phama- NCLEX Questions

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1. auscultate lung sounds Because the biopsy needle insertion site is close to the lung, there is a risk of lung puncture and pneumothorax; therefore, immediately after the procedure, the nurse should determine diminished or absent lung sounds in the right lung. Although fever indicates infection, a rise in temperature is not seen immediately. A CBC is warranted if the vital signs and patient symptoms indicate potential hemorrhage. The needle insertion site is covered with a pressure dressing; there is no need for a dressing requiring packing.

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

D. Non-alcoholic liver disease Major Takeaway Non-alcoholic liver disease develops without exposure to alcohol. Obesity, insulin resistance, and high blood sugar cause fat in the liver. This increase in fat deposits in the liver can cause liver inflammation and nonalcoholic steatohepatitis, which can lead to a buildup of fibrosis in the liver. Main Explanation Non-alcoholic fatty liver disease usually is asymptomatic. When the disease is symptomatic it will present with enlarged liver, fatigue, and pain in the upper right abdomen. Fatty liver can lead to cirrhosis. Non-alcoholic fatty liver disease is often found in those who are overweight or obese with high blood sugar or a resistance to insulin. With all of these health problems, it leads to fat deposits into the liver. Patients can be found with fluid buildup in the abdomen causing ascites. Those who are at the highest risk those with heart disease, obesity, and type 2 diabetes.

A 17-year-old boy comes into the office for a physical examination for football tryouts. He has a family history of diabetes and hypertension. He explains that he has been feeling fatigued and has suffered being overweight the majority of his life. Physical examination shows abdominal swelling, enlarged breasts, and palmar erythema on hands. The spleen is palpable. Lab studies show elevated aspartate aminotransferase (AST) and alanine aminotransferase (ALT). ALT concentrations are greater than AST concentration. Which of the following is most likely the diagnosis? A. Alcoholic hepatitis B. Celiac sprue C. Cirrhosis D. Non-alcoholic liver disease E. Wilson disease

A. Aspartate aminotransferase of 120 U/L and alanine aminotransferase of 60 U/L Major Takeaway Alcoholic hepatitis is inflammation of the liver that results in elevated aspartate aminotransferase and alanine aminotransferase levels. They are classically elevated in a 2:1 ratio. Main Explanation Alcoholic hepatitis is a progressive inflammatory liver condition secondary to excessive alcohol intake. Patients with symptomatic or acute alcoholic hepatitis are generally characterized by nonspecific symptoms such as nausea, malaise, and a low-grade fever. Complications of underlying cirrhosis can be observed and include variceal bleeding, encephalopathy, or ascites. Variceal bleeding can lead to the presence of melanotic stools. Physical examination may show tachycardia, fever, hepatomegaly, and mild right upper quadrant tenderness due to the inflammatory process in the liver. Symptoms of chronic liver disease or alcohol withdrawal may also be present. The diagnosis of alcoholic hepatitis requires a history of alcohol use, symptoms, and physical examination findings consistent with the disease, and laboratory studies revealing elevated liver enzymes. In alcoholic hepatitis, aspartate aminotransferase concentration is elevated relative to alanine amino aspartate - classically by a degree of 2:1 AST:ALT. Other laboratory studies may reveal a neutrophilic leukocytosis, anemia, and thrombocytosis. However, thrombocytopenia is also possible from bone marrow suppression or portal hypertension causing splenic sequestration. Patients with mild alcoholic hepatitis have a good prognosis with the cessation of alcohol. Patients with hepatic encephalopathy; however, have as high as a 50% chance of early death within 30 days of presentation.

A 35-year-old woman comes to the emergency department because of nausea, malaise, and a low-grade fever. She has a history of significant alcohol abuse and still continues to drink. She came to the emergency department with an episode of melena a month ago and was found to have esophageal varices and anemia. Examination shows right upper quadrant tenderness and hepatomegaly. Which of the following laboratory results are most consistent with the patient's symptoms? A. Aspartate aminotransferase of 120 U/L and alanine aminotransferase of 60 U/L B. γ-glutamyl transferase of 30 U/L C. Leukocyte count of 3,500/mm3 D. Serum amylase of 725 U/L E. Total serum bilirubin of 0.1 mg/dL

A. Alanine aminotransferase (ALT) Major Takeaway Cirrhosis is characterized by fibrosis and disruption of normal liver architecture. ALT is believed to be more specific than AST in diagnosing hepatic pathology. Main Explanation Cirrhosis of the liver is characterized by fibrosis and disruption of normal liver architecture. It is among the top 10 causes of death in the western world. Common causes of cirrhosis are alcohol abuse, chronic infection, autoimmune hepatitis, biliary disease, and iron overload. Pathogenesis includes the replacement of type IV collagen in the perisinusoidal space (space of Disse) with type I and III collagen. Sinusoids in liver vasculature are lost, leading to decreased solute exchange and increased portal blood pressure. Liver enzymes, such as alanine aminotransferase (ALT), aspartate aminotransferase (AST), and alkaline phosphatase, are released from damaged hepatocytes and consequently elevated in serum. ALT is found mainly in the cytosol of hepatocytes and in very low levels in other tissues. Therefore, ALT is more specific than other liver enzymes in diagnosing hepatic injury.

A 55-year-old man with a history of hepatitis C infection comes to the office because of unintentional weight loss and weakness. He has lost 6.8-kg (15-lbs) within the last six months. Physical examination shows jaundice, splenomegaly, and caput medusae. A complete metabolic panel is ordered. Which of the following tests is the most specific for this patient's diagnosis? A. Alanine aminotransferase B. Alkaline phosphatase C. Aspartate aminotransferase D. Blood urea nitrogen E. Troponin

B. Biliary atresia Major Takeaway Neonates with biliary atresia initially are characterized by jaundice anytime between birth and eight weeks of age and is unlikely to appear later. Other signs can include acholic stools, dark urine, increased conjugated bilirubin, and increases in serum aminotransferases. Main Explanation Atresia is a condition in which a passage in the body is abnormally closed or absent. Biliary atresia (BA) is a progressive disease of the extrahepatic biliary tree that is characterized by biliary obstruction in the neonatal period. Most infants with biliary atresia are born at full term, have a normal birth weight, and initially thrive and seem normal and healthy. Patients with biliary atresia initially are characterized by jaundice anytime between birth and eight weeks of age and is unlikely to appear later. Other symptoms and signs can include acholic stools, dark urine, increased conjugated bilirubin, and mild or moderate increases in serum aminotransferases. Diagnosis of BA is made with a series of imaging, lab tests, and liver biopsy to exclude other causes of cholestasis in the neonate. Ultrasound imaging may show triangular cord sign, which is highly suggestive of biliary atresia. The sign represents the fibrous ductal remnant of the extrahepatic bile duct in biliary atresia. Confirmed BA is treated with a hepatoportoenterostomy, a procedure in which a roux-en-Y loop of bowel is created and directly anastomosed to the hilum of the liver. The biliary remnant and portal fibrous plate are removed during surgery

A 6-week-old infant born in the United States comes to the clinic because of slow growth, weight gain, foul-smelling stools, and dark urine. His symptoms began four weeks ago and have continued to worsen. He has an enlarged spleen and is jaundiced. Serum AST, ALT, and total bilirubin concentrations are elevated. Abdominal ultrasound shows a triangular cord sign. A HIDA scan shows obstruction of flow from the liver into the gallbladder and small intestine. Which of the following is the most likely diagnosis? A. Acute intermittent porphyria B. Biliary atresia C. Biliary cyst D. Phenylketonuria E. Toxoplasmosis

D. Hypercalcemia Major Takeaway Acute pancreatitis is most commonly caused by alcohol use or gallstones. Other risk factors for acute pancreatitis include hypercalcemia and hypertriglyceridemia. Main Explanation This patient has acute pancreatitis, which is likely to be secondary to hypercalcemia due to hyperparathyroidism. Commonly, patients report acute upper abdominal pain that radiates to the back. These symptoms may persist for days. Diagnostically, serum amylase and lipase concentrations rise within 4-8 hours of onset more than three times the upper limit of normal. The two most common causes of acute pancreatitis are gallstones and alcoholism. Other common causes of acute pancreatitis include hypertriglyceridemia, hypercalcemia (as in this patient), trauma, steroid use, endoscopic retrograde cholangiopancreatography, and drugs such as 6-mercaptopurines, aminosalicylates, valproic acid, and pentamidine. Mnemonic: GET SMASHED. This stands for Gallstones, Ethanol, Trauma, Steroids, Mumps, Autoimmune disease, Scorpion sting, Hypercalcemia/Hyperlipidemia, ERCP,and Drugs.

A 65-year-old woman comes to the emergency department because of mid-epigastric pain that radiates to the back. Despite attempts to alleviate the pain, it has persisted for the past 8 hours. She has not had any melena. She has a history of hyperparathyroidism. Examination shows temperature is 38°C (100.4°F), pulse is 102/min, and blood pressure is 100/70 mm Hg. Her abdomen is mildly distended, tender to palpation, with no guarding. Complete blood cell count shows no abnormalities. Serum lipase concentration is elevated. Which of the following is the greatest risk factor for the likely diagnosis? A. Helicobacter pylori B. Acinar cell loss C. Barrett esophagus D. Hypercalcemia E. Pancreatic pseudocyst

2 Cystic fibrosis affects the pancreatic excretion of digestive enzymes. Without these enzymes, the client is unable to absorb fats, starches, and some proteins from the diet. Pancrelipase provides these enzymes to the client and must be given with every snack and meal so that the client can digest and absorb the nutrients eaten. If the client is not eating when the medication is scheduled, there are no nutrients to digest. Therefore, the dose should be held until the client eats.

