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Ultimate Evidence-Based Nursing Reference for Hepatic, Pancreatic, and Gastrointestinal Disorders: High-Yield Guide to Assessment, Laboratory Interpretation, Pathophysiology, Pharmacologic and Non-Pharmacologic Interventions, Acute and Chronic Management

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Ultimate Evidence-Based Nursing Reference for Hepatic, Pancreatic, and Gastrointestinal Disorders: High-Yield Guide to Assessment, Laboratory Interpretation, Pathophysiology, Pharmacologic and Non-Pharmacologic Interventions, Acute and Chronic Management of Hepatitis, Cirrhosis, Hepatopulmonary Syndrome, Portal Hypertension, Esophageal Varices, Ascites, Pancreatitis, Cholecystitis, Post-Surgical Care, Patient Education, Risk Reduction, Psychosocial Support, and Priority Nursing Actions for Safe and Effective Clinical Practice Exam Questions Verified and Provided with A+ Graded Rationales Latest Updated 2026 1. A nurse obtains a client's health history at a community health clinic. Which statement alerts the nurse to provide health teaching to this client? a. "I drink two glasses of red wine each week." b. "I take a lot of Tylenol for my arthritis pain." c. "I have a cousin who died of liver cancer." d. "I got a hepatitis vaccine before traveling." ANS: B Acetaminophen (Tylenol) can cause liver damage if taken in large amounts. Clients should be taught not to exceed 4000 mg/day of acetaminophen. The nurse should teach the client about this limitation and should explore other drug options with the client to manage his or her arthritis pain. Two glasses of wine each week, a cousin with liver cancer, and the hepatitis vaccine do not place the client at risk for a liver disorder, and therefore do not require any health teaching. A nurse cares for a client who has cirrhosis of the liver. Which action should the nurse take to decrease the presence of ascites? a. Monitor intake and output. b. Provide a low-sodium diet. c. Increase oral fluid intake. d. Weigh the client daily. ANS: B A low-sodium diet is one means of controlling abdominal fluid collection. Monitoring intake and output does not control fluid accumulation, nor does weighing the client. These interventions merely assess or monitor the situation. Increasing fluid intake would not be helpful. A nurse delegates hygiene care for a client who has advanced cirrhosis to an unlicensed nursing personnel (UAP). Which statements should the nurse include when delegating this task to the UAP? (Select all that apply.) a. "Apply lotion to the client's dry skin areas." b. "Use a basin with warm water to bathe the client." c. "For the client's oral care, use a soft toothbrush." d. "Provide clippers so the client can trim the fingernails." e. "Bathe with antibacterial and water-based soaps." ANS: A, C, D Clients with advanced cirrhosis often have pruritus. Lotion will help decrease itchiness from dry skin. A soft toothbrush should be used to prevent gum bleeding, and the client's nails should be trimmed short to prevent the client from scratching himself or herself. These clients should use cool, not warm, water on their skin, and should not use excessive amounts of soap. A nurse assesses a male client who has symptoms of cirrhosis. Which questions should the nurse ask to identify potential factors contributing to this laboratory result? (Select all that apply.) a. "How frequently do you drink alcohol?" b. "Have you ever had sex with a man?" c. "Do you have a family history of cancer?" d. "Have you ever worked as a plumber?" e. "Were you previously incarcerated?" ANS: A, B, E When assessing a client with suspected cirrhosis, the nurse should ask about alcohol consumption, including amount and frequency; sexual history and orientation (specifically men having sex with men); illicit drug use; history of tattoos; and history of military service, incarceration, or work as a firefighter, police officer, or health care provider. A family history of cancer and work as a plumber do not put the client at risk for cirrhosis. A nurse plans care for a client who has hepatopulmonary syndrome. Which interventions should the nurse include in this client's plan of care? (Select all that apply.) a. Oxygen therapy b. Prone position c. Feet elevated on pillows d. Daily weights e. Physical therapy ANS: A, C, D Care for a client who has hepatopulmonary syndrome should include oxygen therapy, the head of bed elevated at least 30 degrees or as high as the client wants to improve breathing, elevated feet to decrease dependent edema, and daily weights. There is no need to place the client in a prone position, on the client's stomach. Although physical therapy may be helpful to a client who has been hospitalized for several days, physical therapy is not an intervention specifically for hepatopulmonary syndrome. An emergency room nurse assesses a client with potential liver trauma. Which clinical manifestations should alert the nurse to internal bleeding and hypovolemic shock? (Select all that apply.) a. Hypertension b. Tachycardia c. Flushed skin d. Confusion e. Shallow respirations ANS: B, D Symptoms of hemorrhage and hypovolemic shock include hypotension, tachycardia, tachypnea, pallor, diaphoresis, cool and clammy skin, and confusion. A nurse assesses a client who has liver disease. Which laboratory findings should the nurse recognize as potentially causing complications of this disorder? (Select all that apply.) a. Elevated aspartate transaminase b. Elevated international normalized ratio (INR) c. Decreased serum globulin levels d. Decreased serum alkaline phosphatase e. Elevated serum ammonia f. Elevated prothrombin time (PT) ANS: B, E, F Elevated INR and PT are indications of clotting disturbances and alert the nurse to the increased possibility of hemorrhage. Elevated ammonia levels increase the client's confusion. The other values are abnormal and associated with liver disease but do not necessarily place the client at increased risk for complications. An infection control nurse develops a plan to decrease the number of health care professionals who contract viral hepatitis at work. Which ideas should the nurse include in this plan? (Select all that apply.) a. Policies related to consistent use of Stan

