الصفحات الشخصية



28. The client asks how he contracted hepatitis A. Hereports all of the following. Which one is mostlikely related to hepatitis A?2. He ate oysters his roommate brought home froma fishing trip.3. He stepped on a nail two weeks ago.4. He donated blood two weeks before he got sick.29. A client has had a liver biopsy. After theprocedure, the nurse should position him on hisright side with a pillow under his rib cage. What isthe primary reason for this position?1. To immobilize the diaphragm2. To facilitate full chest expansion3. To minimize the danger of aspiration4. To reduce the likelihood of bleeding30. A client with cirrhosis is about to have aparacentesis for relief of ascites. Which activity isessential prior to the procedure?1. Administer thorough mouth care.2. Ask the client to empty his bladder.3. Be sure his bowels have moved recently.4. Have the client bathe with betadine.31. The client has severe liver disease. Which ofthe following observations is most indicative ofserious problems?1. The client has generalized urticaria.2. The client is “confused” and can no longerwrite his name legibly.3. The client is jaundiced.4. The client has ecchymotic areas on his arms.Nursing Care of Clients with Disordersof the GallbladderA 45-year-old client is suspected of having cholecystitis.119. When describing the discomfort to the nurse, theclient is most likely to indicate that the pain worsens atwhich time?[ ] 1. Shortly after eating[ ] 2. When the stomach is empty[ ] 3. After periods of activity[ ] 4. Before rising in the morning120. If this client is typical of others with cholecystitis,besides localized pain, the client may describe feeling painthat is referred to which area?[ ] 1. Right shoulder[ ] 2. Midepigastrium[ ] 3. Neck or jaw[ ] 4. Left upper arm121. If the cause of the client’s infl amed gallbladder isgallstones, the nurse would anticipate the laboratory datato indicate which fi nding?[ ] 1. Low red blood cell count[ ] 2. Low hemoglobin level[ ] 3. Elevated cholesterol level[ ] 4. Elevated serum albumin level122. If gallstones obstruct the fl ow of bile, how wouldthe nurse expect the client’s stools to appear?[ ] 1. Black and tarry[ ] 2. Light clay-colored[ ] 3. Brown with bloody mucus[ ] 4. Greenish yellow123. When the dietitian has fi nished instructing the clientabout a low-fat diet, the nurse knows that the clientrequires additional teaching based on which statement?[ ] 1. “I can eat chicken that has been broiled.”[ ] 2. “Because fi sh is good for me, I’ll still get to eat alot of baked fi sh.”[ ] 3. “I can have a hamburger and fries when I go outwith friends.”[ ] 4. “I guess I’ll eat more roasted turkey for dinner.”Because the client’s gallbladder was unable to concentrateand excrete bile, it could not be visualized by cholecystography.The physician orders an ultrasound of the gallbladder.The nurse explains the scheduled procedure to the client.124. Which comment indicates that the client has anaccurate understanding of the preparation necessary for theprocedure?[ ] 1. “Preparation involves withholding food forapproximately 8 to 12 hours.”[ ] 2. “I’ll need to drink a container of barium just beforethe X-ray.”[ ] 3. “I’ll be allowed to eat a large test meal the nightbefore the X-ray.”[ ] 4. “Just before the test, they’ll insert a large needleinto one of my arm veins.”Ultrasound of the client’s gallbladder reveals severalstones in the common bile duct. A laparoscopic cholecystectomyis scheduled.125. Which statements made by the nurse provide thebest explanations of this procedure? Select all that apply.[ ] 1. The procedure will require moderate sedation.[ ] 2. The surgery will require a long period of gastricdecompression.[ ] 3. The abdomen will be infl ated with carbon dioxideto provide a maximum view.[ ] 4. There will be four small puncture sites.[ ] 5. Most clients return home the evening after theprocedure.[ ] 6. A T-tube is inserted to drain bile until the surgicalwound heals.Another client comes to the clinic with signs and symptomsrelated to gallbladder disease but is not a candidate for alaparoscopic cholecystectomy. The surgeon schedules anopen cholecystectomy.The client returns from surgery with a nasogastric tube,a T-tube for bile drainage, and a Jackson-Pratt tube forwound drainage in place.126. Immediately after surgery, the nurse assesses thedrainage from the T-tube. Which assessment fi nding bestindicates that the drainage color is normal at this time?