Exam 3 Practice Questions (ATI)
A nurse assesses clients at a community health fair. Which client is at greatest risk for the development of hepatitis B? a. A 20-year-old college student who has had several sexual partners b. A 46-year-old woman who takes acetaminophen daily for headaches c. A 63-year-old businessman who travels frequently across the country d. An 82-year-old woman who recently ate raw shellfish for dinner
A Hepatitis B can be spread through sexual contact, needle sharing, needle sticks, blood transfusions, hemodialysis, acupuncture, and the maternal-fetal route. A person with multiple sexual partners has more opportunities to contract the infection. Hepatitis B is not transmitted through medications, casual contact with other travelers, or raw shellfish. Although an overdose of acetaminophen can cause liver cirrhosis, this is not associated with hepatitis B. Hepatitis E is found most frequently in international travelers. Hepatitis A is spread through ingestion of contaminated shellfish.
A patient is taking bumetanide (Bumex) and spironolactone (Aldactone). You should explain that using the drugs together may reduce the risk of which of the following adverse effects? A) Hypokalemia B) Hyponatremia C) Hyperglycemia D) Hypochloremia
A) Hypokalemia Spironolactone, a potassium-sparing diuretic, causes retention of potassium. This reduces the risk of hypokalemia due to potassium loss from bumetanide, a high-ceiling loop diuretic. Using the two drugs together will not affect sodium, glucose, or chloride levels. Hyperglycemia, hyponatremia, and hypochloremia remain risks with the use of bumetanide. Hyponatremia remains a risk with the use of spironolactone.
A client previously diagnosed with liver cirrhosis visits the medical clinic. What assessment findings does the nurse expect in this client? Select all that apply. A. Ecchymosis B. Soft abdomen C. Moist, clammy skin D. Jaundice E. Ankle edema F. Fever
A, D, E Clients with advanced cirrhosis often have symptoms such as gastrointestinal (GI) bleeding, jaundice, ascites, and spontaneous bruising. They may also have dry skin, rashes, purpuric lesions (e.g., petechiae), warm and bright red palms of the hands, vascular lesions (spider angiomas), and peripheral dependent edema of the extremities and sacrum.
Which statement by a client with cirrhosis indicates that further instruction is needed about the disease? A) "Cirrhosis is a chronic disease that has scarred my liver." B) "The scars on my liver create problems with blood circulation." C) "Because of the scars on my liver, blood clotting and blood pressure are affected." D) "My liver is scarred, but the cells can regenerate themselves and repair the damage."
D Although cells and tissues will attempt to regenerate, this will result in permanent scarring and irreparable damage. Cirrhosis is a chronic condition that leaves scars on the liver. Permanent scars form in response to attempts by the cells to regenerate and create problems in blood circulation moving through the liver. Liver scarring will create problems with blood clotting, cholesterol levels, and blood pressure, as well as with the metabolism of drugs and toxins.
What client problem has a priority for the client diagnosed with acute pancreatitis? A. Risk for fluid volume deficient B. Alteration in comfort C. Imbalanced nutrition: less than the boy requires D. Knowledge deficient
D Bedrest decreases the metabolic rate. The client should be NPO to rest the pancreas to decrease the auto digestion of the pancreas. Since the client is NPO IV therapy is appropriate. Weight changes will happen as a result of diet and IV fluids therefore daily weights is appropriate.
A nurse delegates hygiene care for a client who has advanced cirrhosis to an unlicensed nursing personnel (UAP). Which statements should the nurse include when delegating this task to the UAP? (Select all that apply.) a. Apply lotion to the clients dry skin areas. b. Use a basin with warm water to bathe the client. c. For the clients oral care, use a soft toothbrush. d. Provide clippers so the client can trim the fingernails. e. Bathe with antibacterial and water-based soaps.
A, C, D Clients with advanced cirrhosis often have pruritus. Lotion will help decrease itchiness from dry skin. A soft toothbrush should be used to prevent gum bleeding, and the clients nails should be trimmed short to prevent the client from scratching himself or herself. These clients should use cool, not warm, water on their skin, and should not use excessive amounts of soap.