A child with cystic fibrosis is to receive a dose of pancrelipase at 12:00 PM. The client states that he is not hungry and will eat his lunch in an hour. Which action is appropriate for the nurse to take? 1. Administer the prescribed pancrelipase 2. Hold the pancrelipase until the client eats 3. Notify the health care provider 4. Skip this dose of the pancrelipase

1, 2, 4, 5 A client with cirrhosis may experience pruritus (itching) due to buildup of bile salts beneath the skin. Clients with cirrhosis are also at an increased risk for skin breakdown due to the development of edema, which increases skin fragility and impedes wound healing, and the loss of muscle and fat tissue from pressure points (eg, heels, sacrum). The nurse encourages the client to cut the nails short, wear cotton gloves, and wear long-sleeved shirts to avoid injury to the skin from scratching (Options 2 and 5). Other comfort measures include baking soda baths; calamine lotion; and cool, wet cloths, which cool and soothe irritated skin (Options 1 and 4). Cholestyramine (Questran) may be prescribed to increase the excretion of bile salts in feces, thereby decreasing pruritus. It is packaged in powdered form, must be mixed with food (applesauce) or juice (apple juice), and should be given 1 hour after all other medications. (Option 3) Temperature extremes (eg, hot baths/showers) may intensify pruritus. The nurse should instruct the client to bathe with tepid water until the pruritus has subsided.

A client diagnosed with cirrhosis is experiencing pruritus. Which strategies are appropriate for the nurse to teach the client to promote comfort and skin integrity? Select all that apply. 1. Apply cool, moist washcloths to the affected areas 2. Keep the fingernails trimmed short to minimize skin scratching 3. Take a hot bath or shower to alleviate itching sensations 4. Use skin protectant or moisturizing cream over unbroken skin 5. Wear cotton gloves or long-sleeved clothing to avoid scratching

4 Pancreatitis is an acute inflammation of the pancreas that results in autodigestion. The most common causes are cholelithiasis and alcoholism. Classic presentation includes severe epigastric pain radiating to the back due to the retroperitoneal location of the pancreas. The pancreatic enzymes (amylase and lipase) are elevated. Serious complications to monitor for include hyperglycemia, hypovolemia (capillary leak → third spacing), latent hypoxia or acute respiratory distress syndrome (ARDS), peritonitis, and hypocalcemia. Pancreatitis can cause hypocalcemia, but the etiology is unclear. Chvostek's (facial twitching) and Trousseau's (carpal spasm) signs are an indication of hypocalcemia from the decrease in threshold for contraction. Sustained muscle contraction (tetany) and decreased cardiac contractility (cardiac arrhythmia) are concerns related to hypocalcemia. (Option 1) Decreased albumin levels are seen with malnutrition; clients who are alcoholics can have low serum albumin but that alone is not responsible for the client's symptom. (Option 2) Troponin elevation is specific to myocardial infarction and is unrelated to pancreatitis. (Option 3) Potassium abnormalities are not usually present in acute pancreatitis. They are more likely to occur with hemolysis, when the intracellular potassium enters the serum. The ecchymoses in pancreatitis (Grey Turner's sign, Cullen's sign) are due to the blood-stained exudates from autodigestion and are usually only seen in severe cases.

A client is admitted with severe acute pancreatitis. While obtaining the client's blood pressure, the nurse notices a carpal spasm. What laboratory result would the nurse assess in response to this symptom? 1. Decreased albumin 2. Elevated troponin 3. Hyperkalemia 4. Hypocalcemia

2 Total parenteral nutrition (TPN) is administered via a central venous catheter to meet the nutritional needs (eg, glucose, amino acids, vitamins, minerals) of clients who cannot digest nutrients via the gastrointestinal tract. The nurse should hang 10% dextrose in water at the same infusion rate of 75 mL/hr until the new bag arrives. If the 20% dextrose solution is temporarily replaced with an infusion lacking dextrose (eg, normal saline, lactated Ringer's [LR]), the pancreas will continue to produce insulin in response to the residual glucose, which may cause hypoglycemia (Option 2). (Option 1) The infusion of 0.9% saline solution without dextrose can lead to hypoglycemia. Rapid infusion (150 mL/hr) of the hypertonic TPN solution can increase the risk for fluid overload and hyperglycemia. The nurse should never increase the rate of central TPN to make up for volume lost during previous hours. (Option 3) Dextran in saline solution is a colloid used to expand intravascular volume in clients with hypovolemia. It can cause fluid overload and so is not an appropriate action. (Option 4) LR contains electrolytes but no glucose; hypoglycemia may result. Educational objective: Abrupt cessation of central total parenteral nutrition (TPN), which usually contains 20%-50% dextrose, increases the risk for hypoglycemia, as the pancreas will continue to produce insulin in response to the residual glucose. When TPN is discontinued, the infusion rate is gradually reduced and then replaced with a solution containing dextrose.

A client is receiving an infusion of total parenteral nutrition (TPN) with 20% dextrose through a central line at 75 mL/hr. The nurse responds to the client's IV pump alarm, which indicates that the bag is empty. The new bag is not expected to arrive from the pharmacy for an hour. What is the most appropriate nursing action? 1. Hang 0.9% normal saline until new bag arrives, then increase TPN to 150 mL/hr for 1 hour 2. Hang 10% dextrose in water until the new bag arrives, then resume TPN at 75 mL/hr 3. Hang dextran in saline until the new bag arrives, then resume TPN at 75 mL/hr 4. Hang lactated Ringer's until the new bag arrives, then resume TPN at 75 mL/hr

2 A complication of total parenteral nutrition (TPN) is hyperglycemia, as evidenced by excessive thirst, increased urination, abdominal pain, headache, fatigue, and blurred vision. The development of hyperglycemia is related to the following: Excessive dextrose infusion A low tolerance for dextrose in critically ill clients due to the inflammatory response and the resulting production of counterregulatory hormones High infusion rate Administration of medications such as steroids Infection Interventions to resolve TPN-associated hyperglycemia include reducing the amount of carbohydrate in the TPN solution, slowing down the infusion rate, and administering subcutaneous insulin. (Option 1) Checking vital signs will not confirm that the client is experiencing hyperglycemia. (Option 3) The nurse first needs to assess. The health care provider will need to be contacted if a change in TPN treatment is indicated. (Option 4) Slowing down the rate of infusion is an intervention to resolve hyperglycemia; the nurse needs to first confirm that the client's symptoms are related to high blood glucose.

A client receiving total parenteral nutrition complains of nausea, abdominal pain, and excessive thirst. What is the best action for the nurse to take? 1. Assess the client's vital signs 2. Check the client's blood glucose 3. Report the findings to the health care provider 4. Slow down the rate of infusion

4 The client with kidney disease is at risk for both hyperkalemia (normal potassium 3.5-5.0 mEq/L [3.5-5.0 mmol/L]) and hyperphosphatemia due to reduced glomerular filtration rate. Untreated hyperkalemia may cause life-threatening cardiac arrhythmias. Sodium polystyrene sulfonate (Kayexalate) can be used to treat hyperkalemia. It works in the gastrointestinal tract to trade sodium for potassium, thereby eliminating excess potassium through the stool and reducing the serum potassium level. (Option 1) Serum calcium levels (normal 8.6-10.2 mg/dL [2.15-2.55 mmol/L]) may decrease with diminished renal function due to lower activation of vitamin D and subsequent impaired gut absorption of calcium. Calcium supplements are used to increase the serum calcium level. Sodium polystyrene sulfonate does not affect the serum calcium level. (Option 2) Sodium polystyrene sulfonate does not affect serum creatinine levels. Creatinine levels may decrease after dialysis. (Option 3) Phosphorus is also not filtered with kidney injury and the levels increase in serum (normal 2.4-4.4 mg/dL [0.78-1.42 mmol/L]). Phosphate binders (calcium acetate/carbonate) administered orally eliminate phosphorous through stool. Sodium polystyrene sulfonate does not bind phosphorous.

A client with a chronic kidney disease has blood laboratory values as shown in the exhibit. Creatinine - 4.5 mg/dL (398 µmol/L) Potassium - 5.9 mEq/L (5.9 mmol/L) Calcium - 6.3 mg/dL (1.57 mmol/L) Phosphorus - 5.2 mg/dL (1.68 mmol/L) The nurse administers sodium polystyrene sulfonate by mouth per the health care provider's prescription. The nurse evaluates that the therapy is effective when which value is noted on the follow-up results? 1. Calcium 7.4 mg/dL (1.85 mmol/L) 2. Creatinine 4.0 mg/dL (353 µmol/L) 3. Phosphorus 3.9 mg/dL (1.26 mmol/L) 4. Potassium 4.9 mEq/L (4.9 mmol/L)

1 Severe hyperkalemia (potassium >7.0 mEq/L [7.0 mmol/L]) requires urgent treatment because cardiac muscle cannot tolerate very high potassium levels. Severe hyperkalemia increases the risk for life-threatening ventricular dysrhythmias (eg, ventricular tachycardia and fibrillation, asystole). IV administration of 50 mL 50% dextrose with 10 units of regular insulin is the priority intervention as it is most effective in reducing the potassium level quickly. The insulin temporarily shifts the potassium from the extracellular fluid back into the intracellular fluid. The dextrose prevents hypoglycemia associated with the increase of insulin in the body and can be eliminated if the client has hyperglycemia (Option 1). If the client has ECG changes (eg, tall peaked T waves), calcium gluconate should be given before insulin/dextrose. This will stabilize the cardiac muscle until the potassium level can be reduced with insulin/dextrose. (Option 2) Furosemide (Lasix) increases the renal excretion of potassium and is usually prescribed for clients with fluid overload. However, administration of furosemide would take time to be effective and is not the priority. (Option 3) Sodium polystyrene sulfonate (Kayexalate) is administered by mouth or enema to remove potassium from the body by exchanging sodium for potassium ions in the intestines; these are then excreted in feces. This is not the priority due to the delayed onset of potassium removal. (Option 4) Hemodialysis is an invasive procedure that can be initiated if more conservative, noninvasive therapies are ineffective in reducing the potassium level. Placement of the catheter will delay treatment.