[ ] 1. The drainage is dark red or pale pink.[ ] 2. The drainage is clear or transparent.[ ] 3. The drainage is bright red or orange.[ ] 4. The drainage is greenish yellow or brown.127. The nurse is required to take which actions whenemptying the drainage receptacle of the client’s Jackson-Pratt closed-wound drain? Select all that apply.[ ] 1. Empty the drainage into a measuring container.[ ] 2. Adjust the suction setting to low continuous suction.[ ] 3. Squeeze the receptacle to expel air.[ ] 4. Release the roller clamp.[ ] 5. Cover the vent.[ ] 6. Stabilize the drainage tube.128. The nurse should anticipate implementing whichinterventions to manage this client’s T-tube? Select all thatapply.[ ] 1. Record the amount of drainage from the T-tube.[ ] 2. Unclamp the T-tube at hourly intervals.[ ] 3. Keep the T-tube drainage bag parallel with theincision.[ ] 4. Inspect the skin around the tube for irritation.[ ] 5. Maintain the client in Fowler’s position.[ ] 6. Notify the physician if the drainage changes color.129. When the nurse assesses the T-tube in the earlypostoperative period, which fi nding requires immediateaction?[ ] 1. The drainage bag is hanging below the abdomen.[ ] 2. The drainage tubing is currently clamped.[ ] 3. The drainage tube is taped to the client’s right side.[ ] 4. The drainage volume was 100 mL in the past 6 hours.130. When the client begins to consume food again,which routine for clamping and unclamping the T-tubeshould the nurse plan to follow?[ ] 1. Unclamp the tube during the day.[ ] 2. Unclamp the tube during the night.[ ] 3. Unclamp the tube for 2 hours after eating.[ ] 4. Unclamp the tube for 2 hours before eating.131. How would the nurse reestablish negative pressurewithin the Jackson-Pratt tube when emptying the drainagebulb reservoir?[ ] 1. By compressing the bulb reservoir and closing thedrainage valve[ ] 2. By opening the drainage valve, allowing the bulbto fi ll with air[ ] 3. By fi lling the bulb reservoir with sterile normalsaline solution[ ] 4. By securing the bulb reservoir to the skin near thewoundNursing Care of Clients with Disordersof the LiverA 20-year-old college student goes to the universityhealth service after developing a sudden onset of fl ulikesymptoms.132. When the health nurse monitors the client’s laboratorytest results, which elevated level would strongly suggesta possible liver disorder?[ ] 1. Serum potassium[ ] 2. Serum creatinine[ ] 3. Blood urea nitrogen (BUN)[ ] 4. Alanine aminotransferase (ALT)The physician determines that the college student hashepatitis A.133. When the client asks the nurse how the hepatitis Awas acquired, what is the best answer?[ ] 1. Fecal-oral route[ ] 2. Insect carriers[ ] 3. Infected blood[ ] 4. Wound drainageAn infection control nurse is consulted on measures forreducing the potential transmission of the hepatitis A virusto others.134. On the basis of the routes of transmission for thisdisease, which infection control measure is essential toinclude in the client’s care plan?[ ] 1. Wear gloves whenever entering the client’s room.[ ] 2. Don a mask and gown when providing direct care.[ ] 3. Maintain the client in a private room at all times.[ ] 4. Perform vigorous hand washing after leaving theroom.Several of the college student’s friends call the healthservice because they are concerned about their own risksfor acquiring hepatitis A.135. To prevent the spread of hepatitis A, the nursecorrectly advises that close contacts receive whichmedication?[ ] 1. An antibiotic[ ] 2. Serum immunoglobulin[ ] 3. Hepatitis vaccine[ ] 4. An anti-infl ammatory drugA 23-year-old develops jaundice and goes to the publichealth department. Testing reveals that the cause of theclient’s jaundice is hepatitis B. The nurse gathers informationregarding the client’s social history.136. What information from the client’s history indicatesa predisposition for acquiring hepatitis B? Select all thatapply.[ ] 1. The client moved from Europe.[ ] 2. The client is a sexually active homosexual.[ ] 3. The client abuses alcohol.