insulin therapy.

Answer: 2, 3 Explanation: 1. There is no truth to this statement. 2. Often patients with type 2 diabetes require insulin while acutely ill. 3. While hospitalized, the patient is under additional stress and may not eat or exercise as at home. These changes may make it necessary to use insulin for glucose control. 4. Generally once patients are discharged to home, they can control their glucose with oral medications. 5. It is recommended that blood glucose rather than urine glucose measurements be used to guide therapy.

The nurse is caring for a patient with acute pancreatitis demonstrating signs of hypovolemic shock. Which interventions will be included in this patient's plan of care? Select all that apply. 1. Administer high doses of potassium. 2. Monitor pulmonary arterial wedge pressure. 3. Administer several liters of intravenous fluids in the first few hours of treatment. 4. Administer anticholinergic medication. 5. Monitor central venous pressure.

Answer: 2, 3, 5 Explanation: 1. Administering electrolyte replacements as prescribed would be useful to prevent or treat complications. The choice of which electrolytes and the amount of electrolytes would be guided by laboratory results. High doses of potassium are not likely. 2. In hypovolemia, the goal is to stabilize the patient's hemodynamic status. Monitoring pulmonary wedge pressure will provide valuable information about fluid balance. 3. Fluid resuscitation generally involves an initial several-liter fluid bolus followed by 250-500 mL/hour continuous infusion. 4. Administering anticholinergic medication may decrease pancreatic stimulation but is not indicated to treat hypovolemia. 5. Central venous pressure is a standard intervention for monitoring hydration status

A patient diagnosed with hyperglycemic hyperosmolar syndrome (HHS) will be started on rehydration fluids. How will the nurse anticipate managing this treatment? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Initial treatment will be with rapidly infused lactated Ringer's solution. 2. Once the patient's blood glucose has decreased to around 300 mg/dL, a glucose-containing solution will be used for the remaining hydration. 3. The patient will be encouraged to drink as much fluid as possible. 4. The nurse will monitor the patient's lungs for signs of overload. 5. The fluid used for resuscitation will contain insulin.

Answer: 2, 4 Explanation: 1. Lactated Ringer's solution will not be used for this patient's fluid resuscitation. 2. In order to prevent hypoglycemia as the blood glucose approaches normal, the original fluid used for resuscitation is changed to a fluid containing glucose. 3. The patient will be held nothing by mouth (NPO) until the crisis state is resolved. 4. This rapid fluid resuscitation places the patient at risk for fluid overload. The nurse should conduct careful assessment for this complication. 5. The patient will receive intravenous insulin by infusion, but this fluid will not be used for fluid resuscitation.

Despite the inherent risks, the patient with diabetic ketoacidosis will be given sodium bicarbonate to reverse severe metabolic acidosis. How does the nurse expect to administer this medication? 1. In enema form 2. As a 50-mL bolus injection intravenously 3. Along with potassium chloride 4. Over at least an 8-hour period

Answer: 3 Explanation: 1. Sodium bicarbonate is not administered by enema. 2. Sodium bicarbonate is not given as a bolus in this application. 3. This sodium bicarbonate will be given in a water solution along with 20 mEq of potassium chloride. 4. It is recommended that the standard dose of 100 mmol be given over a 2-hour period.

A patient presents to the emergency department in acute diabetic ketoacidosis. The nurse administers insulin to correct metabolism of which substance that is directly causative of this condition? 1. Protein 2. Vitamin D 3. Fat 4. Potassium

Answer: 3 Explanation: 1. The effects of insulin deficiency on protein result in protein catabolism. 2. Vitamin D is not involved directly in this process. 3. When glucose cannot be transferred into the cell, as with a deficit of insulin, intracellular glucose drops. Insufficient intracellular glucose results in catabolism of fats. Catabolism of fats results in production of ketones. Increased ketones results in ketoacidosis. 4. While potassium levels are altered in the face of insulin deficit, this is not the best answer for the question asked.

A patient will receive insulin as treatment for diabetic ketoacidosis. The patient weighs 225 pounds and has a pretreatment serum glucose of 288 mg/dL. Which prescription would the nurse be comfortable administering? 1. Administer regular insulin 102 units/hr by intravenous infusion. 2. Administer NPH insulin 20 units twice daily. 3. Administer regular insulin intravenously at 10 units/hr. 4. Administer regular insulin 100 units in 1000 mL NS at 28.8 mL/hr.

Answer: 3 Explanation: 1. This patient weighs approximately 102 kg. An infusion at 100 unit/hr is too high. 2. NPH insulin is a slowly acting insulin and would not be used for this treatment. 3. The recommended insulin dose is 0.1 unit/kg/hr. This patient weighs 102 kg. 102 × 0.1 unit = 10.2. The nurse would be comfortable administering a dose within 0.2 units of recommended. 4. The patient's pretreatment blood glucose is not used as a component of the recommended dose of insulin.

A patient recovering from liver transplant surgery is being instructed on the long-term use of steroid medication. Which education should the nurse provide? 1. Abdominal pain and nausea are side effects and are expected. 2. There are no major side effects associated with this medication. 3. This medication helps prevent organ rejection, but you must report any vision changes and bone pain and be tested for diabetes regularly. 4. This medication works for a few months and will be discontinued.

Answer: 3 Explanation: 1. Abdominal pain and nausea are not expected side effects of glucocorticoid therapy. 2. There are major side effects of steroid medications. 3. Steroid therapy is useful for prevention of rejection and is used in rescue therapy for organ rejection; however, long-term use is associated with severe bone disorders, diabetes mellitus, and cataracts. The patient should be instructed to report any vision changes and bone pain and should be tested regularly for the onset of diabetes. 4. The patient will most likely be on this medication for a very long time, perhaps for life.

A patient is diagnosed with subtotal pancreatic necrosis. Which intervention would the nurse include in this patient's plan of care? 1. Maintain bedrest. 2. Restrict fluids. 3. Administer proton pump inhibitor. 4. Monitor arterial blood gases.

Answer: 3 Explanation: 1. Bedrest is not necessary for this patient. 2. There is no evidence to suggest this patient should be on a fluid restriction. 3. Patients with subtotal pancreatic necrosis usually require a proton pump inhibitor on a daily basis as the bicarbonate secretion of the pancreas is severely diminished, putting the patient at risk for duodenal ulcer. Therefore, the nurse should administer proton pump inhibitors as prescribed. 4. Arterial blood gas assessment might help determine the presence of acidosis because of the reduction of bicarbonate secretion of the pancreas, but a different intervention is the most important at this time.

A patient admitted with general malaise, nausea, and vomiting tells the nurse that he started to feel sick a few weeks after getting a new tattoo on his leg. Which type of hepatitis should the nurse suspect is causing this patient's symptoms? 1. A 2. E 3. C 4. A combination of A and D

Answer: 3 Explanation: 1. Hepatitis A (HAV) is transmitted through the fecal-oral route. Tattooing is not considered a risk factor for HAV. 2. Hepatitis E is transmitted by contaminated water and fecal-oral routes. It is most prevalent in India, China, and Southeast Asia. 3. Hepatitis C is transmitted primarily through blood and blood products. Risk factors for the development of the illness include tattoos conducted in nonprofessional settings. 4. There is no indication that HAV and Hepatitis D (HDV) are associated with receiving a tattoo.

A patient is admitted with the diagnosis of possible acute pancreatitis. Upon assessment, the nurse notes faint bruising over the patient's flank region. How would the nurse report and document this finding? 1. Homan's sign 2. Cullen's sign 3. Turner's sign 4. Chvostek's sign

Answer: 3 Explanation: 1. Homan's sign is an indicator of the presence of deep vein thrombosis, not acute pancreatitis. 2. The Cullen's sign is a bluish discoloration around the umbilicus. 3. While assessing the patient's integumentary status, the nurse might observe a bluish discoloration over the patient's flank region. This discoloration is considered the Grey Turner's sign. 4. Chvostek's sign is seen in hypocalcemia and is characterized by numbness and tingling around the mouth.

