Med Surg Exam 4 testbankgo questions-
Ch. 49, 50, 51, 52 with correct answers
A nurse is caring for a patient with liver failure and is performing an assessment in the
knowledge of the patients increased risk of bleeding. The nurse recognizes that this risk
is related to the patients inability to synthesize prothrombin in the liver. What factor most
likely contributes to this loss of function? - Correct AnswersInability of the liver to use
vitamin K
A nurse is performing an admission assessment of a patient with a diagnosis of
cirrhosis. What technique should the nurse use to palpate the patients liver? - Correct
AnswersPlace hand under right lower rib cage and press down lightly with the other
hand.
A patient with portal hypertension has been admitted to the medical floor. The nurse
should prioritize which of the following assessments related to the manifestations of this
health problem? - Correct AnswersDaily weights and abdominal girth measurement
A nurse educator is teaching a group of recent nursing graduates about their
occupational risks for contracting hepatitis B. What preventative measures should the
educator promote? Select all that apply. - Correct Answers-Immunization
-Use of standard precautions
A nurse is caring for a patient with cancer of the liver whose condition has required the
insertion of a percutaneous biliary drainage system. The nurses most recent
assessment reveals the presence of dark green fluid in the collection container. What is
the nurses best response to this assessment finding? - Correct AnswersDocument the
presence of normal bile output.
A patient who has undergone liver transplantation is ready to be discharged home.
Which outcome of health education should the nurse prioritize? - Correct AnswersThe
patient will take immunosuppressive agents as required.
A triage nurse in the emergency department is assessing a patient who presented with
complaints of general malaise. Assessment reveals the presence of jaundice and
increased abdominal girth. What assessment question best addresses the possible
etiology of this patients presentation? - Correct AnswersHow many alcoholic drinks do
you typically consume in a week?
A nurse is participating in the emergency care of a patient who has just developed
variceal bleeding. What intervention should the nurse anticipate? - Correct AnswersIV
administration of octreotide (Sandostatin)
,A nurse is caring for a patient with hepatic encephalopathy. While making the initial shift
assessment, the nurse notes that the patient has a flapping tremor of the hands. The
nurse should document the presence of what sign of liver disease? - Correct
AnswersAsterixis
A local public health nurse is informed that a cook in a local restaurant has been
diagnosed with hepatitis A. What should the nurse advise individuals to obtain who ate
at this restaurant and have never received the hepatitis A vaccine? - Correct
AnswersAn immune globulin injection
A participant in a health fair has asked the nurse about the role of drugs in liver disease.
What health promotion teaching has the most potential to prevent drug-induced
hepatitis? - Correct AnswersAdhere to dosing recommendations of OTC analgesics.
Diagnostic testing has revealed that a patients hepatocellular carcinoma (HCC) is
limited to one lobe. The nurse should anticipate that this patients plan of care will focus
on what intervention? - Correct AnswersLobectomy
A patient has been diagnosed with advanced stage breast cancer and will soon begin
aggressive treatment. What assessment findings would most strongly suggest that the
patient may have developed liver metastases? - Correct AnswersAbdominal pain and
hepatomegaly
A patient is being discharged after a liver transplant and the nurse is performing
discharge education. When planning this patients continuing care, the nurse should
prioritize which of the following risk diagnoses? - Correct AnswersRisk for Infection
Related to Immunosuppressant Use
A patient with a liver mass is undergoing a percutaneous liver biopsy. What action
should the nurse perform when assisting with this procedure? - Correct
AnswersPosition the patient on the right side with a pillow under the costal margin after
the procedure.
A nurse is caring for a patient with hepatic encephalopathy. The nurses assessment
reveals that the patient exhibits episodes of confusion, is difficult to arouse from sleep
and has rigid extremities. Based on these clinical findings, the nurse should document
what stage of hepatic encephalopathy? - Correct AnswersStage 3
A patient has developed hepatic encephalopathy secondary to cirrhosis and is receiving
care on the medical unit. The patients current medication regimen includes lactulose
(Cephulac) four times daily. What desired outcome should the nurse relate to this
pharmacologic intervention? - Correct AnswersTwo to 3 soft bowel movements daily
A nurse is performing an admission assessment for an 81-year-old patient who
generally enjoys good health. When considering normal, age-related changes to hepatic
, function, the nurse should anticipate what finding? - Correct AnswersA slightly
decreased size of the liver
A nurse is caring for a patient with a blocked bile duct from a tumor. What manifestation
of obstructive jaundice should the nurse anticipate? - Correct AnswersOrange and
foamy urine
During a health education session, a participant has asked about the hepatitis E virus.