[ ] 4. The client works in a restaurant.[ ] 5. The client has had a blood transfusion.[ ] 6. The client was punctured with an unused needle.137. Which measure is most appropriate if a nurse whohas not received a series of vaccinations for hepatitis Bexperiences a needle-stick injury while caring for thisclient?[ ] 1. Obtain immediate immunization with hepatitis Bvaccine.[ ] 2. Receive hepatitis B immunoglobulin within 1 week.[ ] 3. Take penicillin (Pentam) for a minimum of 10 days.[ ] 4. Scrub the puncture site with diluted householdbleach.138. The nurse informs the client that because of thedisease, it is essential to avoid which activity for life?[ ] 1. Sexual activity[ ] 2. Donating blood[ ] 3. Drinking alcohol[ ] 4. Traveling to foreign countriesA 60-year-old client seeks medical attention with symptomsof vomiting blood and passing bloody stools. Thetentative diagnosis is cirrhosis of the liver.139. Which information in the client’s health historymost likely relates to the development of cirrhosis? Selectall that apply.[ ] 1. The client drinks a fi fth of whiskey daily.[ ] 2. The client smokes two packs of cigarettes per day.[ ] 3. The client has a history of pancreatitis.[ ] 4. The client has been taking antihypertensive medicationsfor the past 15 years.[ ] 5. The client eats poorly as a consequence of beinghomeless for 5 years.[ ] 6. The client has been exposed to asbestos.140. If the client’s cirrhosis is advanced, what will thenurse expect to fi nd during the initial health assessment?Select all that apply.[ ] 1. Laboratory results revealing an elevated serumcholesterol level[ ] 2. The presence of spiderlike blood vessels onthe skin[ ] 3. An unusually large and edematous abdomen[ ] 4. An abnormally high blood glucose level[ ] 5. Skin that is jaundiced[ ] 6. Vein engorgement around the umbilicus141. Which assessment fi nding indicates that the client isbleeding from somewhere in the upper GI tract?[ ] 1. The client has midepigastric pain.[ ] 2. The client states, “I feel nauseated.”[ ] 3. The client’s stools are black and sticky.[ ] 4. The client’s abdomen is distended and boardlike.The physician considers performing a liver biopsy to confirm a diagnosis of cirrhosis.142. If the liver biopsy is performed, the nurse mustmonitor the client immediately after the procedure forwhich potential complication?[ ] 1. Hemorrhage[ ] 2. Infection[ ] 3. Blood clots[ ] 4. Collapsed lung143. After a liver biopsy, which nursing order is mostappropriate to add to the client’s care plan?[ ] 1. Ambulate the client twice each shift.[ ] 2. Keep the client in high Fowler’s position.[ ] 3. Position the client on the right side.[ ] 4. Elevate the client’s legs on two pillows.The physician orders magnetic resonance imaging (MRI)instead of the liver biopsy to confi rm the diagnosis.144. Before the magnetic resonance imaging (MRI)study is performed, which nursing action is essential?[ ] 1. Administering a pretest sedative[ ] 2. Removing the client’s dental bridge[ ] 3. Asking if the client is allergic to opiates[ ] 4. Inserting a Foley retention catheterThe care plan indicates that the nurse should monitor theclient with cirrhosis each day for signs and symptoms ofascites.145. To implement this nursing order, which nursingaction is most appropriate?[ ] 1. Reviewing the client’s serum bilirubin levels[ ] 2. Monitoring the client for vomiting and diarrhea[ ] 3. Pressing on the client’s abdomen testing forrebound tenderness[ ] 4. Measuring the client’s abdominal circumferenceMagnetic resonance imaging (MRI) confi rms the diagnosisof hepatic cirrhosis and reveals a large amount of fl uid inthe peritoneal cavity. A paracentesis is planned.146. Which nursing action is most appropriate beforeassisting with the paracentesis?[ ] 1. Asking the client to void[ ] 2. Withholding food and water[ ] 3. Clipping hair from the client’s abdomen[ ] 4. Placing the crash cart outside the client’s room147. After the paracentesis has been performed, whichnursing responsibility is essential?