A patient with liver disease has a decline in his previously elevated urobilinogen levels. The nurse would anticipate further testing for which condition? 1. Overhydration 2. Gastrointestinal bleeding 3. Worsening of the liver failure 4. Protein catabolism

Answer: 3 Explanation: 1. Overhydration will not result in dropping urobilinogen levels. 2. Decrease in a previously increased urobilinogen level does not indicate gastrointestinal bleeding. 3. Urobilinogen is measured as a sensitive test for hepatic damage. It may increase before serum bilirubin levels increase. In early hepatitis or mild liver cell damage, the urine urobilinogen level will increase despite an unchanged serum bilirubin level. However, with severe liver failure, the urine urobilinogen level may start to decrease because less bile will be produced. 4. A drop in the level of a previously increased urobilinogen does not infer that protein catabolism is occurring.

A patient comes into the emergency department with complaints of abdominal pain that have become very severe. Which observation would the nurse evaluate as supporting the tentative diagnosis of acute pancreatitis? 1. The patient is most comfortable sitting on the side of the bed with arms extended back and legs dangling. 2. The patient is most comfortable lying flat in bed. 3. The patient is most comfortable lying on left side, knees pulled up to the chest. 4. The patient is only comfortable while walking around the perimeter of the room with arms wrapped around the abdomen.

Answer: 3 Explanation: 1. Sitting on the side of the bed with the arms extended behind and legs dangling might increase intra-abdominal pressure, which would increase pain. 2. Even though the pain intensity varies greatly from patient to patient, many patients cannot tolerate lying completely flat in bed. 3. The classic pattern of pain is described as a sudden onset of sharp, knifelike, twisting and deep, epigastric pain that frequently radiates to the back, and is often associated with nausea and vomiting. The patient may report some degree of relief by assuming a leaning forward or knee-chest position and may report an increase in pain when doing activities that increase abdominal pressure. The knee-chest position reduces pressure in the abdomen. 4. Walking around with the arms wrapped around the abdomen would increase intra-abdominal pressure, which would make the pain of pancreatitis more intense.

A patient is in congestive heart failure due to damage from a myocardial infarction. Which gastrointestinal manifestation would the nurse expect on assessment? 1. Severe stomach cramping 2. Decreased bowel sounds 3. Enlargement of the liver 4. Esophageal reflux

Answer: 3 Explanation: 1. Stomach cramping is not an expected effect of congestive heart failure. 2. Congestive heart failure does not result in decreased bowel sounds. 3. The liver is a fluid reservoir. During periods of high fluid volume in the right heart, the liver is able to accept approximately one liter of excess volume by distending. 4. Esophageal reflux is not directly correlated with congestive heart failure.

A patient is prescribed N-acetylcysteine (NAC) 140 mg/kg via nasogastric tube. What is the priority nursing intervention? 1. Give the dose slowly over at least 15 minutes. 2. Warn the patient that the medication smells like burning rubber. 3. Give all follow-up doses exactly on time. 4. Ask the patient what he weighs.

Answer: 3 Explanation: 1. There is no indication that this medication must be given slowly. 2. This medication smells like rotten eggs. 3. It is very important that the remaining 17 doses of NAC be given every 4 hours as directed and on time. 4. The nurse should weigh the patient, not depend on an estimated weight.

A patient with severe ascites has undergone abdominal paracentesis with removal of 2 liters of fluid. The nurse anticipates administration of which product? 1. 2 liters of normal saline 2. 4 liters of lactated ringer's solution 3. 16 to 20 grams of albumin 4. 6 to 10 units of platelets

Answer: 3 Explanation: 1. There is no indication that this patient requires 2 liters of normal saline. 2. There is no indication that this patient requires lactated Ringer's (LR) solution. 3. Removing this much fluid may result in profound fluid shifts, which alter hemodynamics. The patient should receive 8 to 10 grams of albumin for each liter of ascites fluid removed. 4. There is no indication that this patient requires platelets.

The nurse is preparing to administer an intravenous insulin drip to a patient admitted with diabetic ketoacidosis. Which laboratory result is of most concern to the nurse? 1. Phosphorus level of 2.8 mEq/L 2. Bicarbonate level of 16 mEq/L 3. Sodium level of 130 mEq/L 4. Potassium level of 3.2 mEq/L

Answer: 4 Explanation: 1. The phosphorus level is within normal limits. 2. The bicarbonate level is low, which is expected with acidosis, but it often corrects itself with insulin and IV fluid replacement. 3. The sodium level is low but is not as critical as another option. 4. Insulin treatment when potassium is below 3.3 mEq/L increases the risk for cardiac dysrhythmia or cardiac arrest.

The nurse is preparing to administer an intravenous infusion containing regular insulin for a patient diagnosed with diabetic ketoacidosis. Which nursing intervention added to the patient's plan of care has the highest priority? 1. Check urine for ketone bodies every shift. 2. Check blood glucose levels every 2 hours. 3. Monitor serum calcium levels closely. 4. Adjust infusion rate according to glucose readings.

Answer: 4 Explanation: 1. The presence of ketones in the urine is significant, but is not an accurate method of evaluating the effectiveness of this treatment. 2. Blood glucose levels need to be checked hourly. 3. Serum calcium levels are important but are not the most important intervention. 4. The most important intervention is to adjust insulin administration in response to glucose readings.

A nurse is reviewing laboratory results for a patient just admitted to the intensive care unit. The patient is not known to have diabetes, but initial non fasting blood sugar is 130 mg/dL. At which point would the nurse expect insulin therapy to begin? 1. When fasting blood sugar exceeds 110 mg/dL 2. When the patient shows assessment findings associated with hyperglycemia 3. If another random blood glucose is in the same range as this initial reading 4. When fasting blood glucose levels reach 180 mg/dL

Answer: 4 Explanation: 1. This blood glucose level would not require insulin administration. 2. Insulin administration need is determined by blood glucose levels. Hyperglycemia shares assessment findings with many other conditions. 3. It is not necessary to treat this blood glucose level with insulin even if it is persistent. 4. Insulin therapy should be initiated for persistent hyperglycemia, starting at a blood glucose level no greater than 180 mg/dL

The nurse is caring for a patient admitted with acute hepatic dysfunction caused by acetaminophen toxicity. Which clinical findings would indicate that the patient's condition is deteriorating? 1. Sweet odor on the breath 2. Tachycardia 3. Hyperresponsive pupillary responses 4. Change in level of consciousness

Answer: 4 Explanation: 1. A sweet odor on the breath is not associated with liver failure. 2. Bradycardia, not tachycardia, is a finding associated with Cushing's triad, which indicates increased intracranial pressure. 3. Pupillary responses typically become sluggish. 4. In acute hepatic dysfunction caused by fulminant hepatic failure, manifestations are the result of cerebral edema and include elevated intracranial pressure and could result in brainstem herniation. One of the first indications that the patient is deteriorating would be a change in level of consciousness.

A patient with acute pancreatitis is demonstrating signs of hypovolemic shock. The nurse will conduct additional assessment for which expected cause of this hypovolemia? 1. Increased urine output 2. Undiagnosed gastrointestinal ulcerations 3. Pulmonary edema 4. Fluid shifts and decreased vascular resistance

Answer: 4 Explanation: 1. An increase in urine output will not place a patient into hypovolemic shock in this situation. 2. Even though hypovolemic shock can be caused by undiagnosed gastrointestinal ulcerations, there is not enough information to support this reason in the patient. 3. Pulmonary edema would be another symptom of third spacing of fluid being shifted from compartments. 4. Vasoactive substances, released from damaged pancreatic tissue, are responsible for vasodilation, decreased systemic vascular resistance, and increased permeability of endothelial linings of vessels. As vessels become more porous, intravascular fluids shift into other compartments and into the retroperitoneal cavity, causing hypovolemia, third spacing, and hypovolemic shock.

