Nursing II - Chapter 35
Perform frequent hand washing and do not share personal items. - ANS-A patient reports that a
family member is diagnosed with hepatitis and asks the nurse the best way to prevent becoming
infected. Which is the best information for the nurse to provide?
Maintain functional ability of the liver. - ANS-The nurse is providing care for a patient admitted
with acute liver failure related to an acetaminophen overdose. Which goal is associated with
care for the patient?
To constrict vessel dilation to the esophageal varices - ANS-A patient with liver failure and
esophageal varices is prescribed to receive vasopressin. For which purpose does the nurse
recognize the need for this medication?
Liver dysfunction - ANS-The nurse is obtaining information from a patient who is obese and has
diabetes mellitus (DM). Upon physical examination, the nurse notes generalized ecchymosis, an
enlarged and tender liver with palpation, and evidence of ascites with percussion. Which
possible disease condition does the nurse identify from the findings?
Maintain low physical activity. - ANS-The nurse is reinforcing teaching provided to a patient with
esophageal varices. Which suggestion is the least important?
"Hold out your arms and hands." - ANS-The nurse is collecting data from a patient with liver
failure to detect hepatic encephalopathy. Which instruction does the nurse give to the patient to
collect the data?
Abdominal distention, respiratory distress, and midepigastric pain - ANS-The nurse is collecting
data from a patient with acute pancreatitis. Which symptoms should
the nurse anticipate?
Place in an upright or slightly leaning forward position. - ANS-The nurse is providing care for a
patient diagnosed with chronic pancreatitis. The patient's vital signs are blood pressure 130/78
mm Hg, respirations 28 breaths/min and labored with O2 saturation rate of 90%, pulse 102
beats/min, and pain level of 7 on a 0-to-10 scale. Which immediate nursing action is
appropriate?
Performance of a Whipple procedure - ANS-A patient just receives a diagnosis of pancreatic
cancer with metastasis to the liver, gallbladder, and stomach. The nurse is informed that the
patient has agreed to palliative care. Which intervention seems unexpected to the nurse?
Perform frequent hand washing and do not share personal items. - ANS-A patient reports that a
family member is diagnosed with hepatitis and asks the nurse the best way to prevent becoming
infected. Which is the best information for the nurse to provide?
Maintain functional ability of the liver. - ANS-The nurse is providing care for a patient admitted
with acute liver failure related to an acetaminophen overdose. Which goal is associated with
care for the patient?
To constrict vessel dilation to the esophageal varices - ANS-A patient with liver failure and
esophageal varices is prescribed to receive vasopressin. For which purpose does the nurse
recognize the need for this medication?
Liver dysfunction - ANS-The nurse is obtaining information from a patient who is obese and has
diabetes mellitus (DM). Upon physical examination, the nurse notes generalized ecchymosis, an
enlarged and tender liver with palpation, and evidence of ascites with percussion. Which
possible disease condition does the nurse identify from the findings?
Maintain low physical activity. - ANS-The nurse is reinforcing teaching provided to a patient with
esophageal varices. Which suggestion is the least important?
"Hold out your arms and hands." - ANS-The nurse is collecting data from a patient with liver
failure to detect hepatic encephalopathy. Which instruction does the nurse give to the patient to
collect the data?
Abdominal distention, respiratory distress, and midepigastric pain - ANS-The nurse is collecting
data from a patient with acute pancreatitis. Which symptoms should
the nurse anticipate?
Place in an upright or slightly leaning forward position. - ANS-The nurse is providing care for a
patient diagnosed with chronic pancreatitis. The patient's vital signs are blood pressure 130/78
mm Hg, respirations 28 breaths/min and labored with O2 saturation rate of 90%, pulse 102
beats/min, and pain level of 7 on a 0-to-10 scale. Which immediate nursing action is
appropriate?
Performance of a Whipple procedure - ANS-A patient just receives a diagnosis of pancreatic
cancer with metastasis to the liver, gallbladder, and stomach. The nurse is informed that the
patient has agreed to palliative care. Which intervention seems unexpected to the nurse?