An infection control nurse develops a plan to decrease the number of health care professionals who contract viral hepatitis at work. Which ideas should the nurse include in this plan? (Select all that apply.) a. Policies related to consistent use of Standard Precautions b. Hepatitis vaccination mandate for workers in high-risk areas c. Implementation of a needleless system for intravenous therapy d. Number of sharps used in client care reduced where possible e. Postexposure prophylaxis provided in a timely manner
A, C, D, E Nurses should always use Standard Precautions for client care, and policies should reflect this. Needleless systems and reduction of sharps can help prevent hepatitis. Postexposure prophylaxis should be provided immediately. All health care workers should receive the hepatitis vaccinations that are available.
A nurse cares for a client who has chronic cirrhosis from substance abuse. The client states, All of my family hates me. How should the nurse respond? a. You should make peace with your family. b. This is not unusual. My family hates me too. c. I will help you identify a support system. d. You must attend Alcoholics Anonymous.
C Clients who have chronic cirrhosis may have alienated relatives over the years because of substance abuse. The nurse should assist the client to identify a friend, neighbor, or person in his or her recovery group for support. The nurse should not minimize the clients concerns by brushing off the clients comment. Attending AA may be appropriate, but this response doesnt address the clients concern. Making peace with the clients family may not be possible. This statement is not client-centered.
A nurse is assessing a client who has pancreatitis. Which of the following actions should the nurse take to assess the presence of Cullen's sign. A. Tap lightly at the costovertebral margin on the client's back B. Palpate the RLQ C. Inspect the skin around the umbilicus D. Auscultate the area below the scapula
C Cullen's sign is indicated by a bluish-gray discoloration in the periumbilical area.
A nurse assesses a client who is recovering from a paracentesis 1 hour ago. Which assessment finding requires action by the nurse? a. Urine output via indwelling urinary catheter is 20 mL/hr b. Blood pressure increases from 110/58 to 120/62 mm Hg c. Respiratory rate decreases from 18 to 14 breaths/min d. A decrease in the clients weight by 6 kg
A Rapid removal of ascetic fluid causes decreased abdominal pressure, which can contribute to hypovolemia. This can be manifested by a decrease in urine output to below 30 mL/hr. A slight increase in systolic blood pressure is insignificant. A decrease in respiratory rate indicates that breathing has been made easier by the procedure. The nurse would expect the clients weight to drop as fluid is removed. Six kilograms is less than 3 pounds and is expected.
When caring for a client with hepatic encephalopathy, in which situation does the nurse question the use of neomycin (Mycifradin)? A. Kidney failure B. Refractory ascites C. Fetor hepaticus D. Paracentesis scheduled for today
A The aminoglycoside drugs, which include neomycin, are nephrotoxic and ototoxic, and should not be taken by the client with hepatic encephalopathy. Cirrhosis and hepatic failure cause both ascites and encephalopathy; no contraindication for neomycin is known. Fetor hepaticus causes an ammonia smell to the breath when serum ammonia levels are elevated; neomycin is used to decrease serum ammonia levels. The client may be NPO for a few hours before paracentesis, but may take neomycin when the procedure is complete, or with less than 30 mL of water, depending on hospital policy.
A nurse cares for a client with hepatopulmonary syndrome who is experiencing dyspnea with oxygen saturations at 92%. The client states, I do not want to wear the oxygen because it causes my nose to bleed. Get out of my room and leave me alone! Which action should the nurse take? a. Instruct the client to sit in as upright a position as possible. b. Add humidity to the oxygen and encourage the client to wear it. c. Document the clients refusal, and call the health care provider. d. Contact the provider to request an extra dose of the clients diuretic.
A The client with hepatopulmonary syndrome is often dyspneic. Because the oxygen saturation is not significantly low, the nurse should first allow the client to sit upright to see if that helps. If the client remains dyspneic, or if the oxygen saturation drops further, the nurse should investigate adding humidity to the oxygen and seeing whether the client will tolerate that. The other two options may be beneficial, but they are not the best choices. If the client is comfortable, his or her agitation will decrease; this will improve respiratory status.
Which intervention will the nurse include in the plan of care for a client with severe liver disease? A. Encourage the client to eat a low-protein, high-carbohydrate diet. B. Administer Kayexalate enemas. C. Encourage the client to eat a high-protein, low-carbohydrate diet. D. Participate in frequent, vigorous physical activities.
