NUR 414 Final Exam QUESTIONS AND CORRECT DETAILED ANSWER
WITH RATIONALES (VERIFIED ANSWERS)
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1. The physician orders A. Improvement in level of consciousness
Lactulose 30 mL by
mouth per day for a client A patient with cirrhosis may experience a com-
with cirrhosis. What find- plication called hepatic encephalopathy. This will
ing below demonstrates cause the patient to become confused (they
the medication is work- may enter into a coma), have pungent, musty
ing effectively? smelling breath (fetor hepaticus), asterixis (invol-
A. untary flapping of the hands). This is due to the
Improvement in level of buildup of ammonia in the blood, which affects
consciousness the brain. Lactulose can be prescribed to help de-
B. crease the ammonia levels. Therefore, if the med-
Presence of asterixis ication is working properly to decrease the level of
C. ammonia the patient would have improving men-
Decreased albumin lev- tal status, decreased ammonia blood level, de-
els creasing or absence of asterixis, and decreased
D. ammonia blood level. Fruity breath is associated
Absence of fruity breath with DKA not hepatic encephalopathy.
2. During the morning as- A. Ammonia level of 68 µ/dL
sessment of a client with
cirrhosis, you note the Based on the assessment findings and the fact
client is disoriented to the client has cirrhosis, the client is experiencing
person and place. In ad- hepatic encephalopathy. This is due to the buildup
dition, while assessing of toxins in the blood, specifically ammonia. The
the upper extremities, the flapping motion of the hands is called "asterix-
client's hands demon- is". Therefore, an increased ammonia level would
strate a flapping motion. confirm these abnormal assessment findings
What lab result would ex- (Normal ammonia: 10-80)
plain these abnormal as-
sessment findings?
A.
Ammonia level of 68 µ/dL
B.
Creatinine level of 2.9
mg/dL
C.
Potassium level of 3.7
mmol/L
D.
, NUR 414 Final Exam QUESTIONS AND CORRECT DETAILED ANSWER
WITH RATIONALES (VERIFIED ANSWERS)
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Calcium level of 10.9
mg/dL
3. A patient diagnosed C. Thrombocytopenia
with hepatitis develops
splenomegaly. When re- The spleen acts as a reservoir for platelets. When
viewing the laboratory re- the spleen is enlarged, as with splenomegaly, up
port, which of the follow- to 90 percent of a person's thrombocytes can be
ing results will the health- sequestered within the enlarged spleen.
care provider anticipate?
A.
Polycythemia
B.
Leukocytosis
C.
Thrombocytopenia
D.
Neutrophilia
4. A client diagnosed with B. Monitor the blood glucose
viral hepatitis devel-
ops liver failure and Interventions for this patient include blood glu-
hepatic encephalopathy. cose monitoring (because of decreased glycogen
Which of these mea- synthesis and storage), monitoring PT and INR
sures should the health- (because of decreased clotting factors), checking
care provider include in reflexes (because of the neurological effects of
this client's plan of care? increased ammonia), providing diet/feedings that
A. are low in protein (to decrease ammonia levels),
Provide high-protein and following standard precautions. The client
feedings should be weighed every day.
B.
Monitor the blood glu-
cose
C.
Institute droplet precau-
tions
D.
Weigh once a week
, NUR 414 Final Exam QUESTIONS AND CORRECT DETAILED ANSWER
WITH RATIONALES (VERIFIED ANSWERS)
Study online at https://quizlet.com/_epj8lc
5. A client with cirrho- A. Hyperkalemia
sis of the liver devel-
ops ascites, and the Spironolactone (Aldactone) is a potassium-spar-
health care provider pre- ing diuretic that is used to treat clients with as-
scribes spironolactone. cites; therefore, the nurse should monitor the
What should the nurse client for signs and symptoms of hyperkalemia.
monitor the client for? Bruising and purpura are associated with cir-
A. rhosis, not with the administration of spironolac-
Hyperkalemia tone. Spironolactone does not cause tachycardia.
B. Spironolactone does not cause hypoglycemia.
Tachycardia
C.
Hypoglycemia
D.
Ecchymosis
6. A health care provider C. Empty the bladder immediately before the pro-
schedules a paracentesis cedure.
for a client with ascites.
What should the nurse The bladder must be emptied immediately before
include in the client's the procedure to decrease the chance of punc-
teaching plan? ture with the trocar used in a paracentesis. A para-
A. centesis usually is performed with the client in the
Consume a diet low in fat Fowler position to assist the flow of fluid by gravity.
for three days before the Eating a diet low in fat for three days before the
procedure. procedure is not necessary for a paracentesis.
B. Staying on a liquid diet is not necessary for a
Stay on a liquid diet for paracentesis.
24 hours after the proce-
dure.
C.
Empty the bladder imme-
diately before the proce-
dure.
D.
Maintain a supine posi-
tion during the proce-
dure.
WITH RATIONALES (VERIFIED ANSWERS)
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1. The physician orders A. Improvement in level of consciousness
Lactulose 30 mL by
mouth per day for a client A patient with cirrhosis may experience a com-
with cirrhosis. What find- plication called hepatic encephalopathy. This will
ing below demonstrates cause the patient to become confused (they
the medication is work- may enter into a coma), have pungent, musty
ing effectively? smelling breath (fetor hepaticus), asterixis (invol-
A. untary flapping of the hands). This is due to the
Improvement in level of buildup of ammonia in the blood, which affects
consciousness the brain. Lactulose can be prescribed to help de-
B. crease the ammonia levels. Therefore, if the med-
Presence of asterixis ication is working properly to decrease the level of
C. ammonia the patient would have improving men-
Decreased albumin lev- tal status, decreased ammonia blood level, de-
els creasing or absence of asterixis, and decreased
D. ammonia blood level. Fruity breath is associated
Absence of fruity breath with DKA not hepatic encephalopathy.
2. During the morning as- A. Ammonia level of 68 µ/dL
sessment of a client with
cirrhosis, you note the Based on the assessment findings and the fact
client is disoriented to the client has cirrhosis, the client is experiencing
person and place. In ad- hepatic encephalopathy. This is due to the buildup
dition, while assessing of toxins in the blood, specifically ammonia. The
the upper extremities, the flapping motion of the hands is called "asterix-
client's hands demon- is". Therefore, an increased ammonia level would
strate a flapping motion. confirm these abnormal assessment findings
What lab result would ex- (Normal ammonia: 10-80)
plain these abnormal as-
sessment findings?
A.
Ammonia level of 68 µ/dL
B.
Creatinine level of 2.9
mg/dL
C.
Potassium level of 3.7
mmol/L
D.
, NUR 414 Final Exam QUESTIONS AND CORRECT DETAILED ANSWER
WITH RATIONALES (VERIFIED ANSWERS)
Study online at https://quizlet.com/_epj8lc
Calcium level of 10.9
mg/dL
3. A patient diagnosed C. Thrombocytopenia
with hepatitis develops
splenomegaly. When re- The spleen acts as a reservