Hepatobiliary System
a. Asterixis and lethargy
A 23-year-old has been admitted with acute liver failure. Which assessment data are most important for the nurse to communicate to the health care provider? a. Asterixis and lethargy b. Jaundiced sclera and skin c. Elevated total bilirubin level d. Liver 3 cm below costal margin
d. anti-hepatitis A virus immunoglobulin M (anti-HAV IgM).
A 24-year-old female contracts hepatitis from contaminated food. During the acute (icteric) phase of the patient's illness, the nurse would expect serologic testing to reveal a. antibody to hepatitis D (anti-HDV). b. hepatitis B surface antigen (HBsAg). c. anti-hepatitis A virus immunoglobulin G (anti-HAV IgG). d. anti-hepatitis A virus immunoglobulin M (anti-HAV IgM).
b. Serum potassium level 6.5 mEq/L
A 25-year-old male patient has been admitted with a severe crushing injury after an industrial accident. Which laboratory result will be most important to report to the health care provider? a. Serum creatinine level 2.1 mg/dL b. Serum potassium level 6.5 mEq/L c. White blood cell count 11,500/μL d. Blood urea nitrogen (BUN) 56 mg/dL
C) Hepatitis C
A 33-year-old male patient with a history of IV heroin and cocaine use has been admitted to the medical unit for the treatment of endocarditis. The nurse should recognize that this patient is also likely to test positive for which of the following hepatitis viruses? A) Hepatitis A B) Hepatitis B C) Hepatitis C D) Hepatitis D
C. Document the findings
The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750 ml of green-brown drainage since the surgery. Which nursing intervention is most appropriate? A. Clamp the T-tube B. Irrigate the T-tube C. Document the findings D. Notify the HCP
b. Pegylated α-interferon (PEG-Intron, Pegasys) SQ daily
A 34-year old patient with chronic hepatitis C infection has several medications prescribed. Which medication requires further discussion with the health care provider before administration? a. Ribavirin (Rebetol, Copegus) 600 mg PO bid b. Pegylated α-interferon (PEG-Intron, Pegasys) SQ daily c. Diphenhydramine (Benadryl) 25 mg PO every 4 hours PRN itching d. Dimenhydrinate (Dramamine) 50 mg PO every 6 hours PRN nausea
b. Positive urine pregnancy test
A 36-year-old female patient is receiving treatment for chronic hepatitis C with pegylated interferon (PEG-Intron, Pegasys), ribavirin (Rebetol), and telaprevir (Incivek). Which finding is most important to communicate to the health care provider? a. Weight loss of 2 lb (1 kg) b. Positive urine pregnancy test c. Hemoglobin level of 10.4 g/dL d. Complaints of nausea and anorexia
a. Schedule the patient for HCV genotype testing.
A 36-year-old male patient in the outpatient clinic is diagnosed with acute hepatitis C (HCV) infection. Which action by the nurse is appropriate? a. Schedule the patient for HCV genotype testing. b. Administer the HCV vaccine and immune globulin. c. Teach the patient about ribavirin (Rebetol) treatment. d. Explain that the infection will resolve over a few months.
c. Glomerular filtration rate (GFR)
A 37-year-old female patient is hospitalized with acute kidney injury (AKI). Which information will be most useful to the nurse in evaluating improvement in kidney function? a. Urine volume b. Creatinine level c. Glomerular filtration rate (GFR) d. Blood urea nitrogen (BUN) level
A) Pancreatitis with possible peritonitis
A 37-year-old male patient presents at the emergency department complaining of nausea and vomiting and severe abdominal pain. While the nurse is assessing the patient, the patient's wife informs the nurse that the patient ingested 24 ounces of vodka last evening. The patient's abdomen is rigid, and there is bruising to the patient's flank. What is the patient exhibiting signs of? A) Pancreatitis with possible peritonitis B) Acute cholecystitis C) Obstruction of the bowel D) Acute appendicitis
b. There is a nontender axillary lump.
A 38-year-old patient who had a kidney transplant 8 years ago is receiving the immunosuppressants tacrolimus (Prograf), cyclosporine (Sandimmune), and prednisone (Deltasone). Which assessment data will be of most concern to the nurse? a. The blood glucose is 144 mg/dL. b. There is a nontender axillary lump. c. The patient's skin is thin and fragile. d. The patient's blood pressure is 150/92.
c. Place the patient on a pressure-relieving mattress.
A 38-year-old patient with cirrhosis has ascites and 4+ edema of the feet and legs. Which nursing action will be included in the plan of care? a. Restrict daily dietary protein intake. b. Reposition the patient every 4 hours. c. Place the patient on a pressure-relieving mattress. d. Perform passive range of motion daily.
A) Maintaining meticulous hand hygiene and infection control
A 40-year-old woman who had fulminant liver failure received a liver transplant 36 hours ago and is now receiving care in the intensive care unit. Which of the following aspects of nursing care addresses one of the major threats to this patient's health at this time? A) Maintaining meticulous hand hygiene and infection control B) Providing total parenteral nutrition (TPN) C) Monitoring the patient closely for signs of skin breakdown D) Providing empathic emotional support to the patient and her family
b. Place the patient on a cardiac monitor.
A 42-year-old patient admitted with acute kidney injury due to dehydration has oliguria, anemia, and hyperkalemia. Which prescribed actions should the nurse take first? a. Insert a urinary retention catheter. b. Place the patient on a cardiac monitor. c. Administer epoetin alfa (Epogen, Procrit). d. Give sodium polystyrene sulfonate (Kayexalate).