A patient with acute hepatic dysfunction has abdominal ascites. The nurse would anticipate which laboratory finding? 1. Serum sodium less than 135 mEq/L 2. Hematocrit less than 36% 3. High-density lipoprotein (HDL) level greater than 40 mg/dL 4. Albumin level lower than 3.5 g/L

Answer: 4 Explanation: 1. Hyponatremia is not associated with abdominal ascites. 2. Hematocrit will generally rise as fluid is shifted out of the circulating system and into the abdomen. 3. An elevated HDL level is not typically associated with ascites. 4. Ascites, an abnormal collection of fluid in the abdominal cavity, develops from decreased colloid osmotic pressure and portal hypertension. Colloid osmotic pressure decreases as a result of a reduction in albumin. Hypoalbuminemia is caused by the inability of the liver to carry out its usual protein metabolism functions, causing a drop in colloid osmotic pressure and shifting fluid from the intravascular compartment into other body compartments.

A patient will have a magnetic resonance cholangiopancreatography (MRCP) to evaluate for pancreatitis. What information would the nurse provide to the patient regarding this test? 1. A small plug of tissue will be removed for biopsy. 2. This test is invasive and will require conscious sedation. 3. This test will allow direct visualization of the pancreatic duct. 4. No contrast is used for this test.

Answer: 4 Explanation: 1. No tissue is removed in this study. 2. This test is not invasive. 3. MRCP uses magnetic resonance imaging, not direct visualization. 4. No contrast is required for this test.

A patient diagnosed with acute pancreatitis is being monitored in the intensive care unit. The patient's cardiac output is trending downward. Increasing intravenous fluids by protocol has not been effective. Which nursing interventions are indicated? 1. Place the patient in a prone position. 2. Offer the patient fluids by mouth. 3. Irrigate the patient's nasogastric (NG) tube. 4. Assess for development of systemic inflammatory response syndrome (SIRS).

Answer: 4 Explanation: 1. Prone positioning would increase pressure on the abdomen and would likely not be tolerated by this patient. This position has no benefit in increasing cardiac output. 2. Patients with acute pancreatitis do not tolerate fluids by mouth and are likely ordered to be put on nothing by mouth (NPO) status. 3. There is no indication that irrigating the NG tube is necessary or that it would be effective in increasing cardiac output. 4. Patients with acute pancreatitis are at risk for the development of SIRS, which would result in reduced cardiac output. The nurse should begin this assessment and collaborate with the healthcare provider regarding other treatment strategies.

The nurse is caring for a patient with acute pancreatitis experiencing pain. How would the nurse expect to treat this pain? 1. Acetaminophen 2. Nonsteroidal anti-inflammatory drugs (NSAIDs) 3. Demerol 4. Morphine

Answer: 4 Explanation: 1. The pain of acute pancreatitis is not likely to be controlled with acetaminophen. 2. The pain of acute pancreatitis is not likely to be controlled with NSAIDs. 3. Meperidine (Demerol) is not considered a drug of choice as its major metabolite can accumulate in the body and is neurotoxic. 4. Since acute pancreatitis is extremely painful, pain control is needed for comfort and to decrease the secretion of pancreatic enzymes. Fentanyl, morphine, and hydromorphone are effective pain relievers for patients with acute pancreatitis

A patient with acute hepatic dysfunction is experiencing a gastrointestinal bleed. The nurse should be prepared to administer which products? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Mannitol 2. Antibiotics 3. Albumin 4. Vitamin K 5. Fresh frozen plasma

Answer: 4, 5 Explanation: 1. Mannitol would be administered for increased cerebral edema, not bleeding. 2. The patient may require antibiotics, but this is not the immediate priority. 3. Albumin is not administered to treat GI bleed. 4. Treatment for an acute gastrointestinal bleed due to acute hepatic dysfunction includes the administration of vitamin K. 5. Since this patient is actively bleeding, the administration of fresh frozen plasma is indicated.

A patient with acute hepatic dysfunction is prescribed lactulose (Cephulac) 45 mL by mouth four times a day. Which findings will the nurse evaluate as indicating the medication is having its desired effect? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The patient's abdominal girth is smaller. 2. The patient has no more oozing from esophageal varices. 3. The patient's hemoglobin has increased. 4. The patient's mentation is clearer. 5. The patient has had three stools in the last 24 hours.

Answer: 4, 5 Explanation: 1. Reduction in abdominal girth is not the intended effect of administration of lactulose; however, some reduction may occur. 2. Decrease in oozing from esophageal varices is not the intended effect of administration of lactulose. 3. Lactulose is not intended to increase the patient's hemoglobin. 4. Lactulose helps to decrease ammonia, which will result in clearer mentation. 5. Lactulose, a synthetic disaccharide, helps prevent the absorption of ammonia through the bowel by moving the stool through the intestines more rapidly to prevent bacteria from breaking down. Three to five stools daily is the intended effect.

A patient was admitted with acute abdominal and back pain. Which test results would the nurse evaluate as indicating additional testing for acute pancreatitis is likely? Select all that apply. 1. Secretin stimulation test 2. Hematocrit level 3. Hemoglobin level 4. Serum lipase level 5. Amylase

Answer: 4, 5 Explanation: 1. The secretin stimulation test helps determine pancreatic activity but will not necessarily aid in the diagnosis of acute pancreatitis. 2. Hematocrit level is not used to help diagnose the presence of acute pancreatitis. 3. Hemoglobin level is not used to help diagnose the presence of acute pancreatitis. 4. Lipase levels in the serum will be elevated if pancreatic inflammation is present. Lipase is currently the best enzyme to identify acute pancreatitis. 5. Amylase is often used as a screening test for pancreatitis. Elevated amylase levels indicate the need for additional testing, as they can be elevated for multiple reasons.

A patient is admitted with suspected acute hepatic failure. Which findings would the nurse evaluate as supporting this suspected diagnosis? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The patient complains of thirst. 2. The patient has a dry cough. 3. The patient's hemoglobin is elevated. 4. The patient's international normalized ratio (INR) is elevated. 5. The patient has new onset of confusion.

Answer: 4, 5 Explanation: 1. Thirst is not a documented effect of acute hepatic failure on any major body system. 2. Crackles and tachypnea are respiratory effects of acute hepatic failure and not a dry cough. 3. Elevation of hemoglobin is not an expected effect of acute liver failure. 4. Within the hematologic system, assessment findings would include impaired coagulation with an elevated INR. 5. Development of encephalopathy is a hallmark of acute liver failure. New onset confusion may herald development of hepatic encephalopathy

The nurse is monitoring the laboratory values of a patient with acute pancreatic dysfunction. Which values would indicate further assessment is required? Select all that apply. 1. Hemoglobin level 13.5 mg/dL (WNL) 2. Serum sodium level 143 mEq/L (WNL) 3. Serum potassium level 4 mEq/L (WNL) 4. Serum calcium level 8 mg/dL (LOW) 5. BUN level is 80 mg/dL (HIGH)

Answer: 4, 5 Explanation: 1. This is a normal hemoglobin level, as would be expected with acute pancreatitis. 2. This is a normal serum sodium level and does not require additional assessment. 3. Electrolyte disturbances do occur with acute pancreatitis; however, this is a normal potassium level so no additional assessment is currently required. 4. Hypocalcemia may develop as a result of fat necrosis because serum calcium migrates to the extravascular space surrounding the pancreas where the fat necrosis is taking place. The nurse should assess the patient further with the serum calcium level of 8.0 mg/dL. 5. Increased BUN level can have many etiologies. Additional nursing assessment is indicated.