A client with advanced kidney disease has serum potassium of 7.1 mEq/L (7.1 mmol/L) and creatinine of 4.5 mg/dL (398 µmol/L). What is the priority prescribed intervention? 1. Administer IV 50% dextrose and regular insulin 2. Administer IV furosemide 3. Administer oral sodium polystyrene sulfonate 4. Prepare the client for hemodialysis catheter placement

3, 4, 5 Paracentesis is performed to remove excess fluid from the abdominal cavity or to provide a specimen of ascitic fluid for diagnostic testing. Paracentesis is not a permanent solution for resolving ascites and is performed only if the client is experiencing impaired breathing or pain due to ascites. Nursing actions include: Explain the procedure, sensations, and expected results Instruct the client to void to prevent puncturing the bladder Assess the client's abdominal girth, weight, and vital signs Place the client in high Fowler's position and remain with the client during the procedure After the procedure, assess and bandage the puncture site and reassess client weight, girth, and vital signs (Option 1) NPO status is not required for this procedure. Paracentesis is often performed at the bedside or an HCP's office with only a local anesthetic. (Option 2) Informed consent can be obtained only by an HCP. The nurse can witness informed consent verifying that it is given voluntarily, the signature is authentic, and the client appears competent to consent.

A client with ascites due to cirrhosis has increasing shortness of breath and abdominal pain. The health care provider (HCP) requests that the nurse prepare the client for a paracentesis. Which nursing actions would the nurse implement prior to the procedure? Select all that apply. 1. Immediately place the client on nothing-by-mouth (NPO) status 2. Obtain informed consent for the procedure 3. Place the client in high Fowler's position 4. Request that the client empty the bladder 5. Take baseline vital signs and weight

3, 4, 5 The creation of an AVF for hemodialysis access involves an anastomosis between an artery and a vein (usually the cephalic or basilic vein). The fistula permits the arterial blood to flow through the vein, causing the vein to become larger in diameter and the walls to thicken, enabling blood to flow at high pressures. After the AVF is placed, it takes 2-4 months for it to mature to accommodate the repeated venipunctures necessary for hemodialysis access. The major complications of an AVF are infection (especially in end-stage kidney disease and diabetes), stenosis, thrombosis, and hemorrhage. Clients are taught the following preventive interventions: Report numbness or tingling of the extremity to the HCP to prevent neuromuscular damage (Option 1) Do not allow anyone (other than dialysis personnel) to draw blood or take blood pressure measurements on the extremity to prevent thrombosis (Option 2) Avoid wearing restrictive clothing or jewelry to prevent thrombosis Do not use the arm with vascular access to carry heavy objects (more than 5 lb [2.26 kg]); however, exercises to increase strength could include squeezing a soft ball or sponge several times a day (Option 3) Check the function of the vascular access several times a day by feeling for vibration to assess for patency, stenosis, and clotting (Option 4) Do not sleep on the arm with vascular access or use creams or lotions on the site (Option 5) Monitor for signs of infection and bleeding after dialysis and report immediately Keep the site clean to help prevent infection

A client with chronic kidney disease has a subcutaneous arteriovenous fistula (AVF) placed in the nondominant left wrist for hemodialysis. Which of the following statements indicate the client understands how to care for the fistula properly? Select all that apply. 1. "I don't need to call my health care provider (HCP) if I have numbness or tingling in my left arm." 2. "I will make sure I always have my blood pressure taken in my nondominant (left) arm." 3. "I will squeeze a small sponge with my left hand several times a day." 4. "I will touch the site and feel for a vibration several times a day." 5. "I will try not to sleep on my left arm."

1 Clients with chronic kidney disease (CKD) have decreased glomerular filtration, resulting in retention of fluid, potassium, and phosphorus. Fluid retention is initially treated with sodium restriction and diuretic therapy. Dietary adjustments should also be made to reduce serum potassium and phosphorus. Laboratory values are key to determining allowable foods. Dairy products (eg, milk, yogurt) and certain fruits (eg, bananas, oranges, coconuts, watermelons, and avocados) contain high potassium levels. Dairy products also contain high phosphorus levels. Examples of allowable foods for CKD clients include apples, pears, grapes, pineapple, blackberries, blueberries, and plums. (Option 2) Avocados are high in potassium; the chips may be high in sodium. (Options 3 and 4) Pudding and yogurt contain dairy products and are high in phosphorous and potassium. Oranges are high in potassium. Educational objective: The diet for a client with chronic kidney disease may need to be restricted in fluids, sodium, potassium, and phosphorus. Dairy products (eg, milk, yogurt) and certain fruits (eg, bananas, oranges, coconuts, watermelons, and avocados) contain high potassium levels. Dairy products are also high in phosphorus.

A client with chronic kidney disease has blood laboratory results as shown in the exhibit. Sodium 150 mEq/L (150 mmol/L) Potassium 6.0 mEq/L (6.0 mmol/L) Chloride 100 mEq/L (100 mmol/L) Calcium 9.0 mg/dL (2.25 mmol/L) Magnesium 2.0 mg/dL (1.0 mmol/L) Phosphorus 5.8 mg/dL (1.87 mmol/L) What is the best afternoon snack to provide to this client? 1. Apple slices with caramel dip 2. Chips and avocado dip 3. Nonfat yogurt with orange slices 4. Vanilla pudding with strawberries

1, 2, 3 Supportive care for symptom relief and prevention of complications are the major goals in clients with acute pancreatitis. These strategies include: NPO status - The client is maintained on NPO status as any ingestion of food will stimulate the excretion of pancreatic enzymes. A nasogastric tube is used to suction out gastric secretions; this will reduce nausea and lessen stimulation of the pancreas as these juices will move to the duodenum. Pain management - Intravenous opioids (eg, hydromorphone, fentanyl) are frequently utilized for pain management. Morphine can also be used; worsening pancreatitis due to increase in sphincter of Oddi pressure has not been proven in studies. IV fluids - Aggressive fluid replacement to prevent hypovolemic shock is critical. Inflammation of the pancreas releases chemical mediators that increase capillary permeability and cause third spacing (fluid going into empty spaces). (Option 4) The client should maintain positions that flex the trunk and draw the knees up to the abdomen (semi-Fowler's) to decrease tension on the abdomen. A side-lying position with the head elevated to 45 degrees will help relieve the pain even better. (Option 5) NPO status is maintained to inhibit stimulation of pancreatic enzymes.

A hospitalized client with acute pancreatitis has nausea, vomiting, epigastric pain, and tachycardia. Laboratory results show elevated serum lipase levels. Which interventions would the nurse anticipate being prescribed for the client? Select all that apply. 1. Administer hydromorphone IV PRN for pain 2. Administer intravenous fluids 3. Insert a nasogastric tube for nasogastric suction 4. Maintain client in a supine position, with head of bed flat 5. Provide small, frequent, high-carbohydrate, high-calorie meals

3 IV iodinated contrast used for CT scan or cardiac catheterization can cause kidney injury (contrast-induced nephropathy). The side effect of metformin (Glucophage) is lactic acidosis. If the client takes metformin and develops kidney injury from contrast, then the lactic acidosis will worsen. As a result, most HCPs discontinue metformin on the day of IV iodine contrast exposure (regardless of baseline creatinine) and restart the drug at least 48 hours later, after stable renal function has been documented. (Options 1, 2, and 4) Amlodipine (Norvasc) is a calcium channel blocker commonly used to treat hypertension. Gabapentin (Neurontin) is commonly used for neuropathic pain. Phenytoin (Dilantin) is an antiseizure medication. None of these medications interact with the iodinated contrast or worsen kidney injury. Therefore, these can be safely administered.

A nurse is giving medications to a client who is being evaluated for a brain malignancy. The health care provider (HCP) has ordered a computed tomography (CT) scan with intravenous (IV) iodinated contrast for the next morning. Which medication should the nurse plan to withhold from this client? 1. Amlodipine 2. Gabapentin 3. Metformin 4. Phenytoin

1 Nephrotic syndrome is a collection of symptoms resulting from various causes of glomerular injury. Below are the 4 classic manifestations of nephrotic syndrome: Massive proteinuria - caused by increased glomerular permeability Hypoalbuminemia - resulting from excess protein loss in the urine Edema - specifically periorbital and peripheral edema and ascites; caused by low serum protein and albumin as fluid is pulled into interstitial spaces and body cavities Hyperlipidemia - related to increased compensatory protein and lipid production by the liver Additional symptoms include decreased urine output, fatigue, pallor, and weight gain. The most common cause of nephrotic syndrome in children is minimal change nephrotic syndrome, which is generally considered idiopathic. Less common secondary causes may be related to systemic disease or infection, such as glomerulonephritis, drug toxicity, or acquired immunodeficiency syndrome. (Option 2) Ascites and edema are often associated with liver disease. However, these symptoms result from fluid shifts related to hypoalbuminemia in nephrotic syndrome. (Option 3) Lipid levels (normal total cholesterol <200 mg/dL [5.2 mmol/L]) can increase with nephrotic syndrome as the liver produces increased lipids and proteins to compensate for protein loss. (Option 4) Although low serum albumin (normal 3.5-5.0 g/dL [35-50 g/L]) could result from malnutrition, hypoalbuminemia in nephrotic syndrome is related to massive proteinuria (negative to trace protein on urinalysis is usually considered normal).

A nurse is reviewing the laboratory values for a 3-year-old client with nephrotic syndrome. Serum albumin - 2.0 g/dL (20 g/L) Serum total cholesterol - 275 mg/dL (7.1 mmol/L) Urinalysis, protein - 3+ The nurse interprets the results to most clearly reflect which physiologic process related to nephrotic syndrome? 1. Glomerular injury 2. Hepatic impairment 3. Inherited hypercholesterolemia 4. Malnutrition

4 This client's urinalysis reveals that the client is most likely dehydrated. Amber color indicates concentrated urine. The specific gravity evaluates the ability of the kidneys to concentrate solutes in the urine. The normal urine specific gravity value ranges from 1.003 to 1.030. Causes of increased specific gravity include fluid deficit. (Option 1) Glucose should be absent in the urine. Its presence is suspicious for diabetes mellitus. (Option 2) Dysuria (burning or difficulty urinating) may be indicative of infection or inflammation. The number of white blood cells (WBCs) should be very few (0-5 per high power field), as seen in this client. Increased numbers indicate infection or inflammation. (Option 3) Hematuria is indicative of possible renal trauma. The normal range for red blood cells is 0-4 per high power field. None are present on this client's urinalysis results.