D) Prior to this current illness, the woman was likely in good health.
A 42-year-old woman was diagnosed with herpes simplex and underwent treatment. However, the woman has been admitted through the emergency department (ED) with signs and symptoms of fulminant liver failure. The nurse in the ED should recognize which of the following characteristics of this patient and her health history? A) The woman has likely been infected with hepatitis C without her knowledge. B) IV drug use or unsafe sexual practices likely contributed to her liver disease. C) Alcohol use has likely contributed to the course of the woman's illness. D) Prior to this current illness, the woman was likely in good health.
b. Ibuprofen (Advil) 400 mg PO PRN for pain
A 48-year-old patient with stage 2 chronic kidney disease (CKD) is scheduled for an intravenous pyelogram (IVP). Which order for the patient will the nurse question? a. NPO for 6 hours before procedure b. Ibuprofen (Advil) 400 mg PO PRN for pain c. Dulcolax suppository 4 hours before procedure d. Normal saline 500 mL IV infused before procedure
c. Stools test negative for occult blood.
A 49-year-old female patient with cirrhosis and esophageal varices has a new prescription for propranolol (Inderal). Which finding is the best indicator that the medication has been effective? a. The patient reports no chest pain. b. Blood pressure is 140/90 mm Hg. c. Stools test negative for occult blood. d. The apical pulse rate is 68 beats/minute.
B) Low-sodium diet and administration of diuretics
A 49-year-old man with a history of heavy alcohol use and liver cirrhosis has been admitted to the hospital's medical unit due to an exacerbation of his health problems that has resulted in massive ascites. The nurse should be prepared to implement which of the following interventions in an effort to resolve the patient's ascites? A) High Fowler's positioning and fluid restriction B) Low-sodium diet and administration of diuretics C) Peritoneal massage and administration of hypertonic IV solutions D) Low-protein diet and administration of IV albumin
b. "Tell me more about what you are thinking regarding dialysis."
A 74-year-old who is progressing to stage 5 chronic kidney disease asks the nurse, "Do you think I should go on dialysis? Which initial response by the nurse is best? a. "It depends on which type of dialysis you are considering." b. "Tell me more about what you are thinking regarding dialysis." c. "You are the only one who can make the decision about dialysis." d. "Many people your age use dialysis and have a good quality of life."
d. Albumin level
Which data will the nurse monitor in relation to the 4+ pitting edema assessed in a patient with cirrhosis? a. Hemoglobin b. Temperature c. Activity level d. Albumin level
C) The previous nurse should have administered the lactulose because it is necessary to remove excess ammonia.
A 50-year-old woman has a long history of hospital admissions related to alcohol abuse and consequent liver failure. During this present admission, the patient has been diagnosed with hepatic encephalopathy and prescribed lactulose (Cephulac). During morning report, the nurse learns that the previous nurse withheld the patient's latest dose of lactulose because the patient had two loose bowel movements during the shift. How should the nurse interpret the previous nurse's action? A) The previous nurse acted correctly because loose bowel movements present a threat to the patient's fluid and electrolyte balance. B) The previous nurse should have obtained an order for a stool softener to replace the scheduled lactulose. C) The previous nurse should have administered the lactulose because it is necessary to remove excess ammonia. D) The previous nurse should have administered a partial dose of the lactulose in spite of the patient's bowel movements.
d. turn, cough, and deep breathe every 2 hours.
A 51-year-old woman had an incisional cholecystectomy 6 hours ago. The nurse will place the highest priority on assisting the patient to a. choose low-fat foods from the menu. b. perform leg exercises hourly while awake. c. ambulate the evening of the operative day. d. turn, cough, and deep breathe every 2 hours.
b. Monitor the patient for shortness of breath.
A 53-year-old patient is being treated for bleeding esophageal varices with balloon tamponade. Which nursing action will be included in the plan of care? a. Instruct the patient to cough every hour. b. Monitor the patient for shortness of breath. c. Verify the position of the balloon every 4 hours. d. Deflate the gastric balloon if the patient reports nausea.
D) Pancreatic enzymes digest the pancreas.
A 55-year-old man with acute pancreatitis is being admitted. How can the critical care nurse best describe acute pancreatitis to the patient's family? A) Toxic substances inflame the pancreas. B) The patient abuses alcohol. C) Viruses digest the pancreas. D) Pancreatic enzymes digest the pancreas.
b. "Do you use any over-the-counter drugs?"
A 55-year-old patient admitted with an abrupt onset of jaundice and nausea has abnormal liver function studies but serologic testing is negative for viral causes of hepatitis. Which question by the nurse is most appropriate? a. "Is there any history of IV drug use?" b. "Do you use any over-the-counter drugs?" c. "Are you taking corticosteroids for any reason?" d. "Have you recently traveled to a foreign country?"
