NURSING 275 EXAM 3 QUESTIONS & ANSWERS
Which statement by a client with cirrhosis indicates that further instruction is needed
about the disease?
A. "Cirrhosis is a chronic disease that has scarred my liver."
B. "The scars on my liver create problems with blood circulation."
C. "Because of the scars on my liver, blood clotting and blood pressure are affected."
D. "My liver is scarred, but the cells can regenerate themselves and repair the damage."
- Answer -"My liver is scarred, but the cells can regenerate themselves and repair the
damage."
Although cells and tissues will attempt to regenerate, this will result in permanent
scarring and irreparable damage. Cirrhosis is a chronic condition that leaves scars on
the liver. Permanent scars form in response to attempts by the cells to regenerate and
create problems in blood circulation moving through the liver. Liver scarring will create
problems with blood clotting, cholesterol levels, and blood pressure, as well as with the
metabolism of drugs and toxins.
Which problem for a client with cirrhosis takes priority?
A. Insufficient knowledge related to the prognosis of the disease process
B. Discomfort related to the progression of the disease process
C. Potential for injury related to hemorrhage
D. Inadequate nutrition related to an inability to tolerate usual dietary intake - Answer -
Potential for injury related to hemorrhage
Potential for injury related to hemorrhage is the priority client problem because this
complication could be life-threatening. Insufficient knowledge, discomfort, and
inadequate nutrition are not priorities because these issues are not immediately life-
threatening.
Clients who have cirrhosis should not take NSAIDs because they may predispose to
bleeding. The client with cirrhosis is prone to bleeding; vitamin K can decrease
bleeding, so it is not necessary to restrict this in the diet. Potassium-sparing diuretics
are used to reduce ascites. Nonabsorbable antibiotics are used to decrease ammonia
levels.
When caring for a client with hepatic encephalopathy, in which situation does the nurse
question the use of neomycin (Mycifradin)?
A. Kidney failure
B. Refractory ascites
C. Fetor hepaticus
,D. Paracentesis scheduled for today - Answer -Kidney failure
The aminoglycoside drugs, which include neomycin, are nephrotoxic and ototoxic, and
should not be taken by the client with hepatic encephalopathy. Cirrhosis and hepatic
failure cause both ascites and encephalopathy; no contraindication for neomycin is
known. Fetor hepaticus causes an ammonia smell to the breath when serum ammonia
levels are elevated; neomycin is used to decrease serum ammonia levels. The client
may be NPO for a few hours before paracentesis, but may take neomycin when the
procedure is complete, or with less than 30 mL of water, depending on hospital policy.
Which activity by the nurse will best relieve symptoms associated with ascites?
A. Administering oxygen
B. Elevating the head of the bed
C. Monitoring serum albumin levels
D. Administering intravenous fluids - Answer -Elevating the head of the bed
The enlarged abdomen of ascites limits respiratory excursion; Fowler's position will
increase excursion and reduce shortness of breath. The client may need oxygen, but
first the nurse should raise the head of the bed to improve respiratory excursion and
oxygenation. Monitoring will detect anticipated decreased serum albumin levels
associated with cirrhosis and hepatic failure but does not relieve the symptoms of
ascites. Administering IV fluids will contribute to fluid volume excess and fluid shifts into
the peritoneal cavity, worsening ascites.
The nurse is caring for clients in the outpatient clinic. Which of these phone calls should
the nurse return first?
A. Client with hepatitis A reporting severe and ongoing itching
B. Client with severe ascites who has a temperature of 101.4° F (38° C)
C. Client with cirrhosis who has had a 3-pound weight gain over 2 days
D. Client with esophageal varices and mild right upper quadrant pain - Answer -Client
with severe ascites who has a temperature of 101.4° F (38° C)
The client with ascites and an elevated temperature may have spontaneous bacterial
peritonitis; the nurse should call this client first. Itching is anticipated with jaundice, this
client may be called last. Weight gain with cirrhosis is not uncommon owing to low
albumin levels. Cirrhosis may cause mild right upper quadrant pain; this client should be
called after the client with severe ascites.
A client with a history of esophageal varices has just been admitted to the emergency
department after vomiting a large quantity of blood. Which action does the nurse take
first?