[ ] 1. Increasing the client’s oral fl uid intake[ ] 2. Recording the volume of withdrawn fl uid[ ] 3. Administering a prescribed analgesic[ ] 4. Encouraging the client to deep-breatheThe client’s I.V. line has infi ltrated and has to be removedand restarted in a new site. The licensed practical nurse(LPN) collaborates with the registered nurse (RN) aboutassisting with these procedures.148. Which nursing action is most appropriately delegatedto the LPN?[ ] 1. Clean the new insertion site with an antiseptic.[ ] 2. Flush the I.V. line with no more than 1 mL at anygiven time.[ ] 3. Obtain a vial of vitamin K to keep at the bedside.[ ] 4. Apply pressure to the old insertion site after I.V.removal.149. Which laboratory result, if elevated, is most indicativethat the client may develop hepatic encephalopathy?[ ] 1. Serum creatinine[ ] 2. Serum bilirubin[ ] 3. Blood ammonia[ ] 4. Blood urea nitrogen150. Which assessment fi nding best indicates that thecirrhotic client’s condition is worsening?[ ] 1. The client is diffi cult to arouse.[ ] 2. The client’s urine output is 100 mL/hour.[ ] 3. The client develops pancreatitis.[ ] 4. The client’s breath smells fruity.The seriousness of the client’s condition is explained to theclient’s spouse. The spouse is prepared for the possibilityof the client’s death.151. When the client’s spouse begins crying while recallingvarious signifi cant events they shared together, whichnursing action is most therapeutic at this time?[ ] 1. Offer to call a close family member.[ ] 2. Listen to the spouse’s expressions of thoughts.[ ] 3. Suggest calling a clergyman from their church.[ ] 4. Ask about the spouse’s future plans.The Client with Cholecystitis1. A client has undergone a laparoscopic cholecystectomy.Which of the following instructionsshould the nurse include in the discharge teaching?■ 1. Empty the bile bag daily.■ 2. If you become nauseated, breathe deeply intoa paper bag.■ 3. Keep adhesive dressings in place for 6 weeks.■ 4. Report bile-colored drainage from anyincision.2. A 40-year-old client is admitted to the hospitalwith a diagnosis of acute cholecystitis. The nurseshould contact the physician to question which ofthe following orders?■ 1. I.V. fl uid therapy of normal saline solutionto be infused at 100 mL/hour until furtherorders.■ 2. Administer morphine sulfate 10 mg I.M.every 4 hours as needed for severe abdominalpain.■ 3. Nothing by mouth (NPO) until further orders.■ 4. Insert a nasogastric tube and connect to lowintermittent suction.3. A client is admitted to the hospital with adiagnosis of cholecystitis from cholelithiasis. Theclient has severe abdominal pain, nausea, and hasvomited several times. Based on these data, whichnursing diagnosis would have the highest priorityfor intervention at this time?■ 1. Anxiety related to severe abdominal discomfort.■ 2. Defi cient fl uid volume related to vomiting.■ 3. Pain related to gallbladder infl ammation.■ 4. Imbalanced nutrition: Less than body requirementsrelated to vomiting.4. A client’s stools are light gray in color. Thenurse should assess the client further for which ofthe following? Select all that apply.■ 1. Intolerance to fatty foods.■ 2. Fever.■ 3. Jaundice.■ 4. Respiratory distress.■ 5. Pain at McBurney’s point.■ 6. Peptic ulcer disease.5. A client who has been scheduled to havea choledocholithotomy expresses anxiety abouthaving surgery. Which nursing intervention wouldbe the most appropriate to achieve the outcome ofanxiety reduction?■ 1. Providing the client with information aboutwhat to expect postoperatively.■ 2. Telling the client it is normal to be afraid.■ 3. Reassuring the client by telling her that surgeryis a common procedure.■ 4. Stressing the importance of following thephysician’s instructions after surgery.6. A client has an open cholecystectomy withbile duct exploration. Following surgery, the clienthas a T-tube. To evaluate the effectiveness of theT-tube, the nurse should:■ 1. Irrigate the tube with 20 mL of normal salineevery 4 hours.■ 2. Unclamp the T-tube and empty the contentsevery day.■ 3. Assess the color and amount of drainageevery shift.■ 4. Monitor the multiple incision sites for biledrainage.7. At 8 a.m., the nurse reviews the amount ofT-tube drainage for a client who underwent an opencholecystectomy yesterday. After reviewing the outputrecord (see chart), the nurse should:Output RecordDate T-tube12 pm 50 mL4 pm 60 mL8 pm 60 mL12 am 70 mL4 am 70 mL8 am 10 mL■ 1. Report the 24-hour drainage amount at12 noon.