A The client with severe liver disease should eat a diet high in carbohydrates and calories with moderate amounts of fat and protein. Kayexalate enemas and frequent, vigorous physical activities should be avoided.
A nurse cares for a client who is prescribed lactulose (Heptalac). The client states, I do not want to take this medication because it causes diarrhea. How should the nurse respond? a. Diarrhea is expected; thats how your body gets rid of ammonia. b. You may take Kaopectate liquid daily for loose stools. c. Do not take any more of the medication until your stools firm up. d. We will need to send a stool specimen to the laboratory.
A The purpose of administering lactulose to this client is to help ammonia leave the circulatory system through the colon. Lactulose draws water into the bowel with its high osmotic gradient, thereby producing a laxative effect and subsequently evacuating ammonia from the bowel. The client must understand that this is an expected and therapeutic effect for him or her to remain compliant. The nurse should not suggest administering anything that would decrease the excretion of ammonia or holding the medication. There is no need to send a stool specimen to the laboratory because diarrhea is the therapeutic response to this medication.
A nurse teaches a client with hepatitis C who is prescribed ribavirin (Copegus). Which statement should the nurse include in this clients discharge education? a. Use a pill organizer to ensure you take this medication as prescribed. b. Transient muscle aching is a common side effect of this medication. c. Follow up with your provider in 1 week to test your blood for toxicity. d. Take your radial pulse for 1 minute prior to taking this medication.
A Treatment of hepatitis C with ribavirin takes up to 48 weeks, making compliance a serious issue. The nurse should work with the client on a strategy to remain compliant for this length of time. Muscle aching is not a common side effect. The client will be on this medication for many weeks and does not need a blood toxicity examination. There is no need for the client to assess his or her radial pulse prior to taking the medication.
A nurse is completing nutritional teaching for a client who has pancreatitis. Which of the following statements by the client indicates an understanding of the teaching? (SATA) A. I plan to eat small, frequent meals. B. I will eat easy-to-digest foods with limited spice C. I will use skim milk when cooking D. I plan to drink regular cola E. I will limit alcohol intake to two drinks per day
A, B, C Patients with pancreatitis should eat small, frequent, easy to digest, low-fat meals. The patient should avoid alcohol and caffeinated beverages.
A nurse is caring for a client who has cirrhosis. Which of thefollowing medications can the nurse expect to administer to this client? (Select all that apply.) A.Diuretic B.Beta‑blocking agent C. Opioid analgesic D. Lactulose E.Sedative
A, B, D Diuretics facilitate excretion of excessfluid from the body in a client who has cirrhosis. Beta‑blocking agents are prescribed for a client. Lactulose is prescribed for a client who hascirrhosis to aid in the elimination of ammonia in the stool.
A nurse is teaching a client whohas hepatitis B about home care.Which of the following instructionsshould the nurse include in theteaching? (Select all that apply.) A. Limit physical activity B. Avoid alcohol. C. Take acetaminophen for comfort. D. Wear a mask when in public places. E. Eat small frequent meals
A, B, E Limiting physical activity and takingfrequent rest breaks conserves energy and assists in therecovery process for a client who has hepatitis B. Alcohol is metabolized in the liver andshould be avoided by the client who has hepatitis B. The client who has hepatitis B should eat small frequentmeals to promote improved nutrition due to the presence of anorexia.
A nurse assesses a male client who has symptoms of cirrhosis. Which questions should the nurse ask to identify potential factors contributing to this laboratory result? (Select all that apply.) a. How frequently do you drink alcohol? b. Have you ever had sex with a man? c. Do you have a family history of cancer? d. Have you ever worked as a plumber? e. Were you previously incarcerated?
A, B, E When assessing a client with suspected cirrhosis, the nurse should ask about alcohol consumption, including amount and frequency; sexual history and orientation (specifically men having sex with men); illicit drug use; history of tattoos; and history of military service, incarceration, or work as a firefighter, police officer, or health care provider. A family history of cancer and work as a plumber do not put the client at risk for cirrhosis.