What prevention measure should the nurse recommend for preventing infection with this
virus? - Correct AnswersFollowing proper hand-washing techniques
A patients physician has ordered a liver panel in response to the patients development
of jaundice. When reviewing the results of this laboratory testing, the nurse should
expect to review what blood tests? Select all that apply. - Correct Answers-Alanine
aminotransferase (ALT)
-Gamma-glutamyl transferase (GGT)
-Aspartate aminotransferase (AST)
A patient with liver disease has developed jaundice; the nurse is collaborating with the
patient to develop a nutritional plan. The nurse should prioritize which of the following in
the patients plan? - Correct AnswersReduction in sodium intake
A nurse is amending a patients plan of care in light of the fact that the patient has
recently developed ascites. What should the nurse include in this patients care plan? -
Correct AnswersAdministration of diuretics as ordered
A nurse is caring for a patient who has been admitted for the treatment of advanced
cirrhosis. What assessment should the nurse prioritize in this patients plan of care? -
Correct AnswersAssessment for variceal bleeding
A patient with a diagnosis of cirrhosis has developed variceal bleeding and will
imminently undergo variceal banding. What psychosocial nursing diagnosis should the
nurse most likely prioritize during this phase of the patients treatment? - Correct
AnswersDeath Anxiety
A patient with a diagnosis of esophageal varices has undergone endoscopy to gauge
the progression of this complication of liver disease. Following the completion of this
diagnostic test, what nursing intervention should the nurse perform? - Correct
AnswersKeep patient NPO until the patients gag reflex returns.
A patient with esophageal varices is being cared for in the ICU. The varices have begun
to bleed and the patient is at risk for hypovolemia. The patient has Ringers lactate at
150 cc/hr infusing. What else might the nurse expect to have ordered to maintain
volume for this patient? - Correct AnswersVolume expanders
Ch. 49, 50, 51, 52 with correct answers
A nurse is caring for a patient with liver failure and is performing an assessment in the
knowledge of the patients increased risk of bleeding. The nurse recognizes that this risk
is related to the patients inability to synthesize prothrombin in the liver. What factor most
likely contributes to this loss of function? - Correct AnswersInability of the liver to use
vitamin K
A nurse is performing an admission assessment of a patient with a diagnosis of
cirrhosis. What technique should the nurse use to palpate the patients liver? - Correct
AnswersPlace hand under right lower rib cage and press down lightly with the other
hand.
A patient with portal hypertension has been admitted to the medical floor. The nurse
should prioritize which of the following assessments related to the manifestations of this
health problem? - Correct AnswersDaily weights and abdominal girth measurement
A nurse educator is teaching a group of recent nursing graduates about their
occupational risks for contracting hepatitis B. What preventative measures should the
educator promote? Select all that apply. - Correct Answers-Immunization
-Use of standard precautions
A nurse is caring for a patient with cancer of the liver whose condition has required the
insertion of a percutaneous biliary drainage system. The nurses most recent
assessment reveals the presence of dark green fluid in the collection container. What is
the nurses best response to this assessment finding? - Correct AnswersDocument the
presence of normal bile output.
A patient who has undergone liver transplantation is ready to be discharged home.
Which outcome of health education should the nurse prioritize? - Correct AnswersThe
patient will take immunosuppressive agents as required.
A triage nurse in the emergency department is assessing a patient who presented with
complaints of general malaise. Assessment reveals the presence of jaundice and
increased abdominal girth. What assessment question best addresses the possible
etiology of this patients presentation? - Correct AnswersHow many alcoholic drinks do
you typically consume in a week?
A nurse is participating in the emergency care of a patient who has just developed
variceal bleeding. What intervention should the nurse anticipate? - Correct AnswersIV
administration of octreotide (Sandostatin)
,A nurse is caring for a patient with hepatic encephalopathy. While making the initial shift
assessment, the nurse notes that the patient has a flapping tremor of the hands. The
nurse should document the presence of what sign of liver disease? - Correct
AnswersAsterixis
A local public health nurse is informed that a cook in a local restaurant has been
diagnosed with hepatitis A. What should the nurse advise individuals to obtain who ate
at this restaurant and have never received the hepatitis A vaccine? - Correct
AnswersAn immune globulin injection
A participant in a health fair has asked the nurse about the role of drugs in liver disease.