■ 2. Clamp the T-tube.■ 3. Evaluate the tube for patency.■ 4. Irrigate the T-tube.8. The nurse measures the amount of bile drainagefrom a T-tube and records it by which one of thefollowing methods?■ 1. Adding it to the client’s urine output.■ 2. Charting it separately on the output record.■ 3. Adding it to the amount of wound drainage.■ 4. Subtracting it from the total intake for eachday.9. After a cholecystectomy, the client is to followa low-fat diet. Which of the following foodswould be most appropriate to include in a low-fatdiet?■ 1. Cheese omelet.■ 2. Peanut butter.■ 3. Ham salad sandwich.■ 4. Roast beef.10. A client with cholecystitis continues to havesevere right upper quadrant pain. The nurse obtainsthe following vital signs: temperature 38.4° C; pulse114; respirations 22; blood pressure 142/90. Usingthe SBAR (Situation-Background-Assessment-Recommendation)technique for communication, thenurse recommends to the primary care provider forthe client to receive:■ 1. Hydromorphone (Dilaudid) I.V.■ 2. Diltiazem (Cardizem) PO.■ 3. Meperidine (Demerol) I.M.■ 4. Promethazine (Phenergan).11. The nurse prepares to administer promethazine(Phenergan) 35 mg I.M. as ordered p.r.n. fora client with cholecystitis complaining of nausea.The ampule label reads that the medication is availablein 25 mg/mL. How many milliliters should thenurse administer?______________________ mL.12. A client undergoes a laparoscopic cholecystectomy.Which of the following dietary instructionsshould the nurse give the client immediately aftersurgery?■ 1. “You cannot eat or drink anything for 24hours.”■ 2. “You may resume your normal diet the dayafter your surgery.”■ 3. “Drink liquids today and eat lightly for a fewdays.”■ 4. “You can progress from a liquid to a blanddiet as tolerated.”13. Which of the following discharge instructionswould be appropriate for a client who has hada laparoscopic cholecystectomy?■ 1. Avoid showering for 48 hours after surgery.■ 2. Return to work within 1 week.■ 3. Leave dressings in place until you see thesurgeon at the postoperative visit.■ 4. Use acetaminophen (Tylenol) to control anyfever.14. After a client who has had a laparoscopiccholecystectomy receives discharge instructions,which of the following client statements would indicatethat the teaching has been successful? Select allthat apply.■ 1. “I can resume my normal diet when I want.”■ 2. “I need to avoid driving for about 4 weeks.”■ 3. “I may experience some pain in my rightshoulder.”■ 4. “I should spend 2 to 3 days in bed beforeresuming activity.”■ 5. “I can wash the puncture site with mild soapand water.”The Client with Viral Hepatitis29. The nurse is assessing a client with chronichepatitis B who is receiving Lamivudine (Epivir).What information is most important to communicateto the physician?■ 1. The client’s daily record indicates a 3 kgweight gain over 2 days.■ 2. The client is complaining of nausea.■ 3. The client has a temperature of 99° F orally.■ 4. The client has fatigue.30. The nurse is assessing a client with hepatitisand notices that the AST and ALT lab values haveincreased. Which of the following statements by theclient requires further instruction by the nurse?■ 1. “I require increased periods of rest.”■ 2. “I follow a low-fat, high carbohydrate diet.”■ 3. “I eat dry toast to relieve my nausea.”■ 4. “I take acetaminophen (Tylenol) for arthritispain.”31. College freshman are participating in a studyabroad program. When teaching them about hepatitisB, the nurse should instruct the students on:■ 1. Water sanitation.■ 2. Single dormitory rooms.■ 3. Vaccination for hepatitis D.■ 4. Safe sexual practices.32. Which of the following is normal for a clientduring the icteric phase of viral hepatitis?■ 1. Tarry stools.■ 2. Yellowed sclera.■ 3. Shortness of breath.■ 4. Light, frothy urine.33. The nurse is planning a home visit for a clientwith hepatitis. In order to prevent transmissionthe nurse should focus teaching on:■ 1. Proper food handling.■ 2. Insulin syringe disposal.■ 3. Alpha-interferon.■ 4. Use of condoms34. A client who is recovering from hepatitis Ahas fatigue and malaise. The client asks the nurse,“When will my strength return?” Which of the followingresponses by the nurse is most appropriate?