c. Hemoglobin level 13 g/dL
A 55-year-old patient with end-stage kidney disease (ESKD) is scheduled to receive a prescribed dose of epoetin alfa (Procrit). Which information should the nurse report to the health care provider before giving the medication? a. Creatinine 1.6 mg/dL b. Oxygen saturation 89% c. Hemoglobin level 13 g/dL d. Blood pressure 98/56 mm Hg
C) Liver transplantation
A 59-year-old male patient was diagnosed with cirrhosis several years ago. After years of successful management of his chronic disease, he experienced a constellation of symptoms that eventually resulted in a diagnosis of hepatocellular carcinoma (HCC). What treatment holds the greatest potential for curing this patient's health problem? A) Hepatic lobectomy B) Radiotherapy C) Liver transplantation D) Laser ablation
B) Bile duct injury
A 59-year-old woman with a recent history of gallstones had a laparoscopic cholecystectomy performed this morning and has just been admitted to the postsurgical unit from the PACU. The nurse who will be providing this patient's immediate care should prioritize assessments that are related to what complication of a laparoscopic cholecystectomy? A) Paralytic ileus B) Bile duct injury C) Hyperbilirubinemia D) Sepsis
A) Daily weights and abdominal girth measurements
A 60-year-old man is receiving care for cirrhosis on a medical unit. The nurse who is planning his care recognizes the risks of fluid imbalances that accompany this health problem. Scheduled assessments of this patient's fluid balance should include: A) Daily weights and abdominal girth measurements B) Asking the patient to track his food intake and estimated sodium intake C) Assessing the patient's skin turgor and skin tone each morning D) Frequent blood pressure (BP) monitoring and sputum analysis
b. Urine output over an 8-hour period is 2500 mL.
A 62-year-old female patient has been hospitalized for 8 days with acute kidney injury (AKI) caused by dehydration. Which information will be most important for the nurse to report to the health care provider? a. The creatinine level is 3.0 mg/dL. b. Urine output over an 8-hour period is 2500 mL. c. The blood urea nitrogen (BUN) level is 67 mg/dL. d. The glomerular filtration rate is <30 mL/ min/1.73m2.
A) Patient will remain on bed rest and remain free of the complications of immobility.
A 62-year-old woman was admitted to the hospital yesterday evening with a diagnosis of cirrhosis. When planning the woman's care, what desired outcome should the nurse identify? A) Patient will remain on bed rest and remain free of the complications of immobility. B) Patient will resume normal activity levels within 72 hours of admission. C) Patient will express an understanding of the importance of early ambulation. D) Patient will become independent with activities of daily living by day 5 of admission.
c. More protein is allowed because urea and creatinine are removed by dialysis.
A 64-year-old male patient who has had progressive chronic kidney disease (CKD) for several years has just begun regular hemodialysis. Which information about diet will the nurse include in patient teaching? a. Increased calories are needed because glucose is lost during hemodialysis. b. Unlimited fluids are allowed because retained fluid is removed during dialysis. c. More protein is allowed because urea and creatinine are removed by dialysis. d. Dietary potassium is not restricted because the level is normalized by dialysis.
d. Abdominal pain is decreased.
A 67-year-old male patient with acute pancreatitis has a nasogastric (NG) tube to suction and is NPO. Which information obtained by the nurse indicates that these therapies have been effective? a. Bowel sounds are present. b. Grey Turner sign resolves. c. Electrolyte levels are normal. d. Abdominal pain is decreased.
a. Insert urethral catheter.
A 72-year-old patient with a history of benign prostatic hyperplasia (BPH) is admitted with acute urinary retention and elevated blood urea nitrogen (BUN) and creatinine levels. Which prescribed therapy should the nurse implement first? a. Insert urethral catheter. b. Obtain renal ultrasound. c. Draw a complete blood count. d. Infuse normal saline at 50 mL/hour.
D. Gray-blue color at the flank E. Abdominal guarding and tenderness F. Left upper quadrant pain with radiation to the back.
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 at the flank E. Abdominal guarding and tenderness F. Left upper quadrant pain with radiation to the back.
A. Malaise
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. Left upper quadrant discomfort
B. Increase intake of fluids, including juice
A client is diagnosed with viral hepatitis, complaining of "no appetite" and "losing my taste for food". What instruction should the nurse give the client to provide adequate nutrition? A. Select foods high in fat B. Increase intake of fluids, including juice C. Eat a good supper when anorexia is not as severe D. Eat less often, preferably only 3 large meals daily
b. The patient's peritoneal effluent appears cloudy.
A female patient with chronic kidney disease (CKD) is receiving peritoneal dialysis with 2 L inflows. Which information should the nurse report immediately to the health care provider? a. The patient has an outflow volume of 1800 mL. b. The patient's peritoneal effluent appears cloudy. c. The patient has abdominal pain during the inflow phase. d. The patient's abdomen appears bloated after the inflow.
c. The LPN/LVN administers the iron supplement and phosphate binder with lunch.
A licensed practical/vocational nurse (LPN/LVN) is caring for a patient with stage 2 chronic kidney disease. Which observation by the RN requires an intervention? a. The LPN/LVN administers the erythropoietin subcutaneously. b. The LPN/LVN assists the patient to ambulate out in the hallway. c. The LPN/LVN administers the iron supplement and phosphate binder with lunch. d. The LPN/LVN carries a tray containing low-protein foods into the patient's room
C) Dietary changes and pharmacological treatment
A man presented to his primary caregiver with complaints of nausea and vomiting and was referred to the emergency department (ED), where he was diagnosed with cholecystitis. The ED nurse should be aware that the preferred intervention for this patient's health problem is: A) Laparoscopic cholecystectomy B) Open cholecystectomy C) Dietary changes and pharmacological treatment D) Creation of a temporary ostomy and supportive care
C. Sodium
A nurse is caring for a patient diagnosed with ascites. What would the nurse expect to be restricted from the patient's diet? A. Potassium B. Calcium C. Sodium D. Magnesium
d. Patient who requires pain management for chronic pancreatitis
A nurse is considering which patient to admit to the same room as a patient who had a liver transplant 3 weeks ago and is now hospitalized with acute rejection. Which patient would be the best choice? a. Patient who is receiving chemotherapy for liver cancer b. Patient who is receiving treatment for acute hepatitis C c. Patient who has a wound infection after cholecystectomy d. Patient who requires pain management for chronic pancreatitis
A) Sodium and water retention B) A damaged liver D) Increased lymphatic flow
A nurse is performing health education with the family member of a patient who has ascites. The nurse should be cognizant of which physiologic processes that cause ascites? Select all that apply. A) Sodium and water retention B) A damaged liver C) Insufficient renal flow D) Increased lymphatic flow E) Decreased synthesis of immunoglobulin G
c. Ask whether the patient has been screened for hepatitis C
A patient born in 1955 had hepatitis A infection 1 year ago. According to Centers for Disease Control and Prevention (CDC) guidelines, which action should the nurse include in care when the patient is seen for a routine annual physical exam? a. Start the hepatitis B immunization series. b. Teach the patient about hepatitis A immune globulin. c. Ask whether the patient has been screened for hepatitis C. d. Test for anti-hepatitis-A virus immune globulin M (anti-HAV-IgM).