A client is admitted with liver failure. Which lab values would the nurse expect to be elevated? Select all that apply. A) Calcium B) Bilirubin C) PT D) PPT E) INR

B, C, D, E. When a client is in liver failure, the lab values that would be elevated would be the client's bilirubin level, prothrombin time, partial prothrombin time, and international normalized ratio. The liver regulates clotting factors, so if it fails, the client is at high risk of bleeding. The liver functions to produce bile. Because the liver has failed, red blood cells are broken down causing the entire body to be jaundiced. Bilirubin may be caused by inflammation in the liver or abnormalities of liver cells so bile cannot be drained properly and it accumulates. Calcium would be low because albumin binds to calcium and albumin is also low in liver failure.

A client with diabetes mellitus type 1 admitted with DKA asks the nurse, What causes DKA to happen? The nurse correctly explains which common causes of DKA? Select all that apply. A) Not taking oral antiglycemic medications B) Emotional stress C) Infection D) Stomach virus E) Taking too much insulin

B, C, D. Diabetic ketoacidosis (DKA) is a very serious complication of diabetes mellitus. It occurs when ketones or blood acids increase in the bloodstream in response to elevated blood glucose levels and inadequate insulin. DKA can occur due to illness, infection, or insufficient insulin. The client with DKA has symptoms including extreme thirst, nausea, abdominal cramping, fruity (acetone) breath, frequent urination, and confusion. The blood glucose is extremely elevated and ketones are found in the blood and urine. The client has to be treated in the hospital and often in the ICU to address the metabolic acidosis. Priority treatments are fluid replacement, insulin therapy, and electrolyte correction.

Which nursing interventions is/are appropriate for a client with hepatitis C? Select all that apply. A) Encourage high protein diet B) Teach avoidance of alcohol C) Promote rest of clustering care D) Educate avoidance of acetaminophen E) Administer isoniazid antibiotic daily

B, C, D. Hepatitis C is a virus that attacks the liver causing inflammation. Since it is a virus, it has flu-like symptoms including fatigue, muscle aches, fever, and headaches. Later in the disease process, symptoms are similar to liver failure because the inflammation can cause similar damage as cirrhosis of the liver. Later stage symptoms of hepatitis C include ascites, jaundice, esophageal varices, and bleeding tendencies. Abnormal laboratory results, including decreased albumin, decreased clotting factors, increased ALT/AST, and cholesterol associated labs occurred as a result of liver failure. Dietary teaching for the client with hepatitis C includes a low to moderate protein, high calorie, high carbohydrate diet. The client should be taught to avoid substances that cause liver toxicity, such as alcohol (ETOH), acetaminophen, and hepatotoxic antibiotics, such as isoniazid (INH) antibiotics. The nurse should be aware of the client's need to rest and cluster nursing care.

While conducting a physical examination of a client, which of the following skin findings would alert the nurse to the likelihood of liver problems? Select all that apply. A. Cyanosis of the lips B. Petechiae C. Ecchymoses D. Aphthous stomatitis E. Jaundice

B, C, E. The skin, mucosa, and sclerae are inspected for jaundice. The nurse observes the skin for petechiae or ecchymotic areas (bruises), spider angiomas, and palmar erythema. Cyanosis of the lips is indicative of a problem with respiratory or cardiovascular dysfunction. Aphthous stomatitis is a term for mouth ulcers and is a gastrointestinal abnormal finding.

Which of the following potential complications of pancreatitis should the nurse monitor for? Select all that apply. A) Hypercalcemia B) Atelectasis C) Hypertension D) Pseudocyst E) Peritonitis

B, D, E. Complications of pancreatitis can lead to mortality so diligence in monitoring clients is vital. Systemic inflammatory chemicals cause severe damage in the respiratory, cardiovascular, and gastrointestinal systems. Pulmonary complications of ARDS, pleural effusions, atelectasis, and pneumonia require the nurse to closely assess the respiratory system. Tachycardia and hypotension occur because of hypovolemia. Pseudocysts and abscesses can form and peritonitis or sepsis is the outcome if these rupture.

A client is admitted with a possible diagnosis of pancreatitis. Which of the following is a strong indicator for this diagnosis? A) Pain in the right upper quadrant of the abdomen B) Elevated lipase and amylase levels C) Hyperactive bowel sounds D) Oxygen saturation level of 95%

B. Acute pancreatitis occurs when the pancreas becomes inflamed. Digestive enzymes protease, amylase, and lipase are normally released into the intestine. An injury leads to the premature release of these enzymes and causes autodigestion of the pancreas. The result is inflammation of the delicate pancreas and elevated levels of amylase and lipase. These two lab tests are strong indicators of pancreatitis. Hyperglycemia occurs because insulin production is diminished secondary to inflammation. The immune system reacts and the white blood count is elevated. Clients can exhibit symptoms of liver disease such as jaundice and increased coagulation time, so PTT, aPTT and bilirubin blood tests will be elevated.

A nurse is caring for a client who has been admitted for the treatment of advanced cirrhosis. What assessment should the nurse prioritize in this client's plan of care? A. Measurement of abdominal girth and body weight B. Assessment for variceal bleeding C. Assessment for signs and symptoms of jaundice D. Monitoring of results of liver function testing

B. Assessment of variceal bleedingRationale: Esophageal varices are a major cause of mortality in patients with uncompensated cirrhosis. Consequently, this should be a focus of the nurse's assessments and should be prioritized over the other listed assessments, even though each should be performed.

Expected findings in a client with diabetic ketoacidosis include: A) Hypokalemia B) Reports of abdominal pain C) BP 78/48 D) Respiratory acidosis

B. DKA is extreme hyperglycemia with associated metabolic acidosis that occurs in clients with Type I diabetes mellitus. Acidosis occurs due to the breakdown of fat instead of glucose due to the absolute deficiency of insulin. As a result of lipolysis, a metabolic acidosis develops with decreased pH and HCO3 levels. Reports of abdominal pain are expected in these clients because of the presence of metabolic acidosis and the breakdown of fat to be used for fuel.

A patient is taking disulfiram (Antabuse) and later consumes several shots of vodka. What effect will be produced from the combination of alcohol and disulfiram? A) Hypertension B) Vomiting C) Hyperalertness D) Oral bleeding

B. Disulfiram interferes with hepatic metabolism of alcohol and allows the accumulation of acetaldehyde. If alcohol is ingested during disulfiram therapy, acetaldehyde causes headaches, confusion, seizures, chest pain, flushing, palpitations, hypotension, sweating, blurred vision, nausea, vomiting, and a garlic-like aftertaste. Disulfiram will not cause hypertension, increased alertness, or bleeding.

A client is admitted to the healthcare facility suspected of having acute pancreatitis and undergoes laboratory testing. Which of the following would the nurse expect to find? A. Decreased white blood cell count B. Elevated urine amylase levels C. Decreased liver enzyme levels D. Increased serum calcium levels

B. Elevated serum and urine amylase, lipase, and liver enzyme levels accompany significant pancreatitis. If the common bile duct is obstructed, the bilirubin level is above normal. Blood glucose levels and white blood cell counts can be elevated. Serum electrolyte levels (calcium, potassium, and magnesium) are low.

A client has an elevated serum ammonia concentration and is exhibiting changes in mental status. The nurse should suspect which condition? A. Cirrhosis B. Hepatic encephalopathy C. Asterixis D. Portal hypertension

B. Hepatic encephalopathy is a central nervous system dysfunction resulting from liver disease. It is frequently associated with an elevated ammonia concentration that produces changes in mental status, altered level of consciousness, and coma. Portal hypertension is an elevated pressure in the portal circulation resulting from obstruction of venous flow into and through the liver. Asterixis is an involuntary flapping movement of the hands associated with metabolic liver dysfunction.