■ 1. “Your fatigue should be gone by now. We willevaluate you for a secondary infection.”■ 2. “Your fatigue is an adverse effect of your drugtherapy. It will disappear when your treatmentregimen is complete.”■ 3. “It is important for you to increase youractivity level. That will help decrease yourfatigue.”■ 4. “It is normal for you to feel fatigued. Thefatigue should go away in the next 2 to 4months.”35. The nurse is developing a plan of care for theclient with viral hepatitis. The nurse should instructthe client to:■ 1. Obtain adequate bed rest.■ 2. Increase fl uid intake.■ 3. Take antibiotic therapy as ordered.■ 4. Drink 8 oz of an electrolyte solution everyday.36. When planning care for a client with viralhepatitis, the nurse should review labororatoryreports for which of the following abnormal laboratoryvalues?■ 1. Prolonged prothrombin time.■ 2. Decreased blood glucose level.■ 3. Elevated serum potassium level.■ 4. Decreased serum calcium level.37. The nurse should teach the client with viralhepatitis to:■ 1. Limit caloric intake and reduce weight.■ 2. Increase carbohydrates and protein in thediet.■ 3. Avoid contact with others and live separately.■ 4. Intensify routine exercise and increasestrength.38. The nurse develops a teaching plan forthe client about how to prevent the transmissionof hepatitis A. Which of the following dischargeinstructions is appropriate for the client?■ 1. Spray the house to eliminate infected insects.■ 2. Tell family members to try to stay away fromthe client.■ 3. Tell family members to wash their hands frequently.■ 4. Disinfect all clothing and eating utensils.39. The nurse assesses that the client with hepatitisis experiencing fatigue, weakness, and a generalfeeling of malaise. The client tires rapidly duringmorning care. Based on this information, which ofthe following would be an appropriate nursing diagnosis?■ 1. Impaired physical mobility related to malaise.■ 2. Self-care defi cit related to fatigue.■ 3. Ineffective coping related to long-term illness.■ 4. Activity intolerance related to fatigue.40. What would be the nurse’s best response tothe client’s expressed feelings of isolation as a resultof having hepatitis?■ 1. “Don’t worry. It’s normal to feel that way.”■ 2. “Your friends are probably afraid of contractinghepatitis from you.”■ 3. “I’m sure you’re imagining that!”■ 4. “Tell me more about your feelings of isolation.”41. Interferon alfa-2b (Intron A) has been prescribedto treat a client with chronic hepatitis B.The nurse should assess the client for which of thefollowing adverse effects?■ 1. Retinopathy.■ 2. Constipation.■ 3. Flulike symptoms.■ 4. Hypoglycemia.42. The nurse is preparing a community educationprogram about preventing hepatitis B infection.Which of the following would be appropriate toincorporate into the teaching plan?■ 1. Hepatitis B is relatively uncommon amongcollege students.■ 2. Frequent ingestion of alcohol can predisposean individual to development of hepatitis B.■ 3. Good personal hygiene habits are most effectiveat preventing the spread of hepatitis B.■ 4. The use of a condom is advised for sexualintercourse.43. Which of the following expected outcomeswould be appropriate for a client with viral hepatitis?The client will:■ 1. Demonstrate a decrease in fl uid retentionrelated to ascites.■ 2. Verbalize the importance of reporting bleedinggums or bloody stools.■ 3. Limit use of alcohol to two to three drinks perweek.■ 4. Restrict activity to within the home to preventThe Client with Cirrhosis44. A client with cirrhosis is receiving Lactulose(Cephulac). During the assessment the nurse notesincreased confusion and asterixis. The nurse should:■ 1. Assess for GI bleeding.■ 2. Hold the Lactulose (Cephulac).■ 3. Increase protein in the diet.■ 4. Monitor serum bilirubin levels.45. The nurse is assessing a client with cirrhosiswho has developed hepatic encephalopathy. Thenurse should notify the physician of a decrease inwhich lab serum that is a potential precipitating factorfor hepatic encephalopathy?■ 1. Aldosterone.■ 2. Creatinine.■ 3. Potassium.■ 4. Protein.46. A client has advanced cirrhosis of the liver.The client’s spouse asks the nurse why his abdomenis swollen, making it very diffi cult for him tofasten his pants. How should the nurse respond toprovide the most accurate explanation of the diseaseprocess?