A. Obtain the charts from the previous admission.
B. Listen for bowel sounds in all quadrants.
,C. Obtain pulse and blood pressure.
D. Ask about abdominal pain. - Answer -Obtain pulse and blood pressure.
The nurse should assess vital signs to detect hypovolemic shock caused by
hemorrhage. Obtaining charts, assessing bowel sounds, and pain assessment can be
delayed until the client has stabilized. Assessment for adequate perfusion is the highest
priority at this time.
Following paracentesis, during which 2500 mL of fluid was removed, which assessment
finding is most important to communicate to the heath care provider?
A. The dressing has a 2-cm area of serous drainage.
B. The client's platelet count is 135,000/mm3.
C. The client's albumin level is 2.8 mg/dL.
D. The client's heart rate is 122 beats/min. - Answer -The client's heart rate is 122
beats/min.
Rapid removal of fluid may cause symptoms of shock; tachycardia, especially when
associated with hypotension, should be reported to the provider. A small amount of
serous fluid may leak; the dressing should be reinforced. Platelets will be checked
before the procedure; these are slightly low, but this is not a cause for concern. An
albumin level of 2.8 mg/dL is an expected finding for a client with cirrhosis; it is not life
threatening.
Awarded 1.0 points out of 1.0 possible points.
How does the home care nurse best modify the client's home environment to manage
side effects of lactulose (Evalose)?
A. Provides small frequent meals for the client
B. Suggests taking daily potassium supplements
C. Elevates the head of the bed in high-Fowler's position
D. Requests a bedside commode for the client - Answer -Requests a bedside
commode for the client
Lactulose therapy increases the frequency of stools, so a bedside commode should be
made available to the client, especially if he or she has difficulty reaching the toilet.
Small frequent meals and elevating the head of the bed will not have any effect on the
side effects of lactulose. Although lactulose produces excessive stools and could
potentially result in loss of potassium, it is inappropriate for the nurse to suggest that the
client take potassium supplements.
In caring for a client who has undergone paracentesis, which changes in the client's
status should be promptly reported to the provider?
A. Increased blood pressure, increased respiratory rate
B. Decreased blood pressure, increased heart rate
, C. Increased respiratory rate, increased apical pulse, pallor
D. Tachypnea, diaphoresis, increased blood pressure - Answer -Decreased blood
pressure, increased heart rate
Decreased blood pressure and increased heart rate are indicative of shock. Increased
blood pressure, increased respiratory rate, increased apical pulse, pallor, tachypnea,
and diaphoresis are all indicative of anxiety on the client's part.
The nurse administers lactulose (Evalose) to a client with cirrhosis for which purpose?
A. Provides enzymes necessary to digest dairy products
B. Reduces portal pressure
C. Promotes gastrointestinal (GI) excretion of ammonia
D. Decreases GI bleeding - Answer -Promotes gastrointestinal (GI) excretion of
ammonia
Lactulose reduces serum ammonia levels by excreting ammonia through the GI tract.
Lactase is the enzyme that digests dairy products. The mechanism of action of lactulose
is not to reduce portal pressure. Lactulose does not affect bleeding.
When providing discharge teaching to a client with cirrhosis, it is essential for the nurse
to emphasize avoidance of which of these?
A. Vitamin K-containing products
B. Potassium-sparing diuretics
C. Nonabsorbable antibiotics
D. Nonsteroidal anti-inflammatory drugs (NSAIDs) - Answer -Nonsteroidal anti-
inflammatory drugs (NSAIDs)
When providing community education, the nurse emphasizes that which group should
receive immunization for hepatitis B?
A. Clients who work with shellfish
B. Men who prefer sex with men
C. Clients traveling to a third-world country
D. Clients with elevations of aspartate aminotransferase and alanine aminotransferase -
Answer -Men who prefer sex with men
Men who prefer sex with men are at increased risk for hepatitis B, which is spread by
the exchange of blood and body fluids during sexual activity. Consuming raw or
undercooked shellfish may cause hepatitis A, not hepatitis B. Travel to third-world
countries exposes the traveler to contaminated water and risk for hepatitis A; hepatitis B
is not of concern, unless the client is exposed to blood and body fluids during travel.
Clients who have liver disease should receive the vaccine, but men who have sex with
men are at higher risk for contracting hepatitis B.