d. infuse a bolus of normal saline.
A patient complains of leg cramps during hemodialysis. The nurse should first a. massage the patient's legs. b. reposition the patient supine. c. give acetaminophen (Tylenol). d. infuse a bolus of normal saline.
B. Ammonia
A patient diagnosed with hepatic encephalopathy is receiving lactulose. When preparing to administer this medication, the nurse understands that it is used to decrease which serum level? A. Calcium B. Ammonia C. Potassium D. Sodium
b. Check blood pressure before starting dialysis.
A patient has arrived for a scheduled hemodialysis session. Which nursing action is most appropriate for the registered nurse (RN) to delegate to a dialysis technician? a. Teach the patient about fluid restrictions. b. Check blood pressure before starting dialysis. c. Assess for causes of an increase in predialysis weight. d. Determine the ultrafiltration rate for the hemodialysis.
A) Risk for bleeding related to complications of liver failure
A patient has been admitted to the critical care unit from the subacute medical unit because his signs and symptoms of liver failure have become more pronounced over the past 24 hours. The critical care nurse who is planning this patient's care should prioritize which of the following nursing diagnoses? A) Risk for bleeding related to complications of liver failure B) Knowledge deficit related to the causes of liver failure C) Bowel incontinence related to treatments for liver failure D) Risk for impaired gas exchange related to complications of liver failure
A) White blood cells (WBCs) C) Amylase D) Lipase
A patient has been admitted to the intensive care unit with a diagnosis of acute pancreatitis. Which of the following laboratory values will the nurse prioritize when gauging the course of his disease? Select all that apply. A) White blood cells (WBCs) B) Creatinine kinase C) Amylase D) Lipase E) Ammonia
A. MR/CT B. Abdominal ultrasound E. Amylase and Lipase
A patient is being seen in the clinic to rule out pancreatitis. The nurse expects which diagnostic test will be performed to diagnose this disease process? Select all that apply. A. MR/CT B. Abdominal ultrasound C. Lumbar puncture D. Endoscopy E. Amylase and Lipase
C) Bleeding esophageal varices
A patient is brought to the emergency department by ambulance. He has hematemesis and alteration in mental status. The patient has tachycardia, cool clammy skin, and hypotension. The patient has a history of alcohol abuse. What would the nurse suspect the patient has? A) Hemolytic jaundice B) Hepatic insufficiency C) Bleeding esophageal varices D) Portal hypertension
D) Bile duct injury
A patient returns to the floor after a laparoscopic cholecystectomy. The nurse caring for the patient is aware that the most serious potential complication is what? A) Pulmonary atelectasis B) Decubitus ulcer C) Wound evisceration D) Bile duct injury
C) Rigidity of the abdomen
A patient who had surgery for gallbladder disease has just returned to the unit. The nurse caring for this patient knows to immediately report what assessment finding to the primary 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
c. Cardiac rhythm
A patient who has acute glomerulonephritis is hospitalized with hyperkalemia. Which information will the nurse monitor to evaluate the effectiveness of the prescribed calcium gluconate IV? a. Urine volume b. Calcium level c. Cardiac rhythm d. Neurologic status
C) The patient will take immunosuppressive agents as required.
A patient who has undergone liver transplantation is ready to be discharged home. The nurse is providing discharge teaching. Which topic will the nurse emphasize most related to discharge teaching? A) The patient will obtain measurement of drainage from the T-tube. B) The patient will exercise three times a week. C) The patient will take immunosuppressive agents as required. D) The patient will monitor for signs of liver dysfunction.
a. A fistula is much less likely to clot.
A patient will need vascular access for hemodialysis. Which statement by the nurse accurately describes an advantage of a fistula over a graft? a. A fistula is much less likely to clot. b. A fistula increases patient mobility. c. A fistula can accommodate larger needles. d. A fistula can be used sooner after surgery.
c. Check the medical record for most recent potassium level.
A patient with acute kidney injury (AKI) has longer QRS intervals on the electrocardiogram (ECG) than were noted on the previous shift. Which action should the nurse take first? a. Notify the patient's health care provider. b. Document the QRS interval measurement. c. Check the medical record for most recent potassium level. d. Check the chart for the patient's current creatinine level.
c. serum creatinine.
A patient with diabetes who has bacterial pneumonia is being treated with IV gentamicin (Garamycin) 60 mg IV BID. The nurse will monitor for adverse effects of the medication by evaluating the patient's a. blood glucose. b. urine osmolality. c. serum creatinine. d. serum potassium.