■ 1. “He must have been eating too many foodswith salt in them. Salt pulls water with it.”■ 2. “The swelling in his ankles must have movedup closer to his heart so the fl uid circulatesbetter.”■ 3. “He must have forgotten to take his dailywater pill.”■ 4. “Blood is not able to fl ow readily through theliver now, and the liver cannot make proteinto keep fl uid inside the blood vessels.”47. A nurse is developing a care plan for a clientwith hepatic encephalopathy. Which of the followingare goals for the care for this client? Select allthat apply.■ 1. Preventing constipation.■ 2. Administering lactulose (Cephulac).■ 3. Monitoring coordination while walking.■ 4. Checking the pupil reaction.■ 5. Providing food and fl uids high in carbohydrate.■ 6. Encouraging physical activity.48. The nurse is assessing a client who is in theearly stages of cirrhosis of the liver. Which focusedassessment is appropriate?■ 1. Peripheral edema.■ 2. Ascites.■ 3. Anorexia.■ 4. Jaundice.49. A client with cirrhosis begins to developascites. Spironolactone (Aldactone) is prescribed totreat the ascites. The nurse should monitor the clientclosely for which of the following drug-relatedadverse effects?■ 1. Constipation.■ 2. Hyperkalemia.■ 3. Irregular pulse.■ 4. Dysuria.50. What diet should be implemented for a clientwho is in the early stages of cirrhosis?■ 1. High-calorie, high-carbohydrate.■ 2. High-protein, low-fat.■ 3. Low-fat, low-protein.■ 4. High-carbohydrate, low-sodium.51. A client with jaundice has pruritis and statesthat he has areas of irritation from scratching. Whatmeasures can the nurse discuss to prevent skinbreakdown? Select all that apply.■ 1. Avoid lotions containing calamine.■ 2. Take baking soda baths.■ 3. Keep nails short and clean.■ 4. Rub with knuckles instead of nails.■ 5. Massage skin with alcohol.■ 6. Increase sodium intake in diet.52. Which of the following health promotionactivities would be appropriate for the nurse to suggestthat the client with cirrhosis add to the dailyroutine at home?■ 1. Supplement the diet with daily multivitamins.■ 2. Limit daily alcohol intake.■ 3. Take a sleeping pill at bedtime.■ 4. Limit contact with other people wheneverpossible.53. The nurse is reviewing the chart informationfor a client with increased ascites. The data include:temperature 37.2° C; heart rate 118; shallow respirations26; blood pressure 128/76; and SpO2 89% onroom air. Which action should receive priority bythe nurse?■ 1. Assess heart sounds.■ 2. Obtain an order for blood cultures.■ 3. Prepare for a paracentesis.■ 4. Raise the head of the bed.54. Which of the following positions would beappropriate for a client with severe ascites?■ 1. Fowler’s.■ 2. Side-lying.■ 3. Reverse Trendelenburg.■ 4. Sims.55. The client with cirrhosis receives 100 mLof 25% serum albumin I.V. Which fi nding wouldbest indicate that the albumin is having its desiredeffect?■ 1. Increased urine output.■ 2. Increased serum albumin level.■ 3. Decreased anorexia.■ 4. Increased ease of breathing.56. The nurse is planning care for a client beingadmitted with bleeding esophageal varices. Vitalsigns are: Pulse 100; respiratory rate 22; and bloodpressure 100/58. The nurse should prepare the clientfor which of the following? Select all that apply.■ 1. Administration of intravenous Octreotide(Sandostatin).■ 2. Endoscopy.■ 3. Administration of a blood product.■ 4. Minnesota tube insertion.■ 5. Transjugular intrahepatic portosystemic shunt(TIPS) procedure.■ 6. Immediate endotracheal intubation.57. A client with a Sengstaken-Blakemore tubehas a sudden drop in SpO2 and increase in respiratoryrate to 40 breaths/minute. The nurse should dowhich of the following in order from fi rst to last?2. Remove the tube.3. Defl ate the tube by cutting with bedsidescissors.4. Apply oxygen via face mask.1. Affi rm airway obstruction by the tube.58. The physician orders oral neomycin (Mycifradin)as well as a neomycin enema for a clientwith cirrhosis. The expected outcome of this therapyis to:■ 1. Reduce abdominal pressure.■ 2. Prevent straining during defecation.■ 3. Block ammonia formation.