N
,SG 233 Medical-Surgical Nursing III Exam 3
1. A nurse is providing discharge teaching to a client with newly diagnosed cirrhosis. Which
statement by the client indicates a need for further teaching?
A) "I should avoid alcohol completely."
B) "I can take acetaminophen for pain as long as I do not exceed 2,000 mg per day."
C) "I should eat a diet low in sodium to prevent fluid buildup."
D) "I should report any confusion or changes in sleep patterns to my provider."
Correct Answer: "I can take acetaminophen for pain as long as I do not exceed 2,000 mg per
day."
Rationale: Clients with cirrhosis have impaired hepatic metabolism and are at increased risk
for hepatotoxicity from acetaminophen. Even reduced doses (2,000 mg/day) can be harmful;
acetaminophen should be avoided or used only with provider approval. Alcohol avoidance,
sodium restriction, and reporting mental status changes are all appropriate teaching points for
a client with cirrhosis.
2. A client with hepatic encephalopathy is prescribed lactulose. The nurse should monitor for
which therapeutic effect?
A) Increased serum ammonia levels
B) Decreased serum ammonia levels
C) Increased serum bilirubin levels
D) Decreased serum albumin levels
Correct Answer: Decreased serum ammonia levels
Rationale: Lactulose is a nonabsorbable disaccharide that acidifies the colon, trapping
ammonia and promoting its excretion in the stool. The therapeutic effect is a decrease in
serum ammonia levels, which improves mental status. Increased ammonia, bilirubin, or
decreased albumin would indicate worsening hepatic function.
,3. A nurse is caring for a client with cirrhosis who has developed ascites. Which nursing
intervention is most appropriate for managing this condition?
A) Encourage a high-sodium diet
B) Restrict daily fluid intake to 1,500 mL
C) Administer spironolactone as prescribed
D) Elevate the head of the bed to 90 degrees
Correct Answer: Administer spironolactone as prescribed
Rationale: Spironolactone is a potassium-sparing diuretic commonly used to manage ascites in
cirrhosis by promoting fluid excretion. Sodium restriction (not high-sodium) is indicated; fluid
restriction may be needed but is not the primary intervention. Elevating the head of the bed
helps with respiratory effort from abdominal distension but does not directly manage ascites.
4. A client with cirrhosis develops hematemesis and is suspected of having bleeding
esophageal varices. Which medication should the nurse anticipate administering?
A) Lactulose
B) Rifaximin
C) Octreotide
D) Spironolactone
Correct Answer: Octreotide
Rationale: Octreotide is a synthetic somatostatin analogue that reduces portal pressure and
splanchnic blood flow, helping to control acute variceal bleeding. Lactulose and rifaximin are
used for hepatic encephalopathy, and spironolactone is used for ascites. Endoscopic band
ligation is also a primary intervention for bleeding varices.
5. A nurse is assessing a client with hepatic encephalopathy. Which finding is characteristic of
this condition?
A) Asterixis
B) Spider angiomas
, C) Palmar erythema
D) Jaundice
Correct Answer: Asterixis
Rationale: Asterixis (liver flap) is a characteristic finding in hepatic encephalopathy, a flapping
tremor of the hands when the wrists are extended. Spider angiomas, palmar erythema, and
jaundice are signs of chronic liver disease but are not specific to hepatic encephalopathy.
6. A nurse is providing education to a client about hepatitis B transmission. Which statement
by the client indicates correct understanding?
A) "I can contract hepatitis B from sharing food or drinks."
B) "Hepatitis B is transmitted through blood and body fluids."
C) "Hepatitis B is transmitted through the fecal-oral route."
D) "I cannot transmit hepatitis B to others once I have recovered."
Correct Answer: "Hepatitis B is transmitted through blood and body fluids."
Rationale: Hepatitis B is transmitted through percutaneous or mucosal exposure to infected
blood, semen, and other body fluids. It is not transmitted through the fecal-oral route, casual
contact, or sharing food/drinks. Even after recovery, the virus may remain in the body and can
be transmitted.
7. A nurse is caring for a client with cirrhosis who is at risk for bleeding. Which laboratory
value should the nurse monitor most closely?