D. Fecal-oral
A patient with hepatitis A is admitted to a general medical- surgical floor. The nurse knows that this type of hepatitis is spread through which mode of transmission? A. Injection of drugs B. Blood C. Semen D. Fecal-oral
C) Ascites
A patient with portal hypertension has been admitted to the medical floor. What will the nurse assess for related to portal hypertension? A) Bowel obstruction B) Vitamin A deficiency C) Ascites D) Hepatic encephalopathy
b. Administer the spironolactone.
A serum potassium level of 3.2 mEq/L (3.2 mmol/L) is reported for a patient with cirrhosis who has scheduled doses of spironolactone (Aldactone) and furosemide (Lasix). due. Which action should the nurse take? a. Administer both drugs. b. Administer the spironolactone. c. Withhold the spironolactone and administer the furosemide. d. Withhold both drugs until discussed with the health care provider.
b. anti-HBs.
Administration of hepatitis B vaccine to a healthy 18-year-old patient has been effective when a specimen of the patient's blood reveals a. HBsAg. b. anti-HBs. c. anti-HBc IgG. d. anti-HBc IgM.
a. Administer hepatitis B vaccine. b. Test for antibodies to hepatitis B. d. Give hepatitis B immune globulin.
After an unimmunized individual is exposed to hepatitis B through a needle-stick injury, which actions will the nurse plan to take (select all that apply)? a. Administer hepatitis B vaccine. b. Test for antibodies to hepatitis B. c. Teach about α-interferon therapy. d. Give hepatitis B immune globulin. e. Teach about choices for oral antiviral therapy.
d. Patient who has just returned from having hemodialysis and has a heart rate of 124/ min
After receiving change-of-shift report, which patient should the nurse assess first? a. Patient who is scheduled for the drain phase of a peritoneal dialysis exchange b. Patient with stage 4 chronic kidney disease who has an elevated phosphate level c. Patient with stage 5 chronic kidney disease who has a potassium level of 3.4 mEq/L d. Patient who has just returned from having hemodialysis and has a heart rate of 124/ min
c. Report the patient's symptoms to the health care provider.
After the insertion of an arteriovenous graft (AVG) in the right forearm, a 54-year-old patient complains of pain and coldness of the right fingers. Which action should the nurse take? a. Teach the patient about normal AVG function. b. Remind the patient to take a daily low- dose aspirin tablet. c. Report the patient's symptoms to the health care provider. d. Elevate the patient's arm on pillows to above the heart level.
c. serum phosphate.
Before administration of calcium carbonate (Caltrate) to a patient with chronic kidney disease (CKD), the nurse should check laboratory results for a. potassium level. b. total cholesterol. c. serum phosphate. d. serum creatinine.
b. potassium.
Before administration of captopril (Capoten) to a patient with stage 2 chronic kidney disease (CKD), the nurse will check the patient's a. glucose. b. potassium. c. creatinine. d. phosphate.
d. Fewer episodes of bleeding varices
Which finding indicates to the nurse that a patient's transjugular intrahepatic portosystemic shunt (TIPS) placed 3 months ago has been effective? a. Increased serum albumin level b. Decreased indirect bilirubin level c. Improved alertness and orientation d. Fewer episodes of bleeding varices
a. The patient is alert and oriented.
Which finding indicates to the nurse that lactulose (Cephulac) is effective for a 72-year-old man who has advanced cirrhosis? a. The patient is alert and oriented. b. The patient denies nausea or anorexia. c. The patient's bilirubin level decreases. d. The patient has at least one stool daily.
c. 55-year-old with cirrhosis and ascites who has an oral temperature of 102° F (38.8° C)
During change-of-shift report, the nurse learns about the following four patients. Which patient requires assessment first? a. 40-year-old with chronic pancreatitis who has gnawing abdominal pain b. 58-year-old who has compensated cirrhosis and is complaining of anorexia c. 55-year-old with cirrhosis and ascites who has an oral temperature of 102° F (38.8° C) d. 36-year-old recovering from a laparoscopic cholecystectomy who has severe shoulder pain
b. Check patient's blood pressure (BP).
During routine hemodialysis, the 68-year-old patient complains of nausea and dizziness. Which action should the nurse take first? a. Slow down the rate of dialysis. b. Check patient's blood pressure (BP). c. Review the hematocrit (Hct) level. d. Give prescribed PRN antiemetic drugs.
b. Providing oral hygiene after a meal
For a patient with cirrhosis, which of the following nursing actions can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP)? a. Assessing the patient for jaundice b. Providing oral hygiene after a meal c. Palpating the abdomen for distention d. Assisting the patient to choose the diet
c. 3
In reviewing the medical record shown in the accompanying figure for a patient admitted with acute pancreatitis, the nurse sees that the patient has a positive Cullen's sign. Indicate the area where the nurse will assess for this change. a. 1 b. 2 c. 3 d. 4
C. "I'm glad I don't have to lie still for this procedure
The nurse has taught the client about an upcoming endoscopic retrograde cholangiopancreatography (ERCP) procedure. The nurse determines that the client needs further information if the client makes which statement? A. "I know I must sign the consent form" B. "I hope the throat spray keeps me from gagging" C. "I'm glad I don't have to lie still for this procedure D. "I'm glad some intravenous medication will be given to relax me"
C) Risk for ineffective management of therapeutic regimen
Over the past 2 years, a 51-year-old man has been admitted to the hospital five times for problems related to alcohol abuse, including falls, acute alcohol withdrawal, and cirrhosis. The man's current admission has been precipitated by signs and symptoms of alcoholic liver disease (ALD). The care team is reasonably pleased with the patient's recovery to this point and discharge planning has begun. When organizing the patient's discharge planning, what psychosocial nursing diagnosis should be prioritized? A) Risk for altered family processes B) Risk for ineffective coping C) Risk for ineffective management of therapeutic regimen D) Risk for altered growth and development
B. Vitamin C
Patients with severe chronic liver dysfunction often have problems related to inadequate intake of sufficient vitamins. What vitamin deficiency would result in hemorrhagic lesions of scurvy? A. Riboflavin B. Vitamin C C. Vitamin A D. Vitamin K
C) "Which restaurants have you eaten in over the past few weeks?"