Which statement by a client with cirrhosis indicates that further instruction is needed
about the disease?
A. "Cirrhosis is a chronic disease that has scarred my liver."
B. "The scars on my liver create problems with blood circulation."
C. "Because of the scars on my liver, blood clotting and blood pressure are affected."
D. "My liver is scarred, but the cells can regenerate themselves and repair the damage."
- Answer -"My liver is scarred, but the cells can regenerate themselves and repair the
damage."
Although cells and tissues will attempt to regenerate, this will result in permanent
scarring and irreparable damage. Cirrhosis is a chronic condition that leaves scars on
the liver. Permanent scars form in response to attempts by the cells to regenerate and
create problems in blood circulation moving through the liver. Liver scarring will create
problems with blood clotting, cholesterol levels, and blood pressure, as well as with the
metabolism of drugs and toxins.
Which problem for a client with cirrhosis takes priority?
A. Insufficient knowledge related to the prognosis of the disease process
B. Discomfort related to the progression of the disease process
C. Potential for injury related to hemorrhage
D. Inadequate nutrition related to an inability to tolerate usual dietary intake - Answer -
Potential for injury related to hemorrhage
Potential for injury related to hemorrhage is the priority client problem because this
complication could be life-threatening. Insufficient knowledge, discomfort, and
inadequate nutrition are not priorities because these issues are not immediately life-
threatening.
Clients who have cirrhosis should not take NSAIDs because they may predispose to
bleeding. The client with cirrhosis is prone to bleeding; vitamin K can decrease
bleeding, so it is not necessary to restrict this in the diet. Potassium-sparing diuretics
are used to reduce ascites. Nonabsorbable antibiotics are used to decrease ammonia
levels.
When caring for a client with hepatic encephalopathy, in which situation does the nurse
question the use of neomycin (Mycifradin)?
A. Kidney failure
B. Refractory ascites
C. Fetor hepaticus
,D. Paracentesis scheduled for today - Answer -Kidney failure
The aminoglycoside drugs, which include neomycin, are nephrotoxic and ototoxic, and
should not be taken by the client with hepatic encephalopathy. Cirrhosis and hepatic
failure cause both ascites and encephalopathy; no contraindication for neomycin is
known. Fetor hepaticus causes an ammonia smell to the breath when serum ammonia
levels are elevated; neomycin is used to decrease serum ammonia levels. The client
may be NPO for a few hours before paracentesis, but may take neomycin when the
procedure is complete, or with less than 30 mL of water, depending on hospital policy.
Which activity by the nurse will best relieve symptoms associated with ascites?
A. Administering oxygen
B. Elevating the head of the bed
C. Monitoring serum albumin levels
D. Administering intravenous fluids - Answer -Elevating the head of the bed
The enlarged abdomen of ascites limits respiratory excursion; Fowler's position will
increase excursion and reduce shortness of breath. The client may need oxygen, but
first the nurse should raise the head of the bed to improve respiratory excursion and
oxygenation. Monitoring will detect anticipated decreased serum albumin levels
associated with cirrhosis and hepatic failure but does not relieve the symptoms of
ascites. Administering IV fluids will contribute to fluid volume excess and fluid shifts into
the peritoneal cavity, worsening ascites.
The nurse is caring for clients in the outpatient clinic. Which of these phone calls should
the nurse return first?
A. Client with hepatitis A reporting severe and ongoing itching
B. Client with severe ascites who has a temperature of 101.4° F (38° C)
C. Client with cirrhosis who has had a 3-pound weight gain over 2 days
D. Client with esophageal varices and mild right upper quadrant pain - Answer -Client
with severe ascites who has a temperature of 101.4° F (38° C)
The client with ascites and an elevated temperature may have spontaneous bacterial
peritonitis; the nurse should call this client first. Itching is anticipated with jaundice, this
client may be called last. Weight gain with cirrhosis is not uncommon owing to low
albumin levels. Cirrhosis may cause mild right upper quadrant pain; this client should be
called after the client with severe ascites.
A client with a history of esophageal varices has just been admitted to the emergency
department after vomiting a large quantity of blood. Which action does the nurse take
first?