Which of the following would the nurse expect to assess in a conscious client with hepatic encephalopathy? A. Increased motor activity B. Asterixis C. Negative Babinski reflex D. Little desire to sleep

B. Hepatic encephalopathy is manifested by numerous central nervous system effects including disorientation, confusion, mood swings, reversed day-night sleep patterns with sleep occurring during the day, agitation, memory loss, a flapping tremor called asterixis, a positive Babinski reflex, sulfurous breath odor (referred to as fetor hepaticus), and lethargy. As hepatic encephalopathy becomes more severe, the client becomes stuporous and eventually comatose.

Following a liver biopsy to confirm hepatitis B, the nurse should position the client in which position? A) Left side-lying B) Right side-lying C) High-Fowler D) Prone lying

B. Hepatitis B is a virus that attacks the liver causing inflammation. Since it is a virus, it has flu-like symptoms including fatigue, muscle aches, fever, and headaches. Later in the disease process, symptoms are similar to liver failure because the inflammation can cause similar damage as cirrhosis of the liver. Later stage, severe symptoms of hepatitis B include abdominal pain, ascites, jaundice, esophageal varices, and bleeding tendencies. Abnormal laboratory results, including decreased albumin, decreased clotting factors, increased white blood cell level, increased ALT/AST, increased PTT, PT, and INR levels, and cholesterol associated labs occur as a result of liver failure. When hepatitis is suspected a positive HBsAg can confirm the suspicion. A liver biopsy may also be performed to examine the liver tissue and rule out other conditions, including cancer. Following a liver biopsy to confirm hepatitis B, the nurse should position the client in the right side-lying position to place pressure on the site and reduce the risk of hemorrhage.

A client discharged after a laparoscopic cholecystectomy calls the surgeon's office reporting severe right shoulder pain 24 hours after surgery. Which statement is the correct information for the nurse to provide to this client? A. This pain may be caused by a bile duct injury. You will need to go to the hospital immediately to have this evaluated. B. This pain is caused from the gas used to inflate your abdominal area during surgery. Sitting upright in a chair, walking, or using a heating pad may ease the discomfort. C. This pain is caused from your incision. Take analgesics as needed and as prescribed and report to the surgeon if pain is unrelieved even with analgesic use. D. This may be the initial symptoms of an infection. You need to come to see the surgeon today for an evaluation.

B. If pain occurs in the right shoulder or scapular area (from migration of the carbon dioxide used to insufflate the abdominal cavity during the procedure), the nurse may recommend using a heating pad for 15 to 20 minutes hourly, sitting up in a bed or chair, or walking.

A client with acute liver failure exhibits confusion, a declining level of consciousness, and slowed respirations. The nurse finds him very difficult to arouse. The diagnostic information which best explains the client's behavior is: A. elevated blood urea nitrogen and creatinine levels and hyperglycemia. B. subnormal serum glucose and elevated serum ammonia levels. C. subnormal clotting factors and platelet count. D. elevated liver enzymes and low serum protein level.

B. In acute liver failure, serum ammonia levels increase because the liver can't adequately detoxify the ammonia produced in the GI tract. In addition, serum glucose levels decline because the liver isn't capable of releasing stored glucose. Elevated serum ammonia and subnormal serum glucose levels depress the level of a client's consciousness. Elevated liver enzymes, low serum protein level, subnormal clotting factors and platelet count, elevated blood urea nitrogen and creatine levels, and hyperglycemia aren't as directly related to the client's level of consciousness.

A nurse is preparing a presentation for a local community group about hepatitis. Which of the following would the nurse include? A. Hepatitis A is frequently spread by sexual contact. B. Hepatitis C increases a person's risk for liver cancer. C. Hepatitis B is transmitted primarily by the oral-fecal route. D. Infection with hepatitis G is similar to hepatitis A.

B. Infection with hepatitis C increases the risk of a person developing hepatic (liver) cancer. Hepatitis A is transmitted primarily by the oral-fecal route; hepatitis B is frequently spread by sexual contact and infected blood. Hepatitis E is similar to hepatitis A whereas hepatitis G is similar to hepatitis C.

A nurse is teaching a client recovering from diabetic ketoacidosis (DKA) about management of sick days. The client asks the nurse why it is important to monitor the urine for ketones. Which statement is the nurse's best response? A. When the body does not have enough insulin, hyperglycemia occurs. Excess glucose is broken down by the liver, causing acidic byproducts to be released. B. Ketones accumulate in the blood and urine when fat breaks down in the absence of insulin. Ketones signal an insulin deficiency that will cause the body to start breaking down stored fat for energy. C. Excess glucose in the blood is metabolized by the liver and turned into ketones, which are an acid. D. Ketones are formed when insufficient insulin leads to cellular starvation. As cells rupture, they release these acids into the blood.

B. Ketones (or ketone bodies) are by-products of fat breakdown in the absence of insulin, and they accumulate in the blood and urine. Ketones in the urine signal an insulin deficiency and that control of type 1 diabetes is deteriorating. When almost no effective insulin is available, the body starts to break down stored fat for energy.

A client comes to the ED with severe abdominal pain, nausea, and vomiting. The physician plans to rule out acute pancreatitis. The nurse would expect the diagnosis to be confirmed by an elevated result on which laboratory test? A. Serum bilirubin B. Serum amylase C. Serum potassium D. Serum calcium

B. Serum amylase and lipase concentrations are used to make the diagnosis of acute pancreatitis. Serum amylase and lipase concentrations are elevated within 24 hours of the onset of symptoms. Serum amylase usually returns to normal within 48 to 72 hours, but the serum lipase concentration may remain elevated for a longer period, often days longer than amylase. Urinary amylase concentrations also become elevated and remain elevated longer than serum amylase concentrations.

A client with a tentative diagnosis of hyperosmolar hyperglycemic nonketotic syndrome (HHNS) has a history of type 2 diabetes that is being controlled with an oral diabetic agent, tolazamide. Which laboratory test is the most important for confirming this disorder? A. Arterial blood gas (ABG) values B. Serum osmolarity C. Serum potassium level D. Serum sodium level

B. Serum osmolarity is the most important test for confirming HHNS; it's also used to guide treatment strategies and determine evaluation criteria. A client with HHNS typically has a serum osmolarity of more than 350 mOsm/L. Serum potassium, serum sodium, and ABG values are also measured, but they aren't as important as serum osmolarity for confirming a diagnosis of HHNS. A client with HHNS typically has hypernatremia and osmotic diuresis. ABG values reveal acidosis, and the potassium level is variable.

A patient is administered cyclosporine (Sandimmune, Neoral) to prevent rejection of a kidney transplant. Which of the following is a major adverse effect of cyclosporine? A) Congestive heart failure B) Nephrotoxicity C) Anaphylaxis D) Respiratory arrest

B. The major adverse effect of cyclosporine is nephrotoxicity. Congestive heart failure is not noted as an adverse effect of cyclosporine. Anaphylaxis and respiratory arrest are not common adverse effects of cyclosporine.

A client with chronic pancreatitis has begun medication therapy with pancrelipase. The nurse evaluates that the medication is having the optimal intended benefit if which effect is observed? A) Weight loss B) Relief of heartburn C) Reduction of steatorrhea D) Absence of abdominal pain

C

The nurse is reviewing the lab results for a client with cirrhosis and notes that the ammonia level is high. Which dietary selection does the nurse suggest to the client? A) Roast pork B) Cheese omelet C) Pasta with sauce D) Tuna fish sandwich

C

The nurse is reviewing the record of a client with diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. How would the nurse assess for rits presence? A) Dorsiflex the client's foot B) Measure the abdominal girth C) Ask the client to extend the arms D) Instruct the client to lean forward

C

The nurse is caring for a client with cirrhosis. Which assessment findings indicate that the client has deficient vitamin K absorption caused by this hepatic disease? A. Dyspnea and fatigue B. Gynecomastia and testicular atrophy C. Purpura and petechiae D. Ascites and orthopnea

C. A hepatic disorder, such as cirrhosis, may disrupt the liver's normal use of vitamin K to produce prothrombin (a clotting factor). Consequently, the nurse should monitor the client for signs of bleeding, including purpura and petechiae. Dyspnea and fatigue suggest anemia. Ascites and orthopnea are unrelated to vitamin K absorption. Gynecomastia and testicular atrophy result from decreased estrogen metabolism by the diseased liver.