Serologic testing of a middle-aged woman with a recent history of severe flu-like symptoms has just resulted in a diagnosis of hepatitis A. Which of the following assessment questions should the nurse prioritize when discussing this diagnosis with the patient? A) "Are you currently in a monogamous sexual relationship?" B) "How would describe your typical diet? C) "Which restaurants have you eaten in over the past few weeks?" D) "Have you ever used recreational drugs?"
a. bowel sounds.
Sodium polystyrene sulfonate (Kayexalate) is ordered for a patient with hyperkalemia. Before administering the medication, the nurse should assess the a. bowel sounds. b. blood glucose. c. blood urea nitrogen (BUN). d. level of consciousness (LOC).
D) Monitoring the patient's mental status
The critical care nurse is caring for a patient with cirrhosis. What is a priority nursing function when caring for a patient with cirrhosis? A) Monitoring the patient's oral intake B) Monitoring the patient's social support network C) Monitoring the patient for signs of hypervolemia D) Monitoring the patient's mental status
B. "I ate shellfish about 2 weeks ago at a local restaurant
The health care provider has determined that a client has contracted hepatitis A based on flu-like symptoms and jaundice. Which statement made by the client supports this medical diagnosis? A. "I have had unprotected sex with multiple partners" B. "I ate shellfish about 2 weeks ago at a local restaurant C. "I was an intravenous drug abuser in the past and shared needles" D. "I had a blood transfusion 30 years ago after major abdominal surgery"
a. leukopenia.
The nurse administering α-interferon and ribavirin (Rebetol) to a patient with chronic hepatitis C will plan to monitor for a. leukopenia. b. hypokalemia. c. polycythemia. d. hypoglycemia.
b. Magnesium hydroxide
The nurse in the dialysis clinic is reviewing the home medications of a patient with chronic kidney disease (CKD). Which medication reported by the patient indicates that patient teaching is required? a. Multivitamin with iron b. Magnesium hydroxide c. Acetaminophen (Tylenol) d. Calcium phosphate (PhosLo)
A. Fever C. Complaints of indigestion E. Pain in the upper right quadrant after a fatty meal
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. A. Fever B. Positive Cullen's sign C. Complaints of indigestion D. Palpable mass in the upper left quadrant E. Pain in the upper right quadrant after a fatty meal F. Vague lower right quadrant abdominal discomfort
b. The patient's central venous pressure (CVP) is decreased.
The nurse is assessing a patient 4 hours after a kidney transplant. Which information is most important to communicate to the health care provider? a. The urine output is 900 to 1100 mL/hr. b. The patient's central venous pressure (CVP) is decreased. c. The patient has a level 7 (0 to 10 point scale) incisional pain. d. The blood urea nitrogen (BUN) and creatinine levels are elevated.
c. Administer prescribed opioids to relieve pain as needed.
The nurse is caring for a 36-year-old patient with pancreatic cancer. Which nursing action is the highest priority? a. Offer psychologic support for depression. b. Offer high-calorie, high-protein dietary choices. c. Administer prescribed opioids to relieve pain as needed. d. Teach about the need to avoid scratching any pruritic areas.
b. The patient's hands flap back and forth when the arms are extended.
The nurse is caring for a 73-year-old man who has cirrhosis. Which data obtained by the nurse during the assessment will be of most concern? a. The patient complains of right upper- quadrant pain with palpation. b. The patient's hands flap back and forth when the arms are extended. c. The patient has ascites and a 2-kg weight gain from the previous day. d. The patient's skin has multiple spider- shaped blood vessels on the abdomen.
A) Asterixis
The nurse is caring for a patient with hepatic encephalopathy. While making the initial shift assessment, the nurse notes that the patient has a flapping tremor of the hands. What will the nurse document this condition as in the patient's chart? A) Asterixis B) Constructional apraxia C) Fetor hepaticus D) Palmar erythema
a. maintaining normal respiratory function.
The nurse is planning care for a 48-year-old woman with acute severe pancreatitis. The highest priority patient outcome is a. maintaining normal respiratory function. b. expressing satisfaction with pain control. c. developing no ongoing pancreatic disease. d. having adequate fluid and electrolyte balance.
b. maintaining cardiac output.
The nurse is planning care for a patient with severe heart failure who has developed elevated blood urea nitrogen (BUN) and creatinine levels. The primary collaborative treatment goal in the plan will be a. augmenting fluid volume. b. maintaining cardiac output. c. diluting nephrotoxic substances. d. preventing systemic hypertension.
B) The patient will abstain from drinking alcohol.