After reviewing the urinalysis report data on a client, which question is most appropriate for the nurse to ask? Urinalysis Specimen type: Midstream Color - Amber Specific gravity - 1.031 Red blood cells - None White blood cells - Rare Protein - None Glucose - Absent 1. "Do you have a family history of diabetes?" 2. "Do you have any burning or difficulty urinating?" 3. "Have you suffered any recent kidney trauma?" 4. "What has your fluid intake been for the last 24 hours?"

2, 3, 5 Hyperosmolar hyperglycemic state is a serious complication usually associated with type 2 diabetes. With this condition, clients are able to produce enough insulin to prevent diabetic ketoacidosis but not enough to prevent extreme hyperglycemia, osmotic diuresis, and extracellular fluid deficit. Because some insulin is produced, blood glucose rises slowly and symptoms may not be recognized until hyperglycemia is extreme, often >600 mg/dL (33.3 mmol/L). This eventually causes neurological manifestations such as blurry vision, lethargy, obtundation, and progression to coma. Because some insulin is present, symptoms associated with ketones and acidosis, such as Kussmaul respirations (hyperventilation) and abdominal pain, are typically absent (Options 1 and 4).

The emergency department nurse cares for a client admitted with a diagnosis of hyperosmolar hyperglycemic state. The nurse understands which characteristics are commonly associated with this complication? Select all that apply. 1. Abdominal pain 2. Blood glucose level >600 mg/dL (33.3 mmol/L) 3. History of type 2 diabetes 4. Kussmaul respirations 5. Neurological manifestations

Catheter occlusion is the most common complication of central venous access devices. Kinked tubing, catheter malposition, medication precipitate, or thrombus can occlude the lumen, preventing the ability to flush or aspirate blood. The nurse should first assess for mechanical, nonthrombotic problems by: Repositioning the client (eg, head, arm) as the catheter tip may be resting against a vessel wall (Option 4) Assessing IV tubing for clamps, kinks, and precipitate The nurse should then attempt to flush the device again. If the occlusion remains, the nurse should not flush against resistance as applying force may damage the catheter or dislodge a thrombus. Instead, the nurse should contact the health care provider (HCP), who may prescribe medication (ie, alteplase) to dissolve a thrombus or fibrin sheath. (Option 1) Most needleless connector manufacturers recommend flushing with normal saline. Some facilities may use heparinized saline flushes; the nurse should follow HCP prescriptions and institution guidelines. Heparin flushes should be at the lowest acceptable dose (eg, 10 units/mL) to prevent heparin-induced thrombocytopenia. (Option 2) Flushing with a syringe smaller than 10 mL causes increased intraluminal pressure and may damage the catheter. (Option 3) The nurse should rule out a mechanical problem before notifying the HCP.

The nurse attempts to flush a client's subclavian vein central venous access device with normal saline using a 10-mL syringe, but meets resistance, is unable to aspirate blood, and suspects an occlusion. What should the nurse do next? 1. Flush and lock with heparinized saline flush 2. Flush with normal saline using a 5-mL syringe 3. Notify the health care provider 4. Reposition the client

2 Nephrotic syndrome, an autoimmune disease, affects children age 2-7 and is characterized by increased permeability of the glomerulus to proteins (eg, albumin, immunoglobulins, natural anticoagulants). Loss of albumin in urine leads to hypoalbuminemia; this causes decreased plasma oncotic pressure, which allows fluid to leak out of the vascular spaces. Reduced plasma volume (hypovolemia) activates kidneys to retain salt and water (renin-angiontensin-aldosterone system). Clients will have generalized edema, weight gain, loss of appetite (from ascites), and decreased urine output. Loss of immunoglobulins makes children susceptible to infection. Treatment typically includes: Corticosteroids and other immunosuppressants (eg, cyclosporine) Loss of appetite management by making foods fun and attractive Infection prevention (eg, limiting social interaction until the child is better) (Option 2) (Option 1) A regular diet without added salt is prescribed to prevent edema while in remission. More stringent sodium restrictions are necessary when symptoms are present. (Option 3) Fluid restriction is needed in severe cases of edema. (Option 4) There is a high risk for recurrence after recovery, and relapses may occur several times per year. The parent/caregiver should test daily for proteinuria, weigh the child weekly, and keep a diary of results. Early detection and treatment improve the course of the illness.

The nurse is caring for a 7-year-old child diagnosed with nephrotic syndrome who will be discharged soon. Which statement by the parent indicates the need for reinforcement of teaching? 1. "Cutting down on added salt will be good for the whole family." 2. "I'll organize a lot of playdates to keep my child's spirits up." 3. "I'll restrict my child's fluids if I notice swelling or weight gain." 4. "I'll test for protein in my child's urine every day."

4 A high-grade fever or abrupt increase in temperature with worsening abdominal pain could be an indication of a pancreatic abscess, a significant complication of acute pancreatitis. A pancreatic abscess requires immediate intervention (eg, antibiotics, surgical drainage) to reduce the risk of rupture and sepsis; therefore, the health care provider should be notified immediately (Option 4). (Option 1) Clients with acute pancreatitis will position themselves in a side-lying position with knees drawn up to the abdomen and trunk flexed to decrease the pain. (Option 2) An early indicator of hypocalcemia, a possible electrolyte disorder of pancreatitis, is numbness and tingling of the lips and fingers. The nurse should further evaluate the client for possible signs of tetany by assessing for a positive Chvostek's sign or Trousseau's sign. Once further assessment is completed, the findings should be reported. (Option 3) The stool in acute pancreatitis is expected to be fatty and foul-smelling.

The nurse is caring for a client with acute pancreatitis. Which subjective and objective assessments would the nurse report immediately? 1. Client is lying with knees drawn up to the abdomen and trunk flexed 2. Client states, "My lips are tingling and numb." 3. Foul-smelling, fatty stool 4. Temperature of 102.2 F (39 C) and increasing abdominal pain

2, 3, 4 Cirrhosis, the end stage of many chronic liver diseases, is characterized by diffuse hepatic fibrosis with replacement of the normal architecture by regenerative nodules. The resulting structural changes alter blood flow through the liver and decrease the liver's functionality. Elevated bilirubin (jaundice) results from functional derangement of liver cells and compression of bile ducts by nodules. The liver has a decreased ability to conjugate and excrete bilirubin (Option 3). Most coagulation factors are produced in the liver. A cirrhotic liver cannot produce the factors essential for blood clotting. As a result, coagulation studies (prothrombin time [PT]/International Normalized Ratio [INR] and activated partial thromboplastin time [aPTT]) are usually elevated (Option 4). Ammonia from intestinal deamination of amino acids normally goes to the liver and is converted to urea and excreted by the kidney. This does not happen in cirrhosis. Instead, the ammonia level rises as the cirrhosis progresses; ammonia crosses the blood-brain barrier and results in hepatic encephalopathy (Option 2). (Options 1 and 5) Albumin holds water inside the blood vessels. In cirrhosis, the liver is unable to synthesize albumin (protein), so hypoalbuminemia would be expected. This is the primary reason that fluid leaks out of vascular spaces into interstitial spaces (eg, edema, ascites). The kidneys perceive this as low perfusion and try to reabsorb (conserve) both sodium and water. The large amount of water in the body results in a dilutional effect (low sodium).

The nurse is caring for a client with cirrhosis of the liver. Which blood test values would the nurse typically anticipate to be elevated when reviewing the client's morning laboratory results? Select all that apply. 1. Albumin 2. Ammonia 3. Bilirubin 4. Prothrombin time 5. Sodium

2, 4, 5 In a client with cirrhosis and ascites, discomfort is often due to pressure of the fluid on the surrounding organs. Shortness of breath occurs due to the upward pressure exerted by the abdominal ascites on the diaphragm, which restricts lung expansion. Positioning the client in semi-Fowler or Fowler position can promote comfort, as this position can reduce the pressure on the diaphragm (Option 2). In semi-Fowler position, the head of the bed is elevated 30-45 degrees; in Fowler position, elevation is 45-60 degrees. Side-lying with the head elevated can also be a position of comfort for the client with ascites as it allows the heavy, enlarged abdomen to rest on the bed, reducing pressure on internal organs and allowing for relaxation. Meticulous skin care is a priority due to the increased susceptibility of skin breakdown from edema, ascites, and pruritus. It is important to use a specialty mattress and implement a turning schedule of every 2 hours (Option 4). A distraction can take the client's mind off the current symptoms and may also help promote comfort in many different situations. Some of these distractions include listening to music, watching television, playing video games, or taking part in hobbies (Option 5). (Option 1) This client has ascites and peripheral edema; higher levels of fluid or sodium intake can worsen these conditions. (Option 3) In Trendelenburg position, the bed is tilted with the head lower than the legs. This position is contraindicated in the client with ascites, as it may exacerbate shortness of breath by causing the abdominal ascites to push upward on the diaphragm, restricting lung expansion.