A nurse plans care for a client who has hepatopulmonary syndrome. Which interventions should the nurse include in this clients plan of care? (Select all that apply.) a. Oxygen therapy b. Prone position c. Feet elevated on pillows d. Daily weights e. Physical therapy
A, C, D Care for a client who has hepatopulmonary syndrome should include oxygen therapy, the head of bed elevated at least 30 degrees or as high as the client wants to improve breathing, elevated feet to decrease dependent edema, and daily weights. There is no need to place the client in a prone position, on the clients stomach. Although physical therapy may be helpful to a client who has been hospitalized for several days, physical therapy is not an intervention specifically for hepatopulmonary syndrome.
Nursing management of the patient with acute pancreatitis includes: (SATA) A. Check for signs of hypocalcemia B. Provide a diet low in carbohydrates C. Giving insulin based on sliding scale D. Observing stools for signs of steatorrhea E. Monitoring for infection, particularly respiratory tract infection
A, E During the acute phase, it is important to monitor vital signs. Hemodynamic stability may be compromised by hypotension, fever, and tachypnea. Injection fluids are ordered, and the response to therapy is monitored. Fluid and electrolyte balances are closely monitored. Frequent vomiting, along with gastric suction, may result in decreased levels of chloride, sodium, and potassium. Because hypocalcemia can occur in acute pancreatitis, the nurse should observe for symptoms of tetany, such as jerking, irritability, and muscular twitching. Numbness or tingling around the lips and in the fingers is an early indicator of hypocalcemia. The patient should be assessed for Chvostek's sign or Trousseau's sign. A patient with acute pancreatitis should be observed for fever and other manifestations of infection. Respiratory infections are common because the retroperitoneal fluid raises the diaphragm, which causes the patient to take shallow, guarded abdominal breaths.
A nurse cares for a client with hepatic portal-systemic encephalopathy (PSE). The client is thin and cachectic in appearance, and the family expresses distress that the client is receiving little dietary protein. How should the nurse respond? a. A low-protein diet will help the liver rest and will restore liver function. b. Less protein in the diet will help prevent confusion associated with liver failure. c. Increasing dietary protein will help the client gain weight and muscle mass. d. Low dietary protein is needed to prevent fluid from leaking into the abdomen.
B A low-protein diet is ordered when serum ammonia levels increase and/or the client shows signs of PSE. A low-protein diet helps reduce excessive breakdown of protein into ammonia by intestinal bacteria. Encephalopathy is caused by excess ammonia. A low-protein diet has no impact on restoring liver function. Increasing the clients dietary protein will cause complications of liver failure and should not be suggested. Increased intravascular protein will help prevent ascites, but clients with liver failure are not able to effectively synthesize dietary protein.
A nurse cares for a client who has cirrhosis of the liver. Which action should the nurse take to decrease the presence of ascites? a. Monitor intake and output. b. Provide a low-sodium diet. c. Increase oral fluid intake. d. Weigh the client daily.
B A low-sodium diet is one means of controlling abdominal fluid collection. Monitoring intake and output does not control fluid accumulation, nor does weighing the client. These interventions merely assess or monitor the situation. Increasing fluid intake would not be helpful
The nurse is caring for a 55-yr-old man patient with acute pancreatitis resulting from gallstones. Which clinical manifestation would the nurse expect? A) Hematochezia B) Left upper abdominal pain C) Ascites and peripheral edema D) Temperature over 102 F
B Abdominal pain (usually in the left upper quadrant) is the predominant manifestation of acute pancreatitis. Other manifestations of acute pancreatitis include nausea and vomiting, low-grade fever, leukocytosis, hypotension, tachycardia, and jaundice. Abdominal tenderness with muscle guarding is common. Bowel sounds may be decreased or absent. Ileus may occur and causes marked abdominal distention. Areas of cyanosis or greenish to yellow-brown discoloration of the abdominal wall may occur. Other areas of ecchymoses are the flanks (Grey Turner's spots or sign, a bluish flank discoloration) and the periumbilical area (Cullen's sign, a bluish periumbilical discoloration).
A nurse obtains a clients health history at a community health clinic. Which statement alerts the nurse to provide health teaching to this client? a. I drink two glasses of red wine each week. b. I take a lot of Tylenol for my arthritis pain. c. I have a cousin who died of liver cancer. d. I got a hepatitis vaccine before traveling.