The nurse is planning the care of a patient who has a diagnosis of chronic pancreatitis. As part of this patient's early discharge planning, the nurse is identifying goals for self-care in collaboration with the patient. Which of the following goals is the most likely priority? A) The patient will plan a nutritionally balanced diet. B) The patient will abstain from drinking alcohol. C) The patient will demonstrate the correct technique for blood glucose testing. D) The patient will demonstrate aseptic technique of a dressing change.
C. Pasta with sauce
The nurse is reviewing the laboratory results for a client with cirrhosis and notes that the ammonia level is 85 mcg/dl (51 mcmol/L). Which dietary selection does the nurse suggest to the client? A. Roast pork B. Cheese omelet C. Pasta with sauce D. Tuna fish sandwich
A. Maintain NPO (nothing by mouth) status B. Encourage coughing and deep breathing E. Give hydromorphone IV as prescribed for pain
The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client? Select all that apply. A. Maintain NPO (nothing by mouth) status B. Encourage coughing and deep breathing C. Give small, frequent high-calorie feedings D. Maintain the client in a supine and flat position E. Give hydromorphone IV as prescribed for pain F. Maintain IV fluids at 10 ml/hour to keep the vein open
C. Ask the client to extend the arms
The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterisks. How should the nurse assess for its presence? A. Dorisflex the client's foot B. Measure the abdominal girth C. Ask the client to extend the arms D. Instruct the client to lean forward
b. Urine output
The nurse is titrating the IV fluid infusion rate immediately after a patient has had kidney transplantation. Which parameter will be most important for the nurse to consider? a. Heart rate b. Urine output c. Creatinine clearance d. Blood urea nitrogen (BUN) level
b. "I can remove the bandages on my incisions tomorrow and take a shower."
The nurse recognizes that teaching a 44-year-old woman following a laparoscopic cholecystectomy has been effective when the patient states which of the following? a. "I can expect yellow-green drainage from the incision for a few days." b. "I can remove the bandages on my incisions tomorrow and take a shower." c. "I should plan to limit my activities and not return to work for 4 to 6 weeks." d. "I will always need to maintain a low-fat diet since I no longer have a gallbladder."
d. alcohol consumption.
The nurse will ask a 64-year-old patient being admitted with acute pancreatitis specifically about a history of a. diabetes mellitus. b. high-protein diet. c. cigarette smoking. d. alcohol consumption.
b. measures for improving the appetite.
The nurse will plan to teach the patient diagnosed with acute hepatitis B about a. side effects of nucleotide analogs. b. measures for improving the appetite. c. ways to increase activity and exercise. d. administering α-interferon (Intron A).
c. with each meal.
The nurse will teach a patient with chronic pancreatitis to take the prescribed pancrelipase (Viokase) a. at bedtime. b. in the morning. c. with each meal. d. for abdominal pain.
c. Temperature 100.8° F (38.2° C)
Which finding is most important for the nurse to communicate to the health care provider about a patient who received a liver transplant 1 week ago? a. Dry palpebral and oral mucosa b. Crackles at bilateral lung bases c. Temperature 100.8° F (38.2° C) d. No bowel movement for 4 days
b. ammonia levels.
To detect possible complications in a patient with severe cirrhosis who has bleeding esophageal varices, it is most important for the nurse to monitor a. bilirubin levels. b. ammonia levels. c. potassium levels. d. prothrombin time.
c. asks the patient to empty the bladder.
To prepare a 56-year-old male patient with ascites for paracentesis, the nurse a. places the patient on NPO status. b. assists the patient to lie flat in bed. c. asks the patient to empty the bladder. d. positions the patient on the right side.
b. rapid, deep respirations.
When a patient with acute kidney injury (AKI) has an arterial blood pH of 7.30, the nurse will expect an assessment finding of a. persistent skin tenting b. rapid, deep respirations. c. bounding peripheral pulses. d. hot, flushed face and neck.
a. Auscultate for a bruit at the fistula site.
When caring for a patient with a left arm arteriovenous fistula, which action will the nurse include in the plan of care to maintain the patency of the fistula? a. Auscultate for a bruit at the fistula site. b. Assess the quality of the left radial pulse. c. Compare blood pressures in the left and right arms. d. Irrigate the fistula site with saline every 8 to 12 hours.
c. Check the calcium level in the chart.
When taking the blood pressure (BP) on the right arm of a patient with severe acute pancreatitis, the nurse notices carpal spasms of the patient's right hand. Which action should the nurse take next? a. Ask the patient about any arm pain. b. Retake the patient's blood pressure. c. Check the calcium level in the chart. d. Notify the health care provider immediately.
c. The patient cleans the catheter while taking a bath each day.
Which action by a 70-year-old patient who is using peritoneal dialysis (PD) indicates that the nurse should provide more teaching about PD? a. The patient leaves the catheter exit site without a dressing. b. The patient plans 30 to 60 minutes for a dialysate exchange. c. The patient cleans the catheter while taking a bath each day. d. The patient slows the inflow rate when experiencing abdominal pain.
c. Check blood pressure (BP), heart rate, and respirations.
Which action should the nurse in the emergency department take first for a new patient who is vomiting blood? a. Insert a large-gauge IV catheter. b. Draw blood for coagulation studies. c. Check blood pressure (BP), heart rate, and respirations. d. Place the patient in the supine position.
b. Ask the patient to extend both arms forward.
Which action should the nurse take to evaluate treatment effectiveness for a patient who has hepatic encephalopathy? a. Request that the patient stand on one foot. b. Ask the patient to extend both arms forward. c. Request that the patient walk with eyes closed. d. Ask the patient to perform the Valsalva maneuver.
d. Review the patient's current medication list.
