,1. A client diagnosed with hepatitis A virus (HAV) works as a cook at a local restaurant. Which
instruction should the nurse provide to the client's household members and sexual contacts?
A) "An antiviral medication will be prescribed for all contacts."
B) "You will need to isolate the client from others for 10-14 days."
C) "We will administer immunoglobulin injections to all household members and sexual
partners."
D) "All contacts will need to be vaccinated for hepatitis B."
Correct Answer: "We will administer immunoglobulin injections to all household members and
sexual partners."
Rationale: Hepatitis A is transmitted via the fecal-oral route, and post-exposure prophylaxis
includes immunoglobulin for close contacts . This provides passive immunity to prevent
infection. Antivirals are not used for hepatitis A post-exposure prophylaxis, and hepatitis B
vaccination does not prevent hepatitis A.
2. A nurse is caring for a client with acute cholecystitis who has just received their dinner tray.
Which food selection by the client requires the nurse to follow up?
A) Baked lemon-butter tilapia, brown rice, and green beans
B) Bacon cheeseburger casserole and chocolate milk
C) Baked potato, broiled chicken, and tea
D) Garden salad, grilled chicken, and a dinner roll
Correct Answer: Bacon cheeseburger casserole and chocolate milk
Rationale: Acute cholecystitis is often triggered by high-fat foods, which stimulate gallbladder
contraction and worsen pain . The bacon cheeseburger casserole and chocolate milk are high in
fat and should be avoided. Low-fat options like baked fish, rice, and green beans are more
appropriate.
,3. The nurse is assessing a client with liver disease who has marked hypoalbuminemia with a
serum albumin level of 2.4 mg/dL. Which assessment finding should the nurse expect?
A) Increased thirst and dry skin
B) Jaundice and fluid retention
C) Weight loss
D) Bleeding from previous puncture sites
Correct Answer: Jaundice and fluid retention
Rationale: Low serum albumin in liver disease reduces oncotic pressure, leading to fluid
retention and ascites . Jaundice results from impaired bilirubin metabolism . The other findings
are not directly caused by hypoalbuminemia.
4. The nurse is teaching nursing students about preventing hepatitis B virus (HBV) transmission.
Which preventive measure should the nurse include?
A) Disinfect needles with alcohol before first use
B) Implement droplet precautions immediately after exposure
C) Infected linens should be bagged and marked for special handling
D) All personnel must wear gloves when handling blood or body fluids
Correct Answer: All personnel must wear gloves when handling blood or body fluids
Rationale: HBV is transmitted through blood and body fluids, so standard precautions including
wearing gloves are essential . Needles should not be reused or disinfected, and HBV is not
transmitted by droplet precautions.
, 5. A client scheduled for an endoscopic retrograde cholangiopancreatography (ERCP) makes
which statement indicating a need for additional teaching?
A) "I will avoid eating or drinking for 1 or 2 days following this procedure."
B) "I will not be able to eat or drink anything after midnight tonight."
C) "I may experience difficulty swallowing due to the anesthetic spray in my throat."
D) "I will need to make arrangements to have someone drive me due to the sedation."
Correct Answer: "I will avoid eating or drinking for 1 or 2 days following this procedure."
Rationale: After ERCP, the client remains NPO until the gag reflex returns (usually a few hours),
not 1-2 days . The other statements reflect correct understanding of pre-procedure NPO status,
anesthesia effects, and need for a driver.
6. The nurse is admitting a client suspected of having acute cholecystitis. Which assessment
finding is consistent with this condition?
A) Hyperactive bowel sounds in all four quadrants
B) Intermittent diarrhea and hematuria
C) Decreased serum sodium and potassium levels
D) Episodic upper abdominal pain with dark or brown-colored urine
Correct Answer: Episodic upper abdominal pain with dark or brown-colored urine
Rationale: Acute cholecystitis presents with right upper quadrant pain and dark urine due to bile
obstruction . Bowel sounds may be decreased, not hyperactive, and electrolyte abnormalities
are not the primary findings.