B Acetaminophen (Tylenol) can cause liver damage if taken in large amounts. Clients should be taught not to exceed 4000 mg/day of acetaminophen. The nurse should teach the client about this limitation and should explore other drug options with the client to manage his or her arthritis pain. Two glasses of wine each week, a cousin with liver cancer, and the hepatitis vaccine do not place the client at risk for a liver disorder, and therefore do not require any health teaching.
A nurse cares for a client with hepatitis C. The clients brother states, I do not want to contract this infection, so I will not go into his hospital room. How should the nurse respond? a. If you wear a gown and gloves, you will not get this virus. b. Viral hepatitis is not spread through casual contact. c. This virus is only transmitted through a fecal specimen. d. I can give you an update on your brothers status from here.
B Although family members may be afraid that they will contract hepatitis C, the nurse should educate the clients family about how the virus is spread. Viral hepatitis, or hepatitis C, is spread via blood-to-blood transmission and is associated with illicit IV drug needle sharing, blood and organ transplantation, accidental needle sticks, unsanitary tattoo equipment, and sharing of intranasal cocaine paraphernalia. Wearing a gown and gloves will not decrease the transmission of this virus. Hepatitis C is not spread through casual contact or a fecal specimen. The nurse would be violating privacy laws by sharing the clients status with the brother.
After teaching a client who has alcohol-induced cirrhosis, a nurse assesses the clients understanding. Which statement made by the client indicates a need for additional teaching? a. I cannot drink any alcohol at all anymore. b. I need to avoid protein in my diet. c. I should not take over-the-counter medications. d. I should eat small, frequent, balanced meals.
B Based on the degree of liver involvement and decreased function, protein intake may have to be decreased. However, some protein is necessary for the synthesis of albumin and normal healing. The other statements indicate accurate understanding of self-care measures for this client.
In caring for a client who has undergone paracentesis, which changes in the client's status should be promptly reported to the provider? A. Increased blood pressure, increased respiratory rate B. Decreased blood pressure, increased heart rate C. Increased respiratory rate, increased apical pulse, pallor D. Tachypnea, diaphoresis, increased blood pressure
B Decreased blood pressure and increased heart rate are indicative of shock. Increased blood pressure, increased respiratory rate, increased apical pulse, pallor, tachypnea, and diaphoresis are all indicative of anxiety on the client's part.
A telehealth nurse speaks with a client who is recovering from a liver transplant 2 weeks ago. The client states, I am experiencing right flank pain and have a temperature of 101 F. How should the nurse respond? a. The anti-rejection drugs you are taking make you susceptible to infection. b. You should go to the hospital immediately to have your new liver checked out. c. You should take an additional dose of cyclosporine today. d. Take acetaminophen (Tylenol) every 4 hours until you feel better.
B Fever, right quadrant or flank pain, and jaundice are signs of liver transplant rejection; the client should be admitted to the hospital as soon as possible for intervention. Anti-rejection drugs do make a client more susceptible to infection, but this client has signs of rejection, not infection. The nurse should not advise the client to take an additional dose of cyclosporine or acetaminophen as these medications will not treat the acute rejection.
A nurse cares for a client who is scheduled for a paracentesis. Which intervention should the nurse delegate to an unlicensed assistive personnel (UAP)? a. Have the client sign the informed consent form. b. Assist the client to void before the procedure. c. Help the client lie flat in bed on the right side. d. Get the client into a chair after the procedure.
B For safety, the client should void just before a paracentesis. The nurse or the provider should have the client sign the consent form. The proper position for a paracentesis is sitting upright in bed or, alternatively, sitting on the side of the bed and leaning over the bedside table. The client will be on bedrest after the procedure.
The client diagnosed with acute pancreatitis is being discharged home. What statement by the client indicates the teaching has been effective? A. I should decrease my intake of coffee, tea, and cola B. I will eat a low fate diet and avoid spicy food C. I will check my amylase and lipase levels daily D. I will return to work tomorrow but take it easy
B High fat and spicy foods stimulate pancreatic enzymes. Caffeinated beverages should be avoided not decreased. There are no daily tests the client can take at home. The client will be fatigued as a result as a lowered metabolic rate and will need to rest.