A. Obtain the charts from the previous admission.
B. Listen for bowel sounds in all quadrants.
,C. Obtain pulse and blood pressure.
D. Ask about abdominal pain. - Answer -Obtain pulse and blood pressure.
The nurse should assess vital signs to detect hypovolemic shock caused by
hemorrhage. Obtaining charts, assessing bowel sounds, and pain assessment can be
delayed until the client has stabilized. Assessment for adequate perfusion is the highest
priority at this time.
Following paracentesis, during which 2500 mL of fluid was removed, which assessment
finding is most important to communicate to the heath care provider?
A. The dressing has a 2-cm area of serous drainage.
B. The client's platelet count is 135,000/mm3.
C. The client's albumin level is 2.8 mg/dL.
D. The client's heart rate is 122 beats/min. - Answer -The client's heart rate is 122
beats/min.
Rapid removal of fluid may cause symptoms of shock; tachycardia, especially when
associated with hypotension, should be reported to the provider. A small amount of
serous fluid may leak; the dressing should be reinforced. Platelets will be checked
before the procedure; these are slightly low, but this is not a cause for concern. An
albumin level of 2.8 mg/dL is an expected finding for a client with cirrhosis; it is not life
threatening.
Awarded 1.0 points out of 1.0 possible points.
How does the home care nurse best modify the client's home environment to manage
side effects of lactulose (Evalose)?
A. Provides small frequent meals for the client
B. Suggests taking daily potassium supplements
C. Elevates the head of the bed in high-Fowler's position
D. Requests a bedside commode for the client - Answer -Requests a bedside
commode for the client
Lactulose therapy increases the frequency of stools, so a bedside commode should be
made available to the client, especially if he or she has difficulty reaching the toilet.
Small frequent meals and elevating the head of the bed will not have any effect on the
side effects of lactulose. Although lactulose produces excessive stools and could
potentially result in loss of potassium, it is inappropriate for the nurse to suggest that the
client take potassium supplements.
In caring for a client who has undergone paracentesis, which changes in the client's
status should be promptly reported to the provider?
A. Increased blood pressure, increased respiratory rate
B. Decreased blood pressure, increased heart rate
, C. Increased respiratory rate, increased apical pulse, pallor
D. Tachypnea, diaphoresis, increased blood pressure - Answer -Decreased blood
pressure, increased heart rate
Decreased blood pressure and increased heart rate are indicative of shock. Increased
blood pressure, increased respiratory rate, increased apical pulse, pallor, tachypnea,
and diaphoresis are all indicative of anxiety on the client's part.
The nurse administers lactulose (Evalose) to a client with cirrhosis for which purpose?
A. Provides enzymes necessary to digest dairy products
B. Reduces portal pressure
C. Promotes gastrointestinal (GI) excretion of ammonia
D. Decreases GI bleeding - Answer -Promotes gastrointestinal (GI) excretion of
ammonia
Lactulose reduces serum ammonia levels by excreting ammonia through the GI tract.
Lactase is the enzyme that digests dairy products. The mechanism of action of lactulose
is not to reduce portal pressure. Lactulose does not affect bleeding.
When providing discharge teaching to a client with cirrhosis, it is essential for the nurse
to emphasize avoidance of which of these?
A. Vitamin K-containing products
B. Potassium-sparing diuretics
C. Nonabsorbable antibiotics
D. Nonsteroidal anti-inflammatory drugs (NSAIDs) - Answer -Nonsteroidal anti-
inflammatory drugs (NSAIDs)
When providing community education, the nurse emphasizes that which group should
receive immunization for hepatitis B?
A. Clients who work with shellfish
B. Men who prefer sex with men
C. Clients traveling to a third-world country
D. Clients with elevations of aspartate aminotransferase and alanine aminotransferase -
Answer -Men who prefer sex with men
Men who prefer sex with men are at increased risk for hepatitis B, which is spread by
the exchange of blood and body fluids during sexual activity. Consuming raw or
undercooked shellfish may cause hepatitis A, not hepatitis B. Travel to third-world
countries exposes the traveler to contaminated water and risk for hepatitis A; hepatitis B
is not of concern, unless the client is exposed to blood and body fluids during travel.
Clients who have liver disease should receive the vaccine, but men who have sex with
men are at higher risk for contracting hepatitis B.