7. The nurse is teaching a client with hepatitis B virus (HBV) about self-management. Which
instruction should the nurse include?
instruction should the nurse provide to the client's household members and sexual contacts?
A) "An antiviral medication will be prescribed for all contacts."
B) "You will need to isolate the client from others for 10-14 days."
C) "We will administer immunoglobulin injections to all household members and sexual
partners."
D) "All contacts will need to be vaccinated for hepatitis B."
Correct Answer: "We will administer immunoglobulin injections to all household members and
sexual partners."
Rationale: Hepatitis A is transmitted via the fecal-oral route, and post-exposure prophylaxis
includes immunoglobulin for close contacts . This provides passive immunity to prevent
infection. Antivirals are not used for hepatitis A post-exposure prophylaxis, and hepatitis B
vaccination does not prevent hepatitis A.
2. A nurse is caring for a client with acute cholecystitis who has just received their dinner tray.
Which food selection by the client requires the nurse to follow up?
A) Baked lemon-butter tilapia, brown rice, and green beans
B) Bacon cheeseburger casserole and chocolate milk
C) Baked potato, broiled chicken, and tea
D) Garden salad, grilled chicken, and a dinner roll
Correct Answer: Bacon cheeseburger casserole and chocolate milk
Rationale: Acute cholecystitis is often triggered by high-fat foods, which stimulate gallbladder
contraction and worsen pain . The bacon cheeseburger casserole and chocolate milk are high in
fat and should be avoided. Low-fat options like baked fish, rice, and green beans are more
appropriate.
,3. The nurse is assessing a client with liver disease who has marked hypoalbuminemia with a
serum albumin level of 2.4 mg/dL. Which assessment finding should the nurse expect?
A) Increased thirst and dry skin
B) Jaundice and fluid retention
C) Weight loss
D) Bleeding from previous puncture sites
Correct Answer: Jaundice and fluid retention
Rationale: Low serum albumin in liver disease reduces oncotic pressure, leading to fluid
retention and ascites . Jaundice results from impaired bilirubin metabolism . The other findings
are not directly caused by hypoalbuminemia.
4. The nurse is teaching nursing students about preventing hepatitis B virus (HBV) transmission.
Which preventive measure should the nurse include?
A) Disinfect needles with alcohol before first use
B) Implement droplet precautions immediately after exposure
C) Infected linens should be bagged and marked for special handling
D) All personnel must wear gloves when handling blood or body fluids
Correct Answer: All personnel must wear gloves when handling blood or body fluids
Rationale: HBV is transmitted through blood and body fluids, so standard precautions including
wearing gloves are essential . Needles should not be reused or disinfected, and HBV is not
transmitted by droplet precautions.
, 5. A client scheduled for an endoscopic retrograde cholangiopancreatography (ERCP) makes
which statement indicating a need for additional teaching?
A) "I will avoid eating or drinking for 1 or 2 days following this procedure."
B) "I will not be able to eat or drink anything after midnight tonight."
C) "I may experience difficulty swallowing due to the anesthetic spray in my throat."
D) "I will need to make arrangements to have someone drive me due to the sedation."
Correct Answer: "I will avoid eating or drinking for 1 or 2 days following this procedure."
Rationale: After ERCP, the client remains NPO until the gag reflex returns (usually a few hours),
not 1-2 days . The other statements reflect correct understanding of pre-procedure NPO status,
anesthesia effects, and need for a driver.
6. The nurse is admitting a client suspected of having acute cholecystitis. Which assessment
finding is consistent with this condition?
A) Hyperactive bowel sounds in all four quadrants
B) Intermittent diarrhea and hematuria
C) Decreased serum sodium and potassium levels
D) Episodic upper abdominal pain with dark or brown-colored urine
Correct Answer: Episodic upper abdominal pain with dark or brown-colored urine
Rationale: Acute cholecystitis presents with right upper quadrant pain and dark urine due to bile
obstruction . Bowel sounds may be decreased, not hyperactive, and electrolyte abnormalities
are not the primary findings.
7. The nurse is teaching a client with hepatitis B virus (HBV) about self-management. Which
instruction should the nurse include?