A patient with sudden pain in the left upper quadrant radiating to the back and vomiting was diagnosed with acute pancreatitis. Which intervention should the nurse include in the patient's plan of care? A) Immediately start enteral feeding to prevent malnutrition. B) Insert an NG and maintain NPO status to allow pancreas to rest. C) Initiate early prophylactic antibiotic therapy to prevent infection. D) Administer acetaminophen (Tylenol) every 4 hours for pain relief.
B Initial treatment with acute pancreatitis will include an NG tube if there is vomiting and being NPO to decrease pancreatic enzyme stimulation and allow the pancreas to rest and heal. Fluid will be administered to treat or prevent shock. The pain will be treated with IV morphine because of the NPO status. Enteral feedings will only be used for the patient with severe acute pancreatitis in whom oral intake is not resumed. Antibiotic therapy is only needed with acute necrotizing pancreatitis and signs of infection.
The nurse is caring for clients in the outpatient clinic. Which of these phone calls should the nurse return first? A. Client with hepatitis A reporting severe and ongoing itching B. Client with severe ascites who has a temperature of 101.4° F (38° C) C. Client with cirrhosis who has had a 3-pound weight gain over 2 days D. Client with esophageal varices and mild right upper quadrant pain
B The client with ascites and an elevated temperature may have spontaneous bacterial peritonitis; the nurse should call this client first. Itching is anticipated with jaundice, this client may be called last. Weight gain with cirrhosis is not uncommon owing to low albumin levels. Cirrhosis may cause mild right upper quadrant pain; this client should be called after the client with severe ascites.
An emergency room nurse assesses a client after a motor vehicle crash. The nurse notices a steering wheel mark across the clients chest. Which action should the nurse take? a. Ask the client where in the car he or she was sitting during the crash. b. Assess the client by gently palpating the abdomen for tenderness. c. Notify the laboratory to draw blood for blood type and crossmatch. d. Place the client on the stretcher in reverse Trendelenburg position.
B The liver is often injured by a steering wheel in a motor vehicle crash. Because the clients chest was marked by the steering wheel, the nurse should perform an abdominal assessment. Assessing the clients position in the crash is not needed because of the steering wheel imprint. The client may or may not need a blood transfusion. The client does not need to be in reverse Trendelenburg position.
After teaching a client who has been diagnosed with hepatitis A, the nurse assesses the clients understanding. Which statement by the client indicates a correct understanding of the teaching? a. Some medications have been known to cause hepatitis A. b. I may have been exposed when we ate shrimp last weekend. c. I was infected with hepatitis A through a recent blood transfusion. d. My infection with Epstein-Barr virus can co-infect me with hepatitis A.
B The route of acquisition of hepatitis A infection is through close personal contact or ingestion of contaminated water or shellfish. Hepatitis A is not transmitted through medications, blood transfusions, or Epstein-Barr virus. Toxic and drug-induced hepatitis is caused from exposure to hepatotoxins, but this is not a form of hepatitis A. Hepatitis B can be spread through blood transfusions. Epstein-Barr virus causes a secondary infection that is not associated with hepatitis A.
A nurse is assessing a client who has advanced cirrhosis. The nurseshould identify which of the following findings as indicators of hepatic encephalopathy?(Select all that apply.) A.Anorexia B.Change in orientation C.Asterixis D.Ascites E.Fetor hepaticus
B, C, E A change in orientation indicates hepaticencephalopathy in a client who has advanced cirrhosis. Asterixis, a coarse tremor of the wristsand fingers, is observed as a late complication in a client who has cirrhosis and hepatic encephalopathy. Fetor hepaticus, a fruity breath odor, is a finding of hepatic encephalopathy in the client who has advanced cirrhosis
An emergency room nurse assesses a client with potential liver trauma. Which clinical manifestations should alert the nurse to internal bleeding and hypovolemic shock? (Select all that apply.) a. Hypertension b. Tachycardia c. Flushed skin d. Confusion e. Shallow respirations
B, D Symptoms of hemorrhage and hypovolemic shock include hypotension, tachycardia, tachypnea, pallor, diaphoresis, cool and clammy skin, and confusion.