The nurse is caring for a client with cirrhosis. Assessment findings include ascites, peripheral edema, shortness of breath, fatigue, and generalized discomfort. Which interventions would be appropriate for the nurse to implement to promote the client's comfort? Select all that apply. 1. Encourage adequate sodium intake 2. Place client in semi-Fowler position 3. Place client in Trendelenburg position 4. Provide alternating air pressure mattress 5. Use music to provide a distraction

1, 2 Hepatic encephalopathy (HE) is a frequent complication of liver cirrhosis. Precipitating factors include hypokalemia, constipation, gastrointestinal hemorrhage, and infection. It results from accumulation of ammonia and other toxic substances in blood. Clinical manifestations of HE range from sleep disturbances (early) to lethargy and coma. Mental status is altered, and clients are not oriented to time, place, or person (Option 1). A characteristic clinical finding of HE is presence of asterixis (flapping tremors of the hands). It is assessed by having the client extend the arms and dorsiflex the wrists (Option 2). Another sign is fetor hepaticus (musty, sweet odor of the breath) from accumulated digestive byproducts. (Option 3) Spider angiomas (eg, small, dilated blood vessels with bright red centers), gynecomastia, testicular atrophy, and palmar erythema are expected findings in cirrhosis due to altered metabolism of hormone in the liver. (Option 4) Jaundice occurs when bilirubin is 2-3 times the normal value. Jaundice can occur in hepatitis and tends to worsen in cirrhosis due to increasing functional derangement. It is not related specifically to encephalopathy. (Option 5) Amylase and lipase are enzymes from pancreatic tissue. Alanine aminotransferase and aspartate aminotransferase are liver enzymes. They would be elevated with hepatitis and are not unique to cirrhosis or HE. Elevated ammonia levels would be more specific to cirrhosis. Educational objective: HE manifests with sleep disturbances, altered mental status, and lethargy. Asterixis and elevated ammonia are characteristic of HE.

The nurse is caring for a client with liver cirrhosis who was admitted for cellulitis of the leg. Which assessments would the nurse perform to determine if the client's condition has progressed to hepatic encephalopathy? Select all that apply. 1. Ask if the client knows what day it is 2. Ask the client to extend the arms 3. Assess for telangiectasia (spider nevi) 4. Determine if the conjunctiva is jaundiced 5. Note amylase and lipase serum levels

2, 3, 5 ALT and AST are the enzymes released when hepatic cells are injured (hepatitis). There are smaller amounts in the cardiac, renal, and skeletal tissues, but ALT/AST are used to diagnose hepatic disorders. Besides viral hepatitis, liver injury can occur with excessive chronic alcohol intake (Option 3), some over-the-counter medications (eg, acetaminophen), and certain herbal and dietary supplements (Option 5). IV illicit drug use increases the risk for hepatitis B and C infection (Option 2). (Option 1) Black tarry stool (melena) is an expected finding from a gastrointestinal bleed (from the digested blood). Melena can be seen in clients with gastric or esophageal varices, which are often complications of hepatic disease (eg, cirrhosis). However, melena is not an etiology of liver injury. (Option 4) Immunizations do not cause liver damage. It is possible to get a small elevation with an intramuscular injection, but not values this high.

The nurse is caring for a client with right upper quadrant pain and jaundice. The client's alanine aminotransferase /aspartate aminotransferase (ALT/AST) levels are 7 times the normal values. What questions would be most helpful regarding the etiology for these findings? Select all that apply. 1. Do you have black tarry stool? 2. Do you use intravenous (IV) illicit drugs? 3. How much alcohol do you typically drink? 4. Were you recently immunized for pneumonia? 5. What over-the-counter drugs do you take?

2. Cut the tube with scissors A balloon tamponade tube is used to temporarily control bleeding from esophageal varices. It contains two balloons and 3 lumens. The gastric lumen drains stomach contents, the esophageal balloon compresses bleeding varices above the esophageal sphincter, and the gastric balloon compresses from below. A weight is attached to the external end of the tube to provide tension and hold the gastric balloon securely in place below the esophageal sphincter. Airway obstruction can occur if the balloon tamponade tube becomes displaced and a balloon migrates into the oropharynx. Scissors are kept at the bedside as a precaution; in the event of airway obstruction, the nurse can emergently cut the tube for rapid balloon deflation and tube removal.

The nurse is caring for a patient with a balloon tamponade tube in place due to bleeding esophageal varices. The patient suddenly develops respiratory distress, and the nurse finds that the tube has been partially pulled out. Which intervention should be the nurse's priority. 1. Contact the health care provider 2. Cut the tube with scissors 3. Increase the gastric suction level 4. Place the patient in high Fowler position

2. Improved mental status. Hepatic encephalopathy in cirrhosis results from higher serum ammonia levels that cause neurotoxic effects, including mental confusion. Oral lactulose is given to reduce the ammonia by trapping it in the gut and then expelling it with a laxative effect. Improved mental status implies reduction of ammonia levels. Patients with cirrhosis typically have hypokalemia due to hyperaldosteronism (as aldosterone is not metabolized by the damaged liver). Hypokalemia can also result from diuretics used to treat the fluid retention and ascites. Lactulose is not intended to treat this pathology. Lactulose is a laxative. In cirrhosis, constipation (Which allows more ammonia to be absorbed) and hard stool are to be avoided. However, the main purpose of lactulose is expelling the ammonia, with resulting benefits. Abdominal distention (ascites) in cirrhosis is treated with diuretics and paracentesis. Lactulose does not influence this pathology or symptom.

The nurse is caring for a patient with cirrhosis who has hepatic encephalopathy. The patient is prescribed lactulose. Which assessment by the nurse will most likely indicate that the medication has achieved the desired therapeutic effect? 1. Higher potassium level 2. Improved mental status 3. Looser stool consistency 4. Reduced abdominal distension

3, 2, 1, 5, 4 Leakage of more than 500 mL of air into a central venous catheter is potentially fatal. An air embolism in the small pulmonary capillaries obstructs blood circulation. A central venous catheter leaks air rapidly at 100 mL/sec. This client requires immediate intervention to prevent further complications (eg, cardiac arrest, death). The nurse should not delay emergency treatment, not even to stop and contact the HCP or the rapid response team (RRT). Priority interventions for active or suspected air embolism are as follows: Clamp the catheter to prevent more air from embolizing into the venous circulation. Place the client in Trendelenburg position on the left side, causing any existing air to rise and become trapped in the right atrium. Administer oxygen if necessary to relieve dyspnea. Notify the HCP or call an RRT to provide further resuscitation measures. Stay with the client to provide reassurance and monitoring as the air trapped in the right atrium is slowly absorbed into the bloodstream over the course of a few hours.

The nurse is performing a central line tubing change when the client suddenly begins gasping for air and writhing. Order the interventions by priority. All options must be used. 1. Administer oxygen as needed 2. Place the client in Trendelenburg position on the left side. 3. Clamp the catheter tubing 4. Stay with the client and provide reassurance 5. Notify the health care provider.

1 Medication administration may require modification on days that clients are scheduled to receive dialysis. The nurse should consider whether the medication will be dialyzed out of the client's system or may create adverse effects during dialysis. Fluid is removed during dialysis, which may cause hypotension. Typically, antihypertensives are held before dialysis to prevent hypotension. In addition, some medications are dialyzed out of the client's system and should therefore be held until after dialysis. Commonly held medications are water-soluble vitamins (eg, vitamins B and C), antibiotics, and digoxin. (Option 2) Clients with chronic kidney disease have high phosphorus levels as the kidney is unable to filter the phosphate from the body; dialysis also does not filter it. Therefore, the client should still take phosphate binders prior to dialysis. Phosphate binders (eg, calcium containing [calcium carbonate and calcium acetate]) and non-calcium containing [sevelamer and lanthanum]) block absorption of ingested phosphate from the intestine and excrete it through feces. (Option 3) Lispro is a fast-acting insulin that should be given 15-30 minutes before meals. It is appropriate to give scheduled lispro with breakfast prior to dialysis. (Option 4) Vitamin E is a fat-soluble vitamin that is not affected by dialysis. It is given to some clients to prevent leg cramps that can be experienced by dialysis clients.

The nurse is preparing to administer morning medications to a client with type 2 diabetes mellitus and end-stage renal disease who is scheduled for dialysis today. Which medication should the nurse hold for clarification prior to administration? Click the exhibit button for more information. Atenolol 50 mg PO daily Calcium acetate 667 mg PO w/each meal Insulin lispro, high-dose sliding-scale subcutaneous injection with meals and before bedtime Vitamin E 400 IU PO daily 1. Atenolol 2. Calcium acetate 3. Insulin lispro 4. Vitamin E

1, 3, 5 Viral hepatitis is a disease of the liver characterized by inflammation, necrosis, and cirrhosis. One of the most common viral strains that causes hepatitis is hepatitis B. The transmission of hepatitis B is primarily through contact with blood, semen, and vaginal secretions (mnemonic: B for body fluids), commonly through unprotected sexual intercourse and intravenous illicit drug use (Options 1, 3, and 5). Infants born to infected mothers are also at risk for vertical transmission of hepatitis B. Although kissing, sneezing, sharing drinks/utensils, and breastfeeding are not known routes of transmission, hepatitis B could possibly be transmitted through saliva entering the bloodstream via sharing a toothbrush or receiving a bite. Hepatitis B has an insidious onset of illness, and clients may be asymptomatic carriers. Early symptoms are often nonspecific (eg, malaise, nausea, vomiting, abdominal pain). Hepatitis B may produce jaundice, weight loss, clay-colored stools, and thrombocytopenia in late stages of illness. An effective vaccine is widely available for hepatitis B. (Option 2) The transmission of hepatitis A occurs through the fecal-oral route via poor hand hygiene and improper food handling. Therefore, this infection is seen primarily in developing countries. Hepatitis B is not transmitted through feces. (Option 4) Urine is not known to be a mode of transmission for any form of hepatitis. Educational objective: The transmission of hepatitis B occurs through parenteral or sexual contact with body fluids such as blood, semen, or vaginal secretions (mnemonic: B for body fluids).

The nurse understands that which of these body substances are modes of transmission for hepatitis B? Select all that apply. 1. Blood 2. Feces 3. Semen 4. Urine 5. Vaginal secretions

1. there is a strong link between alcohol use and acute pancreatitis. Alcoholism is a major cause of acute pancreatitis in the United States and Canada. Because some clients are reluctant to discuss alcohol use, staff may inquire about it in several ways. Generally, alcohol intake does not interfere with the tests used to diagnose pancreatitis. Recent ingestion of large amounts of alcohol, however, may cause an increased serum amylase level. Large amounts of ethyl and methyl alcohol may produce an elevated urinary amylase concentration. All patients are asked about alcohol and drug use on hospital admission, but this information is especially pertinent for patients with pancreatitis. HCPs do need to seek facts, but this can be done while respecting the patient's religious beliefs. Respecting religious beliefs is important in providing holistic patient care.