■ 4. Reduce bleeding within the intestine.59. The nurse monitors a client with cirrhosis forthe development of hepatic encephalopathy. Whichof the following would be an indication that hepaticencephalopathy is developing?■ 1. Decreased mental status.■ 2. Elevated blood pressure.■ 3. Decreased urine output.■ 4. Labored respirations.60. A client’s serum ammonia level is elevated,and the physician orders 30 mL of lactulose (Cephulac).Which of the following is an adverse effect ofthis drug?■ 1. Increased urine output.■ 2. Improved level of consciousness.■ 3. Increased bowel movements.■ 4. Nausea and vomiting.61. The nurse has an order to administer 2 oz oflactulose (Cephulac) to a client who has cirrhosis.How many milliliters of lactulose should the nurseadminister?_______________________ mL.62. A client is to be discharged with a prescriptionfor lactulose (Cephulac). The nurse teaches theclient and the client’s spouse how to administerthis medication. Which of the following statementswould indicate that the client has understood theinformation?■ 1. “I’ll take it with Maalox.”■ 2. “I’ll mix it with apple juice.”■ 3. “I’ll take it with a laxative.”■ 4. “I’ll mix the crushed tablets in some gelatin.”63. The nurse is providing discharge instructionsfor a client with cirrhosis. Which of the followingstatements best indicates that the client has understoodthe teaching?■ 1. “I should eat a high-protein, high-carbohydratediet to provide energy.”■ 2. “It is safer for me to take acetaminophen(Tylenol) for pain instead of aspirin.”■ 3. “I should avoid constipation to decreasechances of bleeding.”■ 4. “If I get enough rest and follow my diet, it ispossible for my cirrhosis to be cured.”64. The nurse is preparing a client for a paracentesis.The nurse should:■ 1. Have the client void immediately before theprocedure.■ 2. Place the client in a side-lying position.■ 3. Initiate an I.V. line to administer sedatives.■ 4. Place the client on nothing-by-mouth (NPO)status 6 hours before the procedure.65. Which of the following interventions shouldthe nurse anticipate incorporating into the client’splan of care when hepatic encephalopathy initiallydevelops?■ 1. Inserting a nasogastric (NG) tube.■ 2. Restricting fl uids to 1,000 mL/day.■ 3. Administering I.V. salt-poor albumin.■ 4. Implementing a low-protein diet.66. A client with ascites and peripheral edemais at risk for impaired skin integrity. To prevent skinbreakdown, the nurse should:■ 1. Institute range-of-motion (ROM) exerciseevery 4 hours.■ 2. Massage the abdomen once a shift.■ 3. Use an alternating air pressure mattress.■ 4. Elevate the lower extremities.67. The nurse is planning a staff developmentprogram on how to care for clients with hepatitisA. Which of the following precautions should thenurse indicate as essential when caring for clientswith hepatitis A?■ 1. Gowning when entering a client’s room.■ 2. Wearing a mask when providing care.■ 3. Assigning the client to a private room.■ 4. Wearing gloves when giving direct care.68. The nurse’s assignment consists of the followingfour clients. From highest to lowest priority,in which order should the nurse assess the clientsafter receiving morning report?2. The client with acute pancreatitis who isrequesting pain medication.3. The client who is 1 day postoperative followinga cholecystectomy and has a T-tubeinserted.4. The client with hepatitis B who has questionsabout his discharge instructions.1. The client with cirrhosis who became confusedand disoriented during the night.69. The nurse should institute which of thefollowing measures to prevent transmission of thehepatitis C virus to health care personnel?■ 1. Administering hepatitis C vaccine to allhealth care personnel.■ 2. Decreasing contact with blood and bloodcontaminatedfl uids.■ 3. Wearing gloves when emptying the bedpan.■ 4. Wearing a gown and mask when providingdirect care.70. The nurse is taking care of a client who hasan I.V. infusion pump. The pump alarm rings. Whatshould the nurse do in order from fi rst to last?2. Determine if the infusion pump is pluggedinto an electrical outlet.3. Assess the client’s access site for infi ltration orinfl ammation.4. Assess the tubing for hindrances to fl ow ofsolution. ................
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