A nurse assesses a client who has liver disease. Which laboratory findings should the nurse recognize as potentially causing complications of this disorder? (Select all that apply.) a. Elevated aspartate transaminase b. Elevated international normalized ratio (INR) c. Decreased serum globulin levels d. Decreased serum alkaline phosphatase e. Elevated serum ammonia f. Elevated prothrombin time (PT)
B, E, F Elevated INR and PT are indications of clotting disturbances and alert the nurse to the increased possibility of hemorrhage. Elevated ammonia levels increase the clients confusion. The other values are abnormal and associated with liver disease but do not necessarily place the client at increased risk for complications.
A nurse is caring for a client whohas a new diagnosis of hepatitis C.Which of the following laboratoryfindings should the nurse expect? A. Presence of immunoglobulinG antibodies (IgG) B. Presence of enzymeimmunoassay (EIA) C. Aspartate aminotransferase(AST) 35 units/L D.Alanine aminotransferase(ALT) 15 IU/L
B. The presence of EIA is an expected laboratoryfinding in a client who has a new diagnosis of hepatitis C.
The nurse administers lactulose (Evalose) to a client with cirrhosis for which purpose? A. Provides enzymes necessary to digest dairy products B. Reduces portal pressure C. Promotes gastrointestinal (GI) excretion of ammonia D. Decreases GI bleeding
C Lactulose reduces serum ammonia levels by excreting ammonia through the GI tract. Lactase is the enzyme that digests dairy products. The mechanism of action of lactulose is not to reduce portal pressure. Lactulose does not affect bleeding.
Which problem for a client with cirrhosis takes priority? A. Insufficient knowledge related to the prognosis of the disease process B. Discomfort related to the progression of the disease process C. Potential for injury related to hemorrhage D. Inadequate nutrition related to an inability to tolerate usual dietary intake
C Potential for injury related to hemorrhage is the priority client problem because this complication could be life-threatening. Insufficient knowledge, discomfort, and inadequate nutrition are not priorities because these issues are not immediately life-threatening.
The client is admitted to the medical department with a diagnosis of R/O acute pancreatitis. What laboratory values should the nurse monitor to confirm this diagnosis? A. Creatinine and BUN B. Troponin and CK-MB C. Serum amylase and lipase D. Serum bilirubin and calcium
C Serum amylase levels increase within two to 12 hours of the onset of acute pancreatitis; lipase elevates and remains elevated for seven to 14 days
After teaching a client who has plans to travel to a non-industrialized country, the nurse assesses the clients understanding regarding the prevention of viral hepatitis. Which statement made by the client indicates a need for additional teaching? a. I should drink bottled water during my travels. b. I will not eat off anothers plate or share utensils. c. I should eat plenty of fresh fruits and vegetables. d. I will wash my hands frequently and thoroughly.
C The client should be advised to avoid fresh, raw fruits and vegetables because they can be contaminated by tap water. Drinking bottled water, and not sharing plates, glasses, or eating utensils are good ways to prevent illness, as is careful handwashing.
The client diagnosed with acute pancreatitis is in pain. Which position should the nurse assist the client to assume to help decrease the pain? A. Recommend lying in the prone position with legs extended B. Maintain a tripod position over the bedside table C. Plance in side-lying position with knees flexed D. Encourage a supine position with a pillow under the knees
C The fetal position deceases pain caused by the stretching of the peritoneum as a result of edema. The pancreas is located abdomen. Anything that causes the abdomen to be stretched will increase pain.
A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for the development of carcinoma of the liver? a. A 22-year-old with a history of blunt liver trauma b. A 48-year-old with a history of diabetes mellitus c. A 66-year-old who has a history of cirrhosis d. An 82-year-old who has chronic malnutrition
C The risk of contracting a primary carcinoma of the liver is higher in clients with cirrhosis from any cause. Blunt liver trauma, diabetes mellitus, and chronic malnutrition do not increase a persons risk for developing liver cancer.
A nurse is completing an admission assessment of a client who has pancreatitis. Which of the following findings should the nurse expect? A. Pain in the UQ rating to the shoulder B. Report of pain being worse when sitting upright C. Pain relieved with defecation D. Epigastric pain radiating to the left shoulder
D A client with pancreatitis will report pain being worse when lying down in the fetal position, and pain that radiates to the back. left flank, or left, shoulder.