The patient who has been hospitalized with pancreatitis does not drink alcohol because of religious convictions. The patient becomes upset when the healthcare provider persists in asking about alcohol intake. The nurse should explain that the reason for these questions is that: 1. there is a strong link between alcohol use and acute pancreatitis 2. alcohol intake can interfere with the tests used to diagnose pancreatitis 3. alcoholism is a major health problem, and all patients are questioned about alcohol intake 4. the HCP must obtain the pertinent facts, regardless of religious beliefs

1, 2, 3, 5 Inflammation of the liver is present in acute viral hepatitis. Liver functions (eg, detoxifying the blood, manufacturing bile for lipid digestion) are disrupted, leading to signs and symptoms in various body systems. These include the digestive (eg, nausea, vomiting, anorexia, right upper-quadrant tenderness), urinary (eg, dark-colored urine), musculoskeletal (eg, fatigue, arthralgia, myalgia), and integumentary (eg, pruritus, jaundice) systems. Nursing interventions for the acute phase of hepatitis focus on resting the liver and providing nutrition for healing: Rest Alternate periods of rest and activity (Option 3) Avoid alcohol and other drugs that increase liver metabolism (Option 5) Medications (eg, appetite stimulants, antipruritics, analgesics) should be used cautiously to allow hepatocytes to heal. Antiemetics can be used to prevent nausea (Option 1). Nutrition Encourage small, frequent meals to decrease nausea. Anorexia is lowest in the morning; promote eating a larger breakfast (Option 2). Provide oral care and avoid extremes in food temperature to increase appetite Drink adequate amounts of fluid (2500-3000 mL/day) and encourage a diet high in carbohydrates and calories (Option 4) Clients with acute hepatitis should eat a diet high in calories and carbohydrates while decreasing fat and protein consumption. The liver produces bile, which aids in lipid digestion. A high-protein diet produces more ammonia and other toxic substances and the inflamed liver may not detoxify these well. Moderation of fat and protein intake allows the liver to rest. Educational objective: Acute viral hepatitis is treated with supportive measures, including rest (alternate activity and rest), avoiding alcohol and hepatotoxic medications, and adequate nutrition (increase calories and carbohydrates; eat small, frequent meals). Clients should reduce their consumption of fats and proteins, which increase liver metabolism.

Which of the following nursing interventions would the nurse implement when caring for a client newly diagnosed with acute viral hepatitis? Select all that apply. 1. Administer antiemetic medications as needed 2. Encourage a good breakfast and small, frequent meals 3. Promote rest periods alternating with periods of activity 4. Provide a diet high in protein and low in fat 5. Teach the client to abstain from alcohol

4 The client is exhibiting signs and symptoms (eg, fever, chills, nausea) of septicemia (blood infection). Other findings include a subnormal body temperature instead of fever, hypotension, tachycardia, decreased urine output, and confusion. Although CVCs are warranted to provide important treatment for many clients, they are often a source of infection that can lead to sepsis and septic shock. It is most important to obtain a culture and sensitivity first so that the specific pathogen can be identified prior to starting antibiotics. Identification of the specific pathogen and the antibiotics to which it is sensitive will allow the health care provider (HCP) to determine the best antibiotic for treatment. If the culture is obtained after antibiotic administration, the results will be altered. In addition to obtaining blood cultures x 2, it is standard procedure to cut off the tip of the discontinued CVC and send it to the lab to ensure it is the source of the septicemia. Broad-spectrum antibiotics are often prescribed after cultures are obtained to begin treatment and prevent progression to septic shock (Option 1). (Option 2) It is important to document this occurrence in the client's medical record and to follow hospital protocol for reporting infections. However, implementation of client care is a priority. (Option 3) Ondansetron may be administered for nausea symptoms. However, treatment of the cause is the most effective way to reduce symptoms; it is a life-saving measure and therefore the priority.

A client in the critical care unit has a central venous catheter (CVC). The site around the CVC becomes red and inflamed. The client reports chills and nausea and has a temperature of 102 F (38.8 C). The nurse should prepare to implement which prescription first? 1. Administer broad-spectrum intravenous (IV) antibiotic through a new IV site 2. Document the occurrence and notify the hospital's infection control nurse 3. Give ondansetron (Zofran) 4 mg IV push to relieve client's nausea 4. Obtain blood cultures and send tip of the discontinued CVC to the lab for culture

3 This client has chronic kidney disease with an elevated serum creatinine level. Ketorolac (Toradol) is a highly potent nonsteroidal anti-inflammatory drug (NSAID) often used for pain and available in intravenous form. However, NSAIDs (eg, indomethacin, ibuprofen, naproxen, ketorolac) are nephrotoxic and should be avoided in clients with kidney disease. Also, the client should not be given 2 types of NSAIDs simultaneously (eg, naproxen plus ibuprofen) as they can be toxic to the stomach and kidneys. (Option 1) Prescribing acetaminophen as needed is appropriate to treat fever. (Option 2) Clients with chronic kidney disease often have anemia due to erythropoietin deficiency. Recombinant erythropoietin injections are often prescribed to treat anemia. (Option 4) Levofloxacin is an appropriate antibiotic to use for treating pneumonia.

A client with chronic kidney disease is admitted with pneumonia and pleurisy. The client's laboratory results are shown in the exhibit. Which prescription will the nurse question? Hemoglobin - 9.0 g/dL (90 g/L) Platelets - 267,000/mm3 (267 × 109/L) White blood cells - 14,500/mm3 (14.5 × 109/L) Creatinine - 2.8 mg/dL (214 µmol/L) 1. Acetaminophen 500 mg PO every 6 hours, as needed for fever 2. Epoetin alfa 15,000 units subcutaneus injection, once weekly 3. Ketorolac 15 mg IV every 6 hours, as needed for pain 4. Levofloxacin 500 mg IV, once daily

3. Have you had a bone density test recently? Long-term therapy with a proton pump inhibitor may decrease the absorption of calcium and promote osteoporosis. A bone density test can assess if the patient already has osteoporosis. Drinking extra water and being upright for 30 minutes after taking biphosphonates is necessary to prevent esophagitis. However, this is not necessary with PPI use. The medication should be taken prior to meals, PPIs do not affect blood pressure.

A patient has been on long-term therapy with pantoprazole. What is essential for the nurse to ask the patient? 1. Are you drinking plenty of water with the medication? 2. Are you taking the medication after meals? 3. Have you had a bone density test recently? 4. Have you had your blood pressure taken recently?

2. hyperkalemia Spironolactone is a potassium-sparing diuretic; therefore, patients should be monitored closely for hyperkalemia. Other common adverse effects include abdominal cramping, diarrhea, dizziness, headache, and rash. Constipation and dysuria are not common adverse effects of spironolactone. An irregular pulse is not an adverse effect of spironolactone but could develop if serum potassium levels are not closely monitored.

A patient with cirrhosis begins to develop ascites. Spironolactone is prescribed to treat the ascites. The nurse should monitor the patient closely for which drug-related adverse effect? 1. constipation 2. hyperkalemia 3. irregular pulse 4. dysuria

2, 3, 4 Baking soda baths can decrease pruritus. Keeping nails short and rubbing the area with knuckles can decrease breakdown when scratching. Calamine lotions help relieve itching. Alcohol will increase skin dryness. Sodium in the diet will increase edema and weaken skin integrity.

A patient with jaundice has pruritus and areas of irritation from scratching. What measures can the nurse suggest the patient use to prevent skin breakdown? Select all that apply. 1. Avoid lotions containing calamine. 2. Add baking soda to the water in a tub bath. 3. Keep nails short and clean. 4. Rub the skin when it itches with knuckles instead of nails. 5. Massage skin with alcohol. 6. Increase sodium intake in diet.

2, 4, 5 Metabolic acidosis is due to an increase in the production or retention of acid or the depletion of bicarbonate via the kidneys or gastrointestinal (GI) tract. In metabolic acidosis there is a decrease in pH (<7.35) and HCO3- (<22 mEq [22 mmol/L]). Common causes of metabolic acidosis include: GI bicarbonate losses (eg, diarrhea) (Option 2) Ketoacidosis (eg, diabetes, alcoholism, starvation) Lactic acidosis (eg, sepsis, hypoperfusion) (Option 4) Renal failure (eg, hemodialysis with inaccessible arteriovenous shunt) (Option 5) Salicylate toxicity (Option 1) A client with claustrophobia who was stuck in an elevator is at risk for an anxiety attack, which leads to hyperventilation and respiratory alkalosis (pH >7.45, PaCO2 <35 mm Hg [4.66 kPa]). (Option 3) A client with excessive vomiting is at risk for metabolic alkalosis due to loss of stomach acid.

The emergency department nurse cares for 5 clients. Which of the clients below are at risk for developing metabolic acidosis? Select all that apply. 1. 25-year-old client with claustrophobia who was stuck in an elevator for 2 hours 2. 36-year-old client with food poisoning and severe diarrhea for the past 3 days 3. 40-year-old client with 3-day history of chemotherapy-induced vomiting 4. 75-year-old client with pyelonephritis and hypotension 5. 82-year-old client due for hemodialysis with clotted arteriovenous shunt

3 In CF, unusually thick mucus obstructs the pancreatic ducts, preventing pancreatic enzymes (amylase, trypsin, and lipase) from reaching the small intestine. The result is malabsorption of carbohydrates, fats, and proteins; the inability to absorb fat-soluble vitamins (A, D, E, and K) is of particular concern. Gastrointestinal signs and symptoms of CF include flatulence, abdominal cramping, ongoing diarrhea, and/or steatorrhea. Nutritional therapy includes the administration pancreatic enzyme supplements with or just before every meal or snack (Option 2). These enzymes are enteric-coated beads designed to dissolve only in an alkaline environment similar to that of the small intestine. They must not be mixed with a substance that would cause them to dissolve prior to reaching the jejunum. Capsule contents may be sprinkled on applesauce, yogurt, or acidic, soft, room-temperature foods with pH <4.5. Capsules should be swallowed whole and not crushed or chewed; chewing the capsules could cause irritation of the oral mucosa. Excessive intake of pancreatic enzymes can result in fibrosing colonopathy (Option 1). (Option 4) This is a true statement; some children have difficulty taking a whole capsule. Capsule contents can be sprinkled in acidic substances such as applesauce. Capsules should not be taken with milk as they can cause it to curdle.