A) Serum albumin
B) Serum ammonia
C) Prothrombin time (PT) and INR
D) Serum bilirubin
Correct Answer: Prothrombin time (PT) and INR
,SG 233 Medical-Surgical Nursing III Exam 3
1. A nurse is providing discharge teaching to a client with newly diagnosed cirrhosis. Which
statement by the client indicates a need for further teaching?
A) "I should avoid alcohol completely."
B) "I can take acetaminophen for pain as long as I do not exceed 2,000 mg per day."
C) "I should eat a diet low in sodium to prevent fluid buildup."
D) "I should report any confusion or changes in sleep patterns to my provider."
Correct Answer: "I can take acetaminophen for pain as long as I do not exceed 2,000 mg per
day."
Rationale: Clients with cirrhosis have impaired hepatic metabolism and are at increased risk
for hepatotoxicity from acetaminophen. Even reduced doses (2,000 mg/day) can be harmful;
acetaminophen should be avoided or used only with provider approval. Alcohol avoidance,
sodium restriction, and reporting mental status changes are all appropriate teaching points for
a client with cirrhosis.
2. A client with hepatic encephalopathy is prescribed lactulose. The nurse should monitor for
which therapeutic effect?
A) Increased serum ammonia levels
B) Decreased serum ammonia levels
C) Increased serum bilirubin levels
D) Decreased serum albumin levels
Correct Answer: Decreased serum ammonia levels
Rationale: Lactulose is a nonabsorbable disaccharide that acidifies the colon, trapping
ammonia and promoting its excretion in the stool. The therapeutic effect is a decrease in
serum ammonia levels, which improves mental status. Increased ammonia, bilirubin, or
decreased albumin would indicate worsening hepatic function.
,3. A nurse is caring for a client with cirrhosis who has developed ascites. Which nursing
intervention is most appropriate for managing this condition?
A) Encourage a high-sodium diet
B) Restrict daily fluid intake to 1,500 mL
C) Administer spironolactone as prescribed
D) Elevate the head of the bed to 90 degrees
Correct Answer: Administer spironolactone as prescribed
Rationale: Spironolactone is a potassium-sparing diuretic commonly used to manage ascites in
cirrhosis by promoting fluid excretion. Sodium restriction (not high-sodium) is indicated; fluid
restriction may be needed but is not the primary intervention. Elevating the head of the bed
helps with respiratory effort from abdominal distension but does not directly manage ascites.
4. A client with cirrhosis develops hematemesis and is suspected of having bleeding
esophageal varices. Which medication should the nurse anticipate administering?
A) Lactulose
B) Rifaximin
C) Octreotide
D) Spironolactone
Correct Answer: Octreotide
Rationale: Octreotide is a synthetic somatostatin analogue that reduces portal pressure and
splanchnic blood flow, helping to control acute variceal bleeding. Lactulose and rifaximin are
used for hepatic encephalopathy, and spironolactone is used for ascites. Endoscopic band
ligation is also a primary intervention for bleeding varices.
5. A nurse is assessing a client with hepatic encephalopathy. Which finding is characteristic of
this condition?
A) Asterixis
B) Spider angiomas
, C) Palmar erythema
D) Jaundice
Correct Answer: Asterixis
Rationale: Asterixis (liver flap) is a characteristic finding in hepatic encephalopathy, a flapping
tremor of the hands when the wrists are extended. Spider angiomas, palmar erythema, and
jaundice are signs of chronic liver disease but are not specific to hepatic encephalopathy.
6. A nurse is providing education to a client about hepatitis B transmission. Which statement
by the client indicates correct understanding?
A) "I can contract hepatitis B from sharing food or drinks."
B) "Hepatitis B is transmitted through blood and body fluids."
C) "Hepatitis B is transmitted through the fecal-oral route."
D) "I cannot transmit hepatitis B to others once I have recovered."
Correct Answer: "Hepatitis B is transmitted through blood and body fluids."
Rationale: Hepatitis B is transmitted through percutaneous or mucosal exposure to infected
blood, semen, and other body fluids. It is not transmitted through the fecal-oral route, casual
contact, or sharing food/drinks. Even after recovery, the virus may remain in the body and can
be transmitted.
7. A nurse is caring for a client with cirrhosis who is at risk for bleeding. Which laboratory
value should the nurse monitor most closely?
A) Serum albumin
B) Serum ammonia
C) Prothrombin time (PT) and INR
D) Serum bilirubin
Correct Answer: Prothrombin time (PT) and INR