A client is being prepared to undergo laboratory and diagnostic testing to confirm the diagnosis of cirrhosis. Which test would the nurse expect to be used to provide definitive confirmation of the disorder? A. Magnetic resonance imaging B. Coagulation studies C. Liver biopsy D. Radioisotope liver scan

C. A liver biopsy which reveals hepatic fibrosis is the most conclusive diagnostic procedure. Coagulation studies provide information about liver function but do not definitively confirm the diagnosis of cirrhosis. Magnetic resonance imaging and radioisotope liver scan help to support the diagnosis but do not confirm it. These tests provide information about the liver enlarged size, nodular configuration, and distorted blood flow.

Ammonia, the major etiologic factor in the development of encephalopathy, inhibits neurotransmission. Increased levels of ammonia are damaging to the body. The largest source of ammonia is from: A. Severe infections and high fevers. B. Excessive diuresis and dehydration. C. The digestion of dietary and blood proteins. D. Excess potassium loss subsequent to prolonged use of diuretics.

C. Circumstances that increase serum ammonia levels tend to aggravate or precipitate hepatic encephalopathy. The largest source of ammonia is the enzymatic and bacterial digestion of dietary and blood proteins in the GI tract. Ammonia from these sources increases as a result of GI bleeding (i.e., bleeding esophageal varices, chronic GI bleeding), a high-protein diet, bacterial infection, or uremia.

The nurse is caring for a client just admitted to the intensive care unit for diabetic ketoacidosis (DKA). Which three priority treatments are critical during diabetic ketoacidosis? A) Potassium replacement, insulin replacement, amiodarone therapy B) Fluid replacement, bicarb replacement, hypertonic saline infusion C) Fluid replacement, insulin therapy, and electrolyte correction D) Oral rinses, fluid replacement, bicarb replacement

C. Diabetic ketoacidosis (DKA) is a very serious complication of diabetes mellitus. It occurs when ketones or blood acids increase in the bloodstream in response to elevated blood glucose levels and inadequate insulin. DKA can occur due to illness, infection, or insufficient insulin. The client with DKA has symptoms including extreme thirst, nausea, abdominal cramping, fruity (acetone) breath, frequent urination, and confusion. The blood glucose is extremely elevated and ketones are found in the blood and urine. The client has to be treated in the hospital and often in the ICU to address the metabolic acidosis. Priority treatments are fluid replacement, insulin therapy, and electrolyte correction.

A client with cirrhosis has a massive hemorrhage from esophageal varices. Balloon tamponade is used temporarily to control hemorrhage and stabilize the client. In planning care, the nurse gives the highest priority to which goal? A. Maintaining fluid volume B. Relieving the client's anxiety C. Maintaining the airway D. Controlling bleeding

C. Esophageal varices are almost always caused by portal hypertension, which results from obstruction of the portal circulation within the damaged liver. Maintaining the airway is the highest priority because oxygenation is essential for life. The airway can be compromised by possible displacement of the tube and the inflated balloon into the oropharynx, which can cause life-threatening obstruction of the airway and asphyxiation.

A client is positive for hepatitis A and asks the nurse how they contracted this. Which is associated with this hepatitis form? A) Being stuck with a dirty needle working as a RN B) Sexual promiscuity as a young adult C) Eating food from a restaurant where workers don't properly wash their hands D) Sharing a razor with a roommate

C. Hepatitis A is spread from contaminated food, water, or close contact with an infected individual. It is spread by fecal-oral routes. Hepatitis is a virus that resolves on its own in a few weeks to a couple of months. Symptoms are flu-like symptoms, including nausea, fatigue, abdominal discomfort, anorexia, and low-grade fever. Prevention of this highly contagious virus can occur through a Hepatitis A vaccination. Hepatitis B and C is most associated with blood exposure and through sexual contact with infected individuals.

The nurse is providing care to a patient with gross ascites who is maintaining a position of comfort in the high semi-Fowler's position. What is the nurse's priority assessment of this patient? A. Skin assessment related to increase in bile salts B. Urinary output related to increased sodium retention C. Respiratory assessment related to increased thoracic pressure D. Peripheral vascular assessment related to immobility

C. If a patient with ascites from liver dysfunction is hospitalized, nursing measures include assessment and documentation of intake and output (I&O;), abdominal girth, and daily weight to assess fluid status. The nurse also closely monitors the respiratory status because large volumes of ascites can compress the thoracic cavity and inhibit adequate lung expansion. The nurse monitors serum ammonia, creatinine, and electrolyte levels to assess electrolyte balance, response to therapy, and indications of encephalopathy.

A child is brought into the emergency department with vomiting, drowsiness, and blowing respirations. The child's parent reports that the symptoms have been progressing throughout the day. The nurse suspects diabetic ketoacidosis (DKA). Which action should the nurse take first in the management of DKA? A. Give prescribed antiemetics. B. Administer bicarbonate to correct acidosis. C. Begin fluid replacements. D. Administer prescribed dose of insulin.

C. Management of DKA is aimed at correcting dehydration, electrolyte loss, and acidosis before correcting the hyperglycemia with insulin.

The nurse caring for a client with pancreatitis assesses new ecchymoses on the client's flanks. How should the nurse report this finding and document it? A) Homan's sign B) Cullen's sign C) Turner's sign D) Kernig's sign

C. One of the clinical manifestations of pancreatitis is bruising (ecchymoses) that results from bloody exudate seeping out of the pancreas and underneath the skin. The location of the ecchymoses determines its name. Cullen's sign is bruising that appears around the umbilicus. Turner's sign, also called Grey Turner's sign, is found on the flanks.

A client with cirrhosis is prescribed oral lactulose for recent signs and symptoms of confusion, memory loss, slurred speech, and asterixis. What is the classification of the therapeutic agent given to the client? A) Diuretic B) Beta-blocker C) Laxative D) Alpha-adrenergic agonist

C. Osmotic laxatives draw water into the large intestine and stimulate peristalsis, resulting in a bowel movement. Lactulose is an osmotic laxative prescribed orally to cirrhosis clients to treat hepatic encephalopathy caused by an increased amount of ammonia in the body and excretes it through stool. In clients with cirrhosis, the liver is unable to filter excess ammonia which gets absorbed in the bloodstream causing hepatic encephalopathy. Ammonia in the bloodstream is toxic and can travel to the brain affecting cognition. Lactulose increases gastrointestinal (GI) motility and draws ammonia from the bloodstream and into the colon where it is removed from the body only through stool, not renal excretion in urine. Lactulose is not a diuretic, therefore does not decrease portal hypertension. Abdominal distension will not improve with the use of lactulose.

Which is a clinical manifestation of cholelithiasis? A. Abdominal pain in the upper left quadrant B. Non Palpable abdominal mass C. Clay-colored stools D. Epigastric distress before a meal

C. The client with gallstones has clay-colored stools and excruciating upper right quadrant pain that radiates to the back or right shoulder. The excretion of bile pigments by the kidneys makes urine very dark. The feces, no longer colored with bile pigments, are grayish (like putty) or clay colored. The client develops a fever and may have a palpable abdominal mass.