What health promotion teaching has the most potential to prevent drug-induced
hepatitis? - Correct AnswersAdhere to dosing recommendations of OTC analgesics.
Diagnostic testing has revealed that a patients hepatocellular carcinoma (HCC) is
limited to one lobe. The nurse should anticipate that this patients plan of care will focus
on what intervention? - Correct AnswersLobectomy
A patient has been diagnosed with advanced stage breast cancer and will soon begin
aggressive treatment. What assessment findings would most strongly suggest that the
patient may have developed liver metastases? - Correct AnswersAbdominal pain and
hepatomegaly
A patient is being discharged after a liver transplant and the nurse is performing
discharge education. When planning this patients continuing care, the nurse should
prioritize which of the following risk diagnoses? - Correct AnswersRisk for Infection
Related to Immunosuppressant Use
A patient with a liver mass is undergoing a percutaneous liver biopsy. What action
should the nurse perform when assisting with this procedure? - Correct
AnswersPosition the patient on the right side with a pillow under the costal margin after
the procedure.
A nurse is caring for a patient with hepatic encephalopathy. The nurses assessment
reveals that the patient exhibits episodes of confusion, is difficult to arouse from sleep
and has rigid extremities. Based on these clinical findings, the nurse should document
what stage of hepatic encephalopathy? - Correct AnswersStage 3
A patient has developed hepatic encephalopathy secondary to cirrhosis and is receiving
care on the medical unit. The patients current medication regimen includes lactulose
(Cephulac) four times daily. What desired outcome should the nurse relate to this
pharmacologic intervention? - Correct AnswersTwo to 3 soft bowel movements daily
A nurse is performing an admission assessment for an 81-year-old patient who
generally enjoys good health. When considering normal, age-related changes to hepatic
, function, the nurse should anticipate what finding? - Correct AnswersA slightly
decreased size of the liver
A nurse is caring for a patient with a blocked bile duct from a tumor. What manifestation
of obstructive jaundice should the nurse anticipate? - Correct AnswersOrange and
foamy urine
During a health education session, a participant has asked about the hepatitis E virus.
What prevention measure should the nurse recommend for preventing infection with this
virus? - Correct AnswersFollowing proper hand-washing techniques
A patients physician has ordered a liver panel in response to the patients development
of jaundice. When reviewing the results of this laboratory testing, the nurse should
expect to review what blood tests? Select all that apply. - Correct Answers-Alanine
aminotransferase (ALT)
-Gamma-glutamyl transferase (GGT)
-Aspartate aminotransferase (AST)
A patient with liver disease has developed jaundice; the nurse is collaborating with the
patient to develop a nutritional plan. The nurse should prioritize which of the following in
the patients plan? - Correct AnswersReduction in sodium intake
A nurse is amending a patients plan of care in light of the fact that the patient has
recently developed ascites. What should the nurse include in this patients care plan? -
Correct AnswersAdministration of diuretics as ordered
A nurse is caring for a patient who has been admitted for the treatment of advanced
cirrhosis. What assessment should the nurse prioritize in this patients plan of care? -
Correct AnswersAssessment for variceal bleeding
A patient with a diagnosis of cirrhosis has developed variceal bleeding and will
imminently undergo variceal banding. What psychosocial nursing diagnosis should the
nurse most likely prioritize during this phase of the patients treatment? - Correct
AnswersDeath Anxiety
A patient with a diagnosis of esophageal varices has undergone endoscopy to gauge
the progression of this complication of liver disease. Following the completion of this
diagnostic test, what nursing intervention should the nurse perform? - Correct
AnswersKeep patient NPO until the patients gag reflex returns.
A patient with esophageal varices is being cared for in the ICU. The varices have begun
to bleed and the patient is at risk for hypovolemia. The patient has Ringers lactate at
150 cc/hr infusing. What else might the nurse expect to have ordered to maintain
volume for this patient? - Correct AnswersVolume expanders