Which action will be included in the care for a patient who has recently been diagnosed with asymptomatic nonalcoholic fatty liver disease (NAFLD)? a. Teach symptoms of variceal bleeding. b. Draw blood for hepatitis serology testing. c. Discuss the need to increase caloric intake. d. Review the patient's current medication list.
b. Schedule for liver cancer screening every 6 months.
Which action will the nurse include in the plan of care for a patient who has been diagnosed with chronic hepatitis B? a. Advise limiting alcohol intake to 1 drink daily. b. Schedule for liver cancer screening every 6 months. c. Initiate administration of the hepatitis C vaccine series. d. Monitor anti-hepatitis B surface antigen (anti-HBs) levels annually.
d. Palpable abdominal mass
Which assessment finding is of most concern for a 46-year-old woman with acute pancreatitis? a. Absent bowel sounds b. Abdominal tenderness c. Left upper quadrant pain d. Palpable abdominal mass
c. Knee and hip joint pain
Which assessment finding may indicate that a patient is experiencing adverse effects to a corticosteroid prescribed after kidney transplantation? a. Postural hypotension b. Recurrent tachycardia c. Knee and hip joint pain d. Increased serum creatinine
d. Muscle twitching and finger numbness
Which assessment finding would the nurse need to report most quickly to the health care provider regarding a patient with acute pancreatitis? a. Nausea and vomiting b. Hypotonic bowel sounds c. Abdominal tenderness and guarding d. Muscle twitching and finger numbness
b. The patient's stools are tan colored.
Which assessment information will be most important for the nurse to report to the health care provider about a patient with acute cholecystitis? a. The patient's urine is bright yellow. b. The patient's stools are tan colored. c. The patient has increased pain after eating. d. The patient complains of chronic heartburn.
b. Maintain adequate nutrition.
Which goal has the highest priority in the plan of care for a 26-year-old homeless patient admitted with viral hepatitis who has severe anorexia and fatigue? a. Increase activity level. b. Maintain adequate nutrition. c. Establish a stable environment. d. Identify sources of hepatitis exposure.
b. The patient used IV drugs about 20 years ago.
Which information given by a 70-year-old patient during a health history indicates to the nurse that the patient should be screened for hepatitis C? a. The patient had a blood transfusion in 2005. b. The patient used IV drugs about 20 years ago. c. The patient frequently eats in fast-food restaurants. d. The patient traveled to a country with poor sanitation.
b. The patient has metastatic lung cancer.
Which information in a patient's history indicates to the nurse that the patient is not an appropriate candidate for kidney transplantation? a. The patient has type 1 diabetes. b. The patient has metastatic lung cancer. c. The patient has a history of chronic hepatitis C infection. d. The patient is infected with the human immunodeficiency virus.
a. Avoid commercial salt substitutes. c. Take phosphate-binders with each meal. d. Choose high-protein foods for most meals.
Which information will be included when the nurse is teaching self- management to a patient who is receiving peritoneal dialysis (select all that apply)? a. Avoid commercial salt substitutes. b. Drink 1500 to 2000 mL of fluids daily. c. Take phosphate-binders with each meal. d. Choose high-protein foods for most meals. e. Have several servings of dairy products daily.
b. Phosphate level
Which information will the nurse monitor in order to determine the effectiveness of prescribed calcium carbonate (Caltrate) for a patient with chronic kidney disease (CKD)? a. Blood pressure b. Phosphate level c. Neurologic status d. Creatinine clearance
b. Restrict physical activity to bed rest.
Which intervention will be included in the plan of care for a male patient with acute kidney injury (AKI) who has a temporary vascular access catheter in the left femoral vein? a. Start continuous pulse oximetry. b. Restrict physical activity to bed rest. c. Restrict the patient's oral protein intake. d. Discontinue the urethral retention catheter.
c. Amylase
Which laboratory test result will the nurse monitor when evaluating the effects of therapy for a 62-year-old female patient who has acute pancreatitis? a. Calcium b. Bilirubin c. Amylase d. Potassium
c. Poached eggs, whole-wheat toast, and apple juice
Which menu choice by the patient who is receiving hemodialysis indicates that the nurse's teaching has been successful? a. Split-pea soup, English muffin, and nonfat milk b. Oatmeal with cream, half a banana, and herbal tea c. Poached eggs, whole-wheat toast, and apple juice d. Cheese sandwich, tomato soup, and cranberry juice
c. The medication will prevent irritation of the enlarged veins.
Which response by the nurse best explains the purpose of ranitidine (Zantac) for a patient admitted with bleeding esophageal varices? a. The medication will reduce the risk for aspiration. b. The medication will inhibit development of gastric ulcers. c. The medication will prevent irritation of the enlarged veins. d. The medication will decrease nausea and improve the appetite.
c. "I will measure my urinary output each day to help calculate the amount I can drink."
Which statement by a 62-year-old patient with stage 5 chronic kidney disease (CKD) indicates that the nurse's teaching about management of CKD has been effective? a. "I need to get most of my protein from low-fat dairy products." b. "I will increase my intake of fruits and vegetables to 5 per day." c. "I will measure my urinary output each day to help calculate the amount I can drink." d. "I need to take erythropoietin to boost my immune system and help prevent infection."
b. Avoiding alcohol ingestion
Which topic is most important to include in patient teaching for a 41-year- old patient diagnosed with early alcoholic cirrhosis? a. Maintaining good nutrition b. Avoiding alcohol ingestion c. Taking lactulose (Cephulac) d. Using vitamin B supplements