A nurse is caring for a client with cirrhosis. The nurse assesses the client at noon and discovers that the client is difficult to arouse and has an elevated serum ammonia level. The nurse should suspect which situation? A. The client is avoiding the nurse. B. The client didn't take his morning dose of lactulose (Cephulac). C. The client's hepatic function is decreasing. D. The client is relaxed and not in pain.

C. The decreased level of consciousness caused by an increased serum ammonia level indicates hepatic dysfunction. If the client didn't take his morning dose of lactulose, he wouldn't have elevated ammonia levels and decreased level of consciousness this soon. These assessment findings don't indicate that the client is relaxed or avoiding the nurse.

Clinical manifestations of common bile duct obstruction include all of the following except: A. Pruritus B. Clay-colored feces C. Light-colored urine D. Jaundice

C. The excretion of the bile pigments by the kidneys gives the urine a very dark color. The feces, no longer colored with bile pigments, are grayish, like putty, or clay-colored. The symptoms may be acute or chronic. Epigastric distress, such as fullness, abdominal distention, and vague pain in the right upper quadrant of the abdomen, may occur. If it goes untreated jaundice and pruritus can occur.

A client newly diagnosed with diabetes mellitus asks why he needs ketone testing when the disease affects his blood glucose levels. How should the nurse respond? A. The spleen releases ketones when your body can't use glucose. B. Ketones help the physician determine how serious your diabetes is. C. Ketones will tell us if your body is using other tissues for energy. D. Ketones can damage your kidneys and eyes.

C. The nurse should tell the client that ketones are a byproduct of fat metabolism and that ketone testing can determine whether the body is breaking down fat to use for energy. The spleen doesn't release ketones when the body can't use glucose. Although ketones can damage the eyes and kidneys and help the physician evaluate the severity of a client's diabetes, these responses by the nurse are incomplete.

A patient with severe chronic liver dysfunction comes to the clinic with bleeding of the gums and blood in the stool. What vitamin deficiency does the nurse suspect the patient may be experiencing? A. Riboflavin deficiency B. Folic acid deficiency C. Vitamin K deficiency D. Vitamin A deficiency

C. Vitamin A deficiency results in night blindness and eye and skin changes. Thiamine deficiency leads to beriberi, polyneuritis, and Wernicke-Korsakoff psychosis. Riboflavin deficiency results in characteristic skin and mucous membrane lesions. Pyridoxine deficiency results in skin and mucous membrane lesions and neurologic changes. Vitamin C deficiency results in the hemorrhagic lesions of scurvy. Vitamin K deficiency results in hypoprothrombinemia, characterized by spontaneous bleeding and ecchymoses. Folic acid deficiency results in macrocytic anemia.

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. A) Diarrhea B) Black, tarry stools C) Hyperactive bowel sounds D) Gray-blue color on the flank E) Abdominal guarding and tenderness F) LUQ pain with radiation to the back

D, E, F.

Which clinical manifestation is specific to a client diagnosed with hyperglycemic-hyperosmolar nonketotic syndrome (HHNS)? Select all that apply. A) Abdominal pain B) Ketones in urine C) pH <7.35 D) Confusion E) BG >675 mg/dL

D, E. Hyperglycemic-hyperosmolar nonketotic syndrome (HHNS) is an increased blood osmolarity state caused by hyperglycemia. The development of HHNS is related to residual insulin secretion. In HHNS, the client secretes just enough insulin to prevent ketosis, but not hyperglycemia. HHNS differs from DKA in that ketone levels are absent, the absence of acid/base imbalance, and the potassium level is within expected levels. The blood glucose will be greater than 600 mg/dL in the client with HHNS. The client with HHNS will develop neurological manifestations ranging from confusion to coma.

A patient with acute pancreatitis puts the call bell on to tell the nurse about an increase in pain. The nurse observes the patient guarding; the abdomen is board-like and no bowel sounds are detected. What is the major concern for this patient? A. The patient requires more pain medication. B. The patient is developing a paralytic ileus. C. The patient has developed renal failure. D. The patient has developed peritonitis.

D. Abdominal guarding is present. A rigid or board-like abdomen may develop and is generally an ominous sign, usually indicating peritonitis

The nurse is assisting the physician with a procedure to remove ascitic fluid from a client with cirrhosis. What procedure does the nurse ensure the client understands will be performed? A. Abdominal CT scan B. Thoracentesis C. Upper endoscopy D. Abdominal paracentesis

D. Abdominal paracentesis may be performed to remove ascitic fluid. Abdominal fluid is rapidly removed by careful introduction of a needle through the abdominal wall, allowing the fluid to drain. Fluid is removed from the lung via a thoracentesis. Fluid cannot be removed with an abdominal CT scan, but it can assist with placement of the needle. Fluid cannot be removed via an upper endoscopy.

The nurse is caring for a client with a biliary disorder who has an elevated amylase level. If this elevation correlates to dysfunction, which body process does the nurse recognize may be impaired? A. Protein digestion B. Protein synthesis C. Fat digestion D. Carbohydrate digestion

D. Amylase is a pancreatic enzyme involved in the breakdown and digestion of carbohydrates. Trypsin aids in the digestion of proteins. Lipase aids in the digestion of fats.

A 60-year-old client comes to the ED reporting weakness, vision problems, increased thirst, increased urination, and frequent infections that do not seem to heal easily. The physician suspects that the client has diabetes. Which classic symptom should the nurse watch for to confirm the diagnosis of diabetes? A. Fatigue B. Numbness C. Dizziness D. Increased hunger

D. Blood glucose needs to be monitored in clients receiving IV insulin because of the risk of hyperglycemia or hypoglycemia. Hypoglycemia might occur if too much insulin is administered. Hypokalemia, not hyperkalemia, might occur because I.V. insulin forces potassium into cells, thereby lowering the plasma level of potassium. Calcium and sodium levels aren't affected by IV insulin administration.

Which combination of adverse effects should a nurse monitor for when administering IV insulin to a client with diabetic ketoacidosis? A. Hyperkalemia and hyperglycemia B. Hypocalcemia and hyperkalemia C. Hypernatremia and hypercalcemia D. Hypokalemia and hypoglycemia

D. Blood glucose needs to be monitored in clients receiving IV insulin because of the risk of hyperglycemia or hypoglycemia. Hypoglycemia might occur if too much insulin is administered. Hypokalemia, not hyperkalemia, might occur because I.V. insulin forces potassium into cells, thereby lowering the plasma level of potassium. Calcium and sodium levels aren't affected by IV insulin administration.

A nurse is caring for a client receiving treatment for hepatic encephalopathy. The client is administered lactulose. How will the nurse evaluate the effectiveness of the medication? A) The client has 2-3 BM per day B) The client has 2-3 BM per week C) The client is awake but has memory loss D) The client is awake and speaking

D. Clients with hepatic encephalopathy will have decreased cognitive function due to an increase in toxic ammonia in the bloodstream caused by a dysfunctional liver. A dysfunctional or cirrhotic liver creates excess ammonia that travels to the brain and causes confusion, memory loss, slurred speech, and asterixis. Clients with hepatic encephalopathy are prescribed oral lactulose to draw excess ammonia from the bloodstream. Lactulose is an osmotic laxative prescribed orally to cirrhosis clients to treat hepatic encephalopathy caused by an increased amount of ammonia in the body. Lactulose draws ammonia from the bloodstream and into the colon where it is removed from the body. Ammonia decreases only through the stool, not urine. The presence of stools is not an indication of the effectiveness of lactulose on mental status. Nurses must evaluate the effectiveness of lactulose for the treatment of hepatic encephalopathy, which is seen as an improved mental status in the client.