The nurse is completing discharge teaching to the client diagnosed with acute pancreatitis. What instruction should the nurse discuss with the client? A. Instruct the importance to avoid all stress B. Explain the correct way to take pancreatic enzymes C. Instruct the client to decrease alcohol intake D. Discuss the importance of stopping smoking
D Alcohol must be avoided completely due to its destruction of the pancreas. Stress stimulates the liver, but it is unrational to avoid all stress. Pancreatic enzymes are only needed for chronic pancreatitis. Smoking stimulates the pancreas to release pancreatic enzymes.
When providing discharge teaching to a client with cirrhosis, it is essential for the nurse to emphasize avoidance of which of these? A. Vitamin K-containing products B. Potassium-sparing diuretics C. Non-absorbable antibiotics D. Non-steroidal anti-inflammatory drugs (NSAIDs)
D Clients who have cirrhosis should not take NSAIDs because they may predispose to bleeding. The client with cirrhosis is prone to bleeding; vitamin K can decrease bleeding, so it is not necessary to restrict this in the diet. Potassium-sparing diuretics are used to reduce ascites. Non-absorbable antibiotics are used to decrease ammonia levels.
How does the home care nurse best modify the client's home environment to manage side effects of lactulose (Evalose)? A. Provides small frequent meals for the client B. Suggests taking daily potassium supplements C. Elevates the head of the bed in high-Fowler's position D. Requests a bedside commode for the client
D Lactulose therapy increases the frequency of stools, so a bedside commode should be made available to the client, especially if he or she has difficulty reaching the toilet. Small frequent meals and elevating the head of the bed will not have any effect on the side effects of lactulose. Although lactulose produces excessive stools and could potentially result in loss of potassium, it is inappropriate for the nurse to suggest that the client take potassium supplements.
A nurse cares for a client who is hemorrhaging from bleeding esophageal varices and has an esophagogastric tube. Which action should the nurse take first? a. Sedate the client to prevent tube dislodgement. b. Maintain balloon pressure at 15 and 20 mm Hg. c. Irrigate the gastric lumen with normal saline. d. Assess the client for airway patency.
D Maintaining airway patency is the primary nursing intervention for this client. The nurse suctions oral secretions to prevent aspiration and occlusion of the airway. The client usually is intubated and mechanically ventilated during this treatment. The client should be sedated, balloon pressure should be maintained between 15 and 20 mm Hg, and the lumen can be irrigated with saline or tap water. However, these are not a higher priority than airway patency.
A nurse assesses a client who is prescribed an infusion of vasopressin (Pitressin) for bleeding esophageal varices. Which clinical manifestation should alert the nurse to a serious adverse effect? a. Nausea and vomiting b. Frontal headache c. Vertigo and syncope d. Mid-sternal chest pain
D Mid-sternal chest pain is indicative of acute angina or myocardial infarction, which can be precipitated by vasopressin. Nausea and vomiting, headache, and vertigo and syncope are not side effects of vasopressin.
The nurse is providing teaching for a client scheduled for a paracentesis. Which statement by the client indicates the teaching has been successful? A. "I must not use the bathroom prior to the procedure." B. "I will lie on my stomach while the procedure is performed." C. "I will not be allowed to eat or drink anything the night before surgery." D. "The physician will likely remove 2 to 3 liters of fluid from my abdomen."
D The client should void before the procedure to prevent injury to the bladder. The client will lie in bed with the head of the bed elevated during the procedure.
A nurse is completing the admission assessment of a client who has acute pancreatitis. Which finding is the first priority? A) History of cholelithiasis B) Elevated serum amylase levels C) Decrease in bowel sounds upon auscultation D) Hand spasms present when blood pressure is checked
D The greatest risk to the client is ECG changes and hypotension from hypocalcemia. Hand spasms when taking blood pressure is a manifestation of hypocalcemia
A nurse on a medical‑surgical unit is admitting a client who has hepatitis B with ascites. Which of the following actions should the nurse include in the plan of care? A.Initiate contact precautions. B.Weigh the client weekly. C.Measure abdominal girth 7.5 cm (3 in) abovethe umbilicus. D.Provide a high‑calorie, high‑carbohydrate diet.
D. The client who has hepatitis B shouldhave a diet high in calories and carbohydrates.