The mother of a 6-year-old child with cystic fibrosis (CF) has received instruction on the use of pancreatic enzymes. Which statement made by the mother indicates a need for further teaching? 1. "I need to monitor the total amount of this medication that I give to my child every day." 2. "I should give this medication with or just before my child has a meal or snack." 3. "It is okay for my child to chew this medication." 4. "It is okay to open the capsule and sprinkle the medicine on a tablespoon of applesauce."

1. Black tarry The nurse would expect a client experiencing an upper gastrointestinal bleed to have black tarry stools (melena). As blood passes through the GI tract, digestion of the blood ensues, producing the black tarry appearance. Bright red blood stool (hematochezia) would indicate a lower GI hemorrhage. Decreased bile flow into the intestine due to biliary obstruction would produce a light gray "clay colored" stool. Small, dry, rocky-hard masses are an indication of constipation. Inactivity, slow peristalsis, low intake of fiber in the diet, decreased fluid intake, and some medications (anticholinergics) may contribute to constipation.

The nurse assessing the patient with an upper gastrointestinal bleed would expect the patient's stool to have which appearance? 1. Black tarry 2. Bright red bloody 3. Light gray "clay colored" 4. Small, dry, rocky-hard masses

60mL 30 mL = 1oz The following formula is used to calculate the correct dosage: 30mL/1oz = XmL/2oz X = 60mL

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

4. pneumonia The patient with acute pancreatitis is prone to complications associated with the respiratory system. Pneumonia, atelectasis, and pleural effusion are examples of respiratory complications that can develop as a result of pancreatic enzyme exudate. Pancreatitis does not cause heart failure, ulcer formation, or cirrhosis.

The nurse should monitor the patient with acute pancreatitis for which complication? 1. heart failure 2. duodenal ulcer 3. cirrhosis 4. pneumonia

4. Raise the head of the bed Elevating the head of the bed will allow for increased lung expansion by decreasing the ascites pressing on the diaphragm. The patient requires reassessment. A paracentesis is reserved for symptomatic clients with ascites with impaired respiration or abdominal pain not responding to other measures such as sodium restriction and diuretics. There is no indication for blood cultures. Heart sounds are assessed with the routine physical assessment.

The nurse is reviewing the chart information for a patient with increased ascites. The data include the following: temperature of 98.9F, heart rate 118 bpm, shallow respirations 26/min, blood pressure 128/76 mm Hg, and SpO2 89% on room air. The nurse should first: 1. Assess heart sounds 2. obtain a prescription for blood cultures 3. prepare for paracentesis 4. raise the head of the bed

4 Hypomagnesemia, a low blood magnesium level (normal 1.5-2.5 mEq/L [0.75-1.25 mmol/L]), is associated with alcohol abuse due to poor absorption, inadequate nutritional intake, and increased losses via the gastrointestinal and renal systems. It is associated with 2 major issues: Ventricular arrhythmias (torsades de pointes): This is the most serious concern (priority). Neuromuscular excitability: Manifestations of low magnesium, similar to those found in hypocalcemia and demonstrated by neuromuscular excitability, include tremors, hyperactive reflexes, positive Trousseau and Chvostek signs, and seizures. (Option 1) Constipation and polyuria indicate hypercalcemia. Calcium has a diuretic effect. (Option 2) Increased thirst with dry mucous membranes indicates hypernatremia. (Option 3) Hypokalemia results in muscle weakness/paralysis and soft, flabby muscles. Paralytic ileus (abdominal distension, decreased bowel sounds) is also common with hypokalemia. However, the most serious complication is cardiac arrhythmias.

The nurse prepares to assess a newly admitted client diagnosed with chronic alcohol abuse whose laboratory report shows a magnesium level of 1.0 mEq/L (0.5 mmol/L). Which assessment finding does the nurse anticipate? 1. Constipation and polyuria 2. Increased thirst and dry mucous membranes 3. Leg weakness and soft, flabby muscles 4. Tremors and brisk deep-tendon reflexes

3. observing stools for steatorrhea If the dosage and administration of pancreatic enzymes are adequate, the patient's stool will be relatively normal. Any increase in odor or fat content would indicate the need for dosage adjustment. Stable body weight would be another indirect indicator. Fluid intake does not affect enzyme replacement therapy. If diabetes has developed, the patient will need to monitor glucose levels. However, glucose and ketone levels are not affected by pancreatic enzymes therapy and would not indicate the effectiveness of therapy.

The nurse should teach the patient with chronic pancreatitis to monitor the effectiveness of pancreatic enzyme replacement therapy by: 1. recording daily fluid intake 2. performing glucose fingerstick tests twice a day 3. observing stools for steatorrhea 4. testing urine for ketones

1. Avoid crash dieting Crash dieting or bingeing may cause an acute attack of pancreatitis and should be avoided. Carbohydrate intake should be increased because carbohydrates are less stimulating to the pancreas. There is no need to maintain a dietary pattern of six meals a day; the patient can eat whenever desired. There is no need to place the patient on a sodium-restricted diet because pancreatitis does not promote fluid retention.

Which dietary instruction would be appropriate for the nurse to give to a patient who is recovering from acute pancreatitis? 1. Avoid crash dieting. 2. Restrict carbohydrate intake. 3. Eat six small meals a day. 4. Decrease sodium in the diet.

1. Fowler's Ascites can compromise the action of the diaphragm and increase the patient's risk of respiratory problems. Ascites also greatly increases the risk of skin breakdown. Frequent position changes are important, but the preferred position is Fowler's. Placing the patient in Fowler's position helps facilitate the patient's breathing by relieving pressure on the diaphragm. The other positions do not relieve pressure on the diaphragm.

Which position would be appropriate for a patient with severe ascites? 1. Fowler's 2. Side-lying 3. Reverse Trendelenburg 4. Sims

2. With each meal and snack In chronic pancreatitis, destruction of pancreatic tissue requires pancreatic enzyme replacement. Pancreatic enzymes are prescribed to facilitate the digestion of proteins and fats and should be taken in conjunction with every meal and snack. Specified hours or limited times for administration are ineffective because the enzymes must be taken in conjunction with food ingestion.

Pancreatic enzyme replacements are prescribed for the patient with chronic pancreatitis. When should the nurse instruct the patient to take them to obtain the most therapeutic effect? 1. Three times daily between meals 2. With each meal and snack 3. In the morning and at bedtime 4. Every 4 hours, at specified times

1. furosemide Furosemide can cause pancreatitis. Additionally, hypovolemia can develop with acute pancreatitis, and furosemide will further deplete fluid volume. Imipenem is indicated in the treatment of acute pancreatitis with necrosis and infection. Research no longer supports meperidine over other opiates. Morphine and hydromorphone are opiates of choice in acute pancreatitis to get pain under control. Famotidine is a histamine-2 receptor antagonist used to decrease acid secretion and prevent stress or peptic ulcers

The nurse should question which prescription for medications for a patient with acute pancreatitis? 1. furosemide 20 mg IV push 2. imipenem 500 mg IV 3. morphine sulfate 2 mg IV push 4. famotidine 20 mg IV push

B. Hepatic encephalopathy Major Takeaway Chronic liver disease patients are prone to hepatic encephalopathy, which may be associated with spontaneous bacterial peritonitis. Other more dangerous causes for altered mental status must also be ruled out. Main Explanation Altered mental status in chronic liver patients has a number of potentially dangerous etiologies. Once more serious causes - such as GI bleeding, intracranial hemorrhage, meningitis/encephalitis, and severe sepsis - have been excluded, a diagnosis of hepatic encephalopathy can be entertained. This disease is a clinical diagnosis made on the basis of excluding other potentially fatal causes of altered mental status. The typical patient with hepatic encephalopathy has chronic liver disease and experiences the acute onset of forgetfulness, confusion, altered states of arousal (e.g. lethargy, or even a flipped sleep schedule), and sometimes asterixis. Hepatic encephalopathy is suspected to occur due to increased toxin buildup in the blood caused by decreased liver function.

A 65-year-old man with a history of alcoholic cirrhosis and ascites comes to the emergency department because of 7 days of worsening confusion and impaired memory. For the past 2 days, he has been increasingly agitated at night and spends a large portion of the daytime asleep. He denies diarrhea, melena, hematemesis, impaired balance, and double vision. He takes no medications. His temperature is 37.7°C (100°F), pulse is 90/min, respirations are 16/min, and blood pressure is 130/74 mm Hg. Abdominal examination shows a tender, distended abdomen with shifting dullness. The rest of the examination and a computed tomography scan of the head show no other abnormalities. Urinalysis and fecal occult blood test show no abnormalities. Serum laboratory results are shown below: Ethanol: 0.0 mg/dL Leukocytes: 8,500/mm3 Total bilirubin: 0.9 mg/dL AST: 75 U/L ALT: 62 U/L Phosphatase (alkaline): 87 U/L Which of the following is the most appropriate diagnosis? A. Alzheimer dementia B. Hepatic encephalopathy C. Intracranial hemorrhage D. Urinary tract infection E. Wernicke encephalopathy

4 The client should be asked to perform the Valsalva maneuver during tubing changes. This helps avoid air embolism during tubing changes. The nurse asks the client to take a deep breath, hold it, and bear down. If the intravenous line is on the right, the client turns his or her head to the left. This position increases intrathoracic pressure. Breathing normally and exhaling slowly and evenly are inappropriate and could enhance the potential for an air embolism during the tubing change.

The nurse is preparing to change the parenteral nutrition solution bag and tubing. The client's central venous line is located in the right subclavian vein. The nurse asks the patient to take which essential action during the tubing change? 1. Breathe normally 2. Turn the head to the right. 3. Exhale slowly and evenly 4. Take a deep breath, hold it, and bear down.