While caring for a client diagnosed with Type I diabetes mellitus, what is the most identified cause of the development of diabetic ketoacidosis (DKA)? A) Decrease in fluid intake B) Change in exercise pattern C) Increased carb intake D) Presence of infection

D. Diabetic ketoacidosis (DKA) is most common among patients with type 1 diabetes mellitus. It develops when insulin levels are insufficient to meet the body's basic metabolic requirements. The presentation of DKA most often occurs from the presence of an acute infection. The presence of an acute infection increases hyperglycemia as a response to the infection. This increased hyperglycemia causes a need for increased insulin. When this need is not met, DKA can develop.

Which is the most common cause of esophageal varices? A. Ascites B. Asterixis C. Jaundice D. Portal hypertension

D. Esophageal varices are almost always caused by portal hypertension, which results from obstruction of the portal circulation within the damaged liver. Jaundice occurs when the bilirubin concentration in the blood is abnormally elevated. Ascites results from circulatory changes within the diseased liver. Asterixis is an involuntary flapping movement of the hands associated with metabolic liver dysfunction.

A client is admitted with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which laboratory finding should the nurse expect in this client? A. Arterial pH 7.25 B. Plasma bicarbonate 12 mEq/L C. Blood urea nitrogen (BUN) 15 mg/dl D. Blood glucose level 1,100 mg/dl

D. HHNS occurs most frequently in older clients. It can occur in clients with either type 1 or type 2 diabetes mellitus but occurs most commonly in those with type 2. The blood glucose level rises to above 600 mg/dl in response to illness or infection. As the blood glucose level rises, the body attempts to rid itself of the excess glucose by producing urine. Initially, the client produces large quantities of urine. If fluid intake isn't increased at this time, the client becomes dehydrated, causing BUN levels to rise. Arterial pH and plasma bicarbonate levels typically remain within normal limits.

When performing a physical examination on a client with cirrhosis, a nurse notices that the client's abdomen is enlarged. Which of the following interventions should the nurse consider? A. Provide the client with non prescription laxatives. B. Report the condition to the physician immediately. C. Ask the client about food intake. D. Measure abdominal girth according to a set routine.

D. If the abdomen appears enlarged, the nurse measures it according to a set routine. The nurse reports any change in mental status or signs of gastrointestinal bleeding immediately. It is not essential for the client to take laxatives unless prescribed. The client's food intake does not affect the size of the abdomen in case of cirrhosis.

A client with liver cirrhosis is prescribed lactulose. What is an additional function of the administered medication? A) Increases sodium through urination B) Decreases potassium loss in urine C) Increased lactate through stool D) Decreases ammonia through stool

D. In clients with cirrhosis, the liver is unable to filter excess ammonia which gets absorbed in the bloodstream causing hepatic encephalopathy. Ammonia in the bloodstream is toxic and can travel to the brain affecting cognition. Lactulose is an osmotic laxative prescribed orally to cirrhosis clients to treat hepatic encephalopathy caused by an increased amount of ammonia in the body. Lactulose draws ammonia from the bloodstream and into the colon where it is removed from the body. Ammonia decreases only through the stool, not urine.

A client with cirrhosis has portal hypertension, which is causing esophageal varices. What is the goal of the interventions that the nurse will provide? A. Treat the esophageal varices. B. Promote optimal neurologic function. C. Cure the cirrhosis. D. Reduce fluid accumulation and venous pressure.

D. Methods of treating portal hypertension aim to reduce fluid accumulation and venous pressure. There is no cure for cirrhosis; treating the esophageal varices is only a small portion of the overall objective. Promoting optimal neurologic function will not reduce portal hypertension.

Which of the following agents that act on the lower gastrointestinal (GI) tract acts to increase gut motility and decrease ammonia levels in the body? A) Docusate sodium B) Bisacodyl C) Loperamide D) Lactulose

D. Osmotic laxatives draw water into the large intestine and stimulate peristalsis, resulting in a bowel movement. Lactulose is an osmotic laxative prescribed orally to cirrhosis clients to treat hepatic encephalopathy caused by an increased amount of ammonia in the body. In clients with cirrhosis, the liver is unable to filter excess ammonia which gets absorbed in the bloodstream causing hepatic encephalopathy. Ammonia in the bloodstream is toxic and can travel to the brain affecting cognition. Lactulose increases gastrointestinal (GI) motility and draws ammonia from the bloodstream and into the colon where it is removed from the body.

Which clinical manifestation is expected upon initial assessment of a client with acute pancreatitis? A) Ascites B) Hypovolemic shock C) Constipation D) LUQ pain

D. The focus of this question is asking the nurse to identify an expected assessment finding in a client with acute pancreatitis. The pancreas is located in the left upper abdominal quadrant so reports of left upper quadrant pain are very characteristic of acute pancreatitis. Additional symptoms of acute pancreatitis include fever, nausea and vomiting.

The nurse is preparing to interview a client with cirrhosis. Based on an understanding of this disorder, which question would be most important to include? A. What type of over-the-counter pain reliever do you use? B. Does your work expose you to chemicals? C. Have you had an infection recently? D. How often do you drink alcohol?

D. The most common type of cirrhosis results from chronic alcohol intake and is frequently associated with poor nutrition. Although it can follow chronic poisoning with chemicals or ingestion of hepatotoxic drugs such as acetaminophen, asking about alcohol intake would be most important. Asking about an infection or exposure to hepatotoxins or industrial chemicals would be important if the client had postnecrotic cirrhosis.

A client with a history of alcohol abuse comes to the emergency department and complains of abdominal pain. Laboratory studies help confirm a diagnosis of acute pancreatitis. The client's vital signs are stable, but the client's pain is worsening and radiating to his back. Which intervention takes priority for this client? A. Placing the client in a semi-Fowler's position B. Providing mouth care C. Maintaining nothing-by-mouth (NPO) status D. Administering morphine I.V. as ordered

D. The nurse should address the client's pain issues first by administering morphine I.V. as ordered. Placing the client in a Semi-Fowler's position, maintaining NPO status, and providing mouth care don't take priority over addressing the client's pain issues.

Which instruction should a nurse give to a client with diabetes mellitus when teaching about sick day rules? A. Follow your regular meal plan, even if you're nauseous. B. It's okay for your blood glucose to go above 300 mg/dl while you're sick. C. Don't take your insulin or oral antidiabetic agent if you don't eat. D. Test your blood glucose every 4 hours.

D. The nurse should instruct a client with diabetes mellitus to check his blood glucose levels every 3 to 4 hours and take insulin or an oral antidiabetic agent as usual, even when he's sick. If the client's blood glucose level rises above 300 mg/dl, he should call his physician immediately. If the client is unable to follow the regular meal plan because of nausea, he should substitute soft foods, such as gelatin, soup, and custard.

Total parenteral nutrition (TPN) should be used cautiously in clients with pancreatitis because such clients: A. are at risk for hepatic encephalopathy. B. are at risk for gallbladder contraction. C. can digest high-fat foods. D. cannot tolerate high-glucose concentration.

D. Total parenteral nutrition (TPN) is used carefully in clients with pancreatitis because some clients cannot tolerate a high-glucose concentration even with insulin coverage. Intake of coffee increases the risk for gallbladder contraction, whereas intake of high protein increases risk for hepatic encephalopathy in clients with cirrhosis. Patients with pancreatitis should not be given high-fat foods because they are difficult to digest. with Total parenteral nutrition (TPN) should be used cautiously in clients with pancreatitis because such clients: A. are at risk for hepatic encephalopathy. B. are at risk for gallbladder contraction. C. can digest high-fat foods. D. cannot tolerate high-glucose concentration.

A client with chronic pancreatitis is treated for uncontrolled pain. Which complication does the nurse recognize is most common in the client with chronic pancreatitis? A. Hypertension B. Diarrhea C. Fatigue D. Weight loss

D. Weight loss is most common in the client with chronic pancreatitis due to decreased dietary intake secondary to anorexia or fear that eating will precipitate another attack. The other answer choices are not the most common complications related to chronic pancreatitis.