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Ultimate Evidence-Based Nursing Reference for
Hepatic, Pancreatic, and Gastrointestinal
Disorders: High-Yield Guide to Assessment,
Laboratory Interpretation, Pathophysiology,
Pharmacologic and Non-Pharmacologic
Interventions, Acute and Chronic Management of
Hepatitis, Cirrhosis, Hepatopulmonary Syndrome,
Portal Hypertension, Esophageal Varices, Ascites,
Pancreatitis, Cholecystitis, Post-Surgical Care,
Patient Education, Risk Reduction, Psychosocial
Support, and Priority Nursing Actions for Safe and
Effective Clinical Practice Exam Questions Verified
and Provided with A+ Graded Rationales Latest
Updated 2026


1. A nurse obtains a client's health history at a community health clinic. Which statement alerts
the nurse to provide health teaching to this client?
a. "I drink two glasses of red wine each week."
b. "I take a lot of Tylenol for my arthritis pain."
c. "I have a cousin who died of liver cancer."
d. "I got a hepatitis vaccine before traveling."

ANS: B
Acetaminophen (Tylenol) can cause liver damage if taken in large amounts. Clients should be
taught not to exceed 4000 mg/day of acetaminophen. The nurse should teach the client about
this limitation and should explore other drug options with the client to manage his or her
arthritis pain. Two glasses of wine each week, a cousin with liver cancer, and the hepatitis
vaccine do not place the client at risk for a liver disorder, and therefore do not require any
health teaching.

A nurse cares for a client who has cirrhosis of the liver. Which action should the nurse take to
decrease the presence of ascites?
a. Monitor intake and output.
b. Provide a low-sodium diet.

, c. Increase oral fluid intake.
d. Weigh the client daily.

ANS: B
A low-sodium diet is one means of controlling abdominal fluid collection. Monitoring intake and
output does not control fluid accumulation, nor does weighing the client. These interventions
merely assess or monitor the situation. Increasing fluid intake would not be helpful.

A nurse delegates hygiene care for a client who has advanced cirrhosis to an unlicensed nursing
personnel (UAP). Which statements should the nurse include when delegating this task to the
UAP? (Select all that apply.)
a. "Apply lotion to the client's dry skin areas."
b. "Use a basin with warm water to bathe the client."
c. "For the client's oral care, use a soft toothbrush."
d. "Provide clippers so the client can trim the fingernails."
e. "Bathe with antibacterial and water-based soaps."

ANS: A, C, D
Clients with advanced cirrhosis often have pruritus. Lotion will help decrease itchiness from dry
skin. A soft toothbrush should be used to prevent gum bleeding, and the client's nails should be
trimmed short to prevent the client from scratching himself or herself. These clients should use
cool, not warm, water on their skin, and should not use excessive amounts of soap.

A nurse assesses a male client who has symptoms of cirrhosis. Which questions should the
nurse ask to identify potential factors contributing to this laboratory result? (Select all that
apply.)
a. "How frequently do you drink alcohol?"
b. "Have you ever had sex with a man?"
c. "Do you have a family history of cancer?"
d. "Have you ever worked as a plumber?"
e. "Were you previously incarcerated?"

ANS: A, B, E
When assessing a client with suspected cirrhosis, the nurse should ask about alcohol
consumption, including amount and frequency; sexual history and orientation (specifically men
having sex with men); illicit drug use; history of tattoos; and history of military service,
incarceration, or work as a firefighter, police officer, or health care provider. A family history of
cancer and work as a plumber do not put the client at risk for cirrhosis.

A nurse plans care for a client who has hepatopulmonary syndrome. Which interventions should
the nurse include in this client's plan of care? (Select all that apply.)

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