MED SURG EXAM 4 | QUESTIONS AND
ANSWERS | CHAPTERS 49, 50, 51, 52 |
RATED A+
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? - Inability 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? - Place
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? - Daily 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. - -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? - Document 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? - The 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? - How 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? - IV 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? - Asterixis
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? - An 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? - Adhere 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? - Lobectomy
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? - Abdominal 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? - Risk 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? - Position 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? - Stage 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? - Two 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? - A 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? - Orange 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? - Following proper hand-washing techniques
A spatients sphysician shas sordered sa sliver spanel sin sresponse sto sthe spatients sdevelopment
sof sjaundice. sWhen sreviewing sthe sresults sof sthis slaboratory stesting, sthe snurse sshould
sexpect sto sreview swhat sblood stests? sSelect sall sthat sapply. s- s s-Alanine saminotransferase
s(ALT)
-Gamma-glutamyl stransferase s(GGT)
-Aspartate saminotransferase s(AST)
A spatient swith sliver sdisease shas sdeveloped sjaundice; sthe snurse sis scollaborating swith sthe
spatient sto sdevelop sa snutritional splan. sThe snurse sshould sprioritize swhich sof sthe sfollowing
sin sthe spatients splan? s- s sReduction sin ssodium sintake
A snurse sis samending sa spatients splan sof scare sin slight sof sthe sfact sthat sthe spatient shas
srecently sdeveloped sascites. sWhat sshould sthe snurse sinclude sin sthis spatients scare splan? s-
s sAdministration sof sdiuretics sas sordered
A snurse sis scaring sfor sa spatient swho shas sbeen sadmitted sfor sthe streatment sof sadvanced
scirrhosis. sWhat sassessment sshould sthe snurse sprioritize sin sthis spatients splan sof scare? s- s
sAssessment sfor svariceal sbleeding
A spatient swith sa sdiagnosis sof scirrhosis shas sdeveloped svariceal sbleeding sand swill
simminently sundergo svariceal sbanding. sWhat spsychosocial snursing sdiagnosis sshould sthe
snurse smost slikely sprioritize sduring sthis sphase sof sthe spatients streatment? s- s sDeath
sAnxiety
A spatient swith sa sdiagnosis sof sesophageal svarices shas sundergone sendoscopy sto sgauge
sthe sprogression sof sthis scomplication sof sliver sdisease. sFollowing sthe scompletion sof sthis
sdiagnostic stest, swhat snursing sintervention sshould sthe snurse sperform? s- s sKeep spatient
sNPO suntil sthe spatients sgag sreflex sreturns.
A spatient swith sesophageal svarices sis sbeing scared sfor sin sthe sICU. sThe svarices shave
sbegun sto sbleed sand sthe spatient sis sat srisk sfor shypovolemia. sThe spatient shas sRingers
slactate sat s150 scc/hr sinfusing. sWhat selse smight sthe snurse sexpect sto shave sordered sto
smaintain svolume sfor sthis spatient? s- s sVolume sexpanders
ANSWERS | CHAPTERS 49, 50, 51, 52 |
RATED A+
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? - Inability 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? - Place
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? - Daily 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. - -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? - Document 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? - The 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? - How 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? - IV 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? - Asterixis
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? - An 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? - Adhere 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? - Lobectomy
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? - Abdominal 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? - Risk 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? - Position 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? - Stage 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? - Two 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? - A 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? - Orange 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? - Following proper hand-washing techniques
A spatients sphysician shas sordered sa sliver spanel sin sresponse sto sthe spatients sdevelopment
sof sjaundice. sWhen sreviewing sthe sresults sof sthis slaboratory stesting, sthe snurse sshould
sexpect sto sreview swhat sblood stests? sSelect sall sthat sapply. s- s s-Alanine saminotransferase
s(ALT)
-Gamma-glutamyl stransferase s(GGT)
-Aspartate saminotransferase s(AST)
A spatient swith sliver sdisease shas sdeveloped sjaundice; sthe snurse sis scollaborating swith sthe
spatient sto sdevelop sa snutritional splan. sThe snurse sshould sprioritize swhich sof sthe sfollowing
sin sthe spatients splan? s- s sReduction sin ssodium sintake
A snurse sis samending sa spatients splan sof scare sin slight sof sthe sfact sthat sthe spatient shas
srecently sdeveloped sascites. sWhat sshould sthe snurse sinclude sin sthis spatients scare splan? s-
s sAdministration sof sdiuretics sas sordered
A snurse sis scaring sfor sa spatient swho shas sbeen sadmitted sfor sthe streatment sof sadvanced
scirrhosis. sWhat sassessment sshould sthe snurse sprioritize sin sthis spatients splan sof scare? s- s
sAssessment sfor svariceal sbleeding
A spatient swith sa sdiagnosis sof scirrhosis shas sdeveloped svariceal sbleeding sand swill
simminently sundergo svariceal sbanding. sWhat spsychosocial snursing sdiagnosis sshould sthe
snurse smost slikely sprioritize sduring sthis sphase sof sthe spatients streatment? s- s sDeath
sAnxiety
A spatient swith sa sdiagnosis sof sesophageal svarices shas sundergone sendoscopy sto sgauge
sthe sprogression sof sthis scomplication sof sliver sdisease. sFollowing sthe scompletion sof sthis
sdiagnostic stest, swhat snursing sintervention sshould sthe snurse sperform? s- s sKeep spatient
sNPO suntil sthe spatients sgag sreflex sreturns.
A spatient swith sesophageal svarices sis sbeing scared sfor sin sthe sICU. sThe svarices shave
sbegun sto sbleed sand sthe spatient sis sat srisk sfor shypovolemia. sThe spatient shas sRingers
slactate sat s150 scc/hr sinfusing. sWhat selse smight sthe snurse sexpect sto shave sordered sto
smaintain svolume sfor sthis spatient? s- s sVolume sexpanders