3 Cirrhosis is a progressive, degenerative disease caused by destruction and subsequent disordered regeneration of the liver parenchyma. Clients with cirrhosis suffer from various complications (eg, ascites, varices, encephalopathy) that will progressively intensify without lifestyle modifications. (Option 1) Alcoholism is one of the leading causes of cirrhosis. All clients with alcoholism should abstain from drinking to prevent further liver damage. (Option 2) Aspirin and ibuprofen (a nonsteroidal anti-inflammatory drug [NSAID]) may cause gastrointestinal bleeding. Clients with esophageal varices or portal hypertension have an increased risk of bleeding and should avoid these medications. They should contact the health care provider regarding any pain or fever. (Option 4) Although a low-sodium diet is important to prevent worsening hypertension and ascites, a low-protein diet is not usually recommended. Many clients with cirrhosis suffer from protein-calorie malnutrition; therefore, an intake of 1.2-1.5 g/kg of protein a day is commonly prescribed.

The nurse provides discharge instructions to a client with cirrhosis who has portal hypertension, ascites, and esophageal varices. Which statement by the client indicates that the teaching was effective? 1. "I may have one alcoholic drink a day, but no more." 2. "I may take aspirin instead of acetaminophen for fever or pain." 3. "I should avoid straining while having a bowel movement." 4. "I should eat a protein- and sodium-restricted diet."

2. Place an intravenous line Grey Turner's sign is a bluish discoloration in the flank area caused by retroperitoneal bleeding. The vital signs are showing hemodynamic instability. IV access should be obtained to provide immediate volume replacement. The urine output will provide information on the fluid status. A nasogastric tube is indicated for clients with uncontrolled nausea and vomiting or gastric distention. Repositioning the client may be considered for pain management once the client's vital signs are stable.

A patient with acute pancreatitis has a blood pressure of 88/40 mm Hg, heart rate of 128 bpm, respirations of 28/min, and Grey Turner's sign. What prescription should the nurse implement first? 1. Initiate intake/output record 2. Place an intravenous line 3. Position on the left side 4. Insert a nasogastric tube.

3. increased bowel movements Lactulose increases intestinal motility, thereby trapping and expelling ammonia in the feces. An increase in the number of bowel movements is expected as an adverse effect. Lactulose does not affect urine output. Any improvements in mental status would be the result of increased ammonia elimination, not an adverse effect of the drug. Nausea and vomiting are not common adverse effects of lactulose.

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

1. Hypocalcemia develops in severe cases of acute pancreatitis. The exact cause is unknown. Sign and symptoms of hypocalcemia include jerking and muscle twitching, numbness of the fingers and lips, and irritability. Meperidine may cause tremors or seizures as an adverse effect, but not muscle twitching. Muscle twitching is not caused by a nutritional deficit, not dies it indicate that the client needs a muscle relaxant.

The nurse notes that a patient with acute pancreatitis occasionally experiences muscle twitching and jerking. How should the nurse interpret the significance of these symptoms? 1. The patient may be developing hypocalcemia. 2. The patient is experiencing a reaction to meperidine. 3. The patient has a nutritional imbalance. 4. The patient needs a muscle relaxant to promote rest.

2 Jaundice is associated with elevated bilirubin levels and yellowing of the sclera (icterus). It often causes intense itching that can be exacerbated by the use of hot water and strong soaps. Therefore, when delegating hygiene tasks, the registered nurse should instruct the unlicensed assistive personnel to use cool water and the minimum necessary amount of mild soap (Options 2, 3, and 4). (Option 1) The client with jaundice due to liver disease may be at risk for falls and requires supervision during a shower. However, unsteadiness and confusion is not evident in this scenario; therefore, this is not the best answer.

The nurse is caring for an alert client with jaundice, scleral icterus, and a bilirubin level of 12.3 mg/dL (210 µmol/L). Which instruction would be most important to include when delegating the client's morning hygiene tasks to unlicensed assistive personnel? 1. Do not leave the client alone in the shower 2. Use cool water in the shower 3. Use hot water in the shower 4. Wash client with antibacterial soap

3 A person with sudden kidney failure that will require immediate dialysis will have a central venous catheter placed. The catheter will be used until an AVG or AVF can be placed and is ready for use. The catheter should always be the last access option for long-term dialysis due to risk of infection and mechanical malfunction (eg, thrombosis). (Options 1 and 2) An AVF or AVG will require several days to weeks to mature prior to first use. (Option 4) Excess fluid and solutes are removed at a more gradual rate with peritoneal dialysis. This slower rate of metabolite removal is a disadvantage in sudden kidney failure. It is more helpful for clients who want dialysis at home or in an ambulatory setting as it requires multiple exchanges per day.

A client requires immediate dialysis after suffering sudden kidney failure. What is the most appropriate procedure for which the nurse should prepare the client? 1. Arteriovenous fistula (AVF) placement in the arm 2. Arteriovenous graft (AVG) placement in the arm 3. Central line placement in the groin area 4. Peritoneal dialysis catheter placement in the abdomen

1, 2, 3 Hepatic encephalopathy is a serious complication of end-stage liver disease (ESLD) that results from inadequate detoxification of ammonia from the blood. Symptoms include lethargy, confusion, and slurred speech; coma can occur if this condition remains untreated. Asterixis, or a flapping tremor of the hands when the arms are extended with the hands facing forward, may also be noted in the client with encephalopathy. The client with ESLD exhibiting confusion and lethargy should be evaluated for worsening encephalopathy by assessing for asterixis and comparing current mental status and ammonia level to previous findings. If encephalopathy continues to worsen, medical treatment should include higher doses of lactulose and rifaximin, and discharge should be delayed until the client is stable. (Option 4) The client with lethargy and confusion is at risk for falling. Ambulation is not an appropriate intervention at this point. (Option 5) Lactulose is the primary drug used for hepatic encephalopathy treatment. It helps to excrete ammonia through the bowels as soft or loose stools. Lactulose should not be held if the client's hepatic encephalopathy continues to worsen.

During morning rounds, the nurse notices that a client admitted 3 days ago with hepatic encephalopathy is sleepy and confused. The client is scheduled for discharge later today. Which interventions are appropriate for the nurse to implement? Select all that apply. 1. Assess the client's hand movements with the arms extended 2. Compare current mental status findings with those from previous shifts 3. Contact the health care provider to request a blood draw for ammonia level 4. Encourage the client to ambulate in the hallway 5. Hold the client's morning dose of lactulose

4. Patient with severe acute pancreatitis who has inspiratory crackles at the lung bases Patients with acute pancreatitis can develop respiratory complications including pleural effusions, atelectasis, and ARDS. These complications are often due to activated pancreatic enzymes and cytokines that are released from the pancreas into the circulation and cause focal or systemic inflammation. ARDS is the most severe form of these complications and can rapidly progress to respiratory failure within a few hours. Therefore, the presence of inspiratory crackles in this patient could indicate early ARDS and needs to be assessed further for progression. Fine crackles are a series of distinct, discontinuous, and high-pitched snapping sounds usually heard on inspiration. The sound originates as small atelectatic bronchioles quickly reinflate and can be expected in patients who have undergone abdominal surgery due to shallow breathing related to pain. Although the presence of fine crackles requires treatment, this is not the priority assessment. Rhonchi are continuous, low-pitched wheezes usually heard on expiration that sound like moaning or snoring. The sound originates from air moving through large airways (bronchi_ filled with mucus secretions are are expected in patients with chronic bronchitis. Although they require treatment, this is not the priority assessment. The lung under the pleural efusion is compressed, and the breath sounds are decreased/absent if auscultated over the area; this is an expected finding. Until the pleural effusion is treated with diuretics or thoracentesis, these findings will remain unchanged.

Based on the lung assessment information included in the hand-off report, which patient should the nurse assess first? 1. Patient 1-day postoperative abdominal surgery who has fine inspiratory crackles at the lung bases 2. Patient with chronic bronchitis who has rhonchi in the anterior and posterior chest 3. Patient with right-sided pleural effusion who has decreased breath sounds at the right lung base 4. Patient with severe acute pancreatitis who has inspiratory crackles at the lung bases

4 Peritoneal dialysis (PD) is a process that uses the abdominal lining (peritoneum) as a semipermeable membrane to dialyze a client whose kidneys are not functioning properly. A catheter is placed in the peritoneal cavity for infusing dialysate (dialysis fluid). Dialysate is infused into the cavity and then the tubing is clamped to allow the fluid to dwell for a specified period. After the specified dwell time, the catheter is unclamped and the fluid (effluent) drains out via gravity. Waste products and electrolytes cross the membrane into the dialysate during the dwell time with the aid of added osmotic agents. Peritonitis, an infection of the peritoneal cavity, is a major concern with PD. There is also a risk for infection at the catheter exit site, which can lead to peritonitis if untreated. Using sterile technique when spiking and attaching bags of dialysate fluid to the client's catheter is a priority to prevent contamination and decrease the incidence of infection. Any signs of developing complications (eg, cloudy effluent, low-grade fever, redness or tenderness of the exit site) should be reported to the health care provider. (Option 1) The catheter drainage bag is placed below the level of the abdomen to aid gravity in fluid outflow (effluent). The placement is important but not the highest priority. (Option 2) The client is typically placed in Fowler's or semi-Fowler's position to utilize gravity. If the outflow becomes sluggish, the client can be turned from side to side to increase flow. The positioning is important but not a priority. (Option 3) Cloudy effluent indicates infection, bloody effluent indicates possible perforation, and brown effluent indicates suspected bowel perforation. Therefore, documenting the effluent characteristics is important but not a priority over sterile technique (prevention).

The nurse prepares to instill dialysate for a client receiving peritoneal dialysis. Which nursing action is priority? 1. Ensuring that the drainage collection bag is below the level of the abdomen 2. Placing the client in semi-Fowler's position 3. Recording the characteristics (eg, color) of output dialysate 4. Using sterile technique when spiking and attaching the bag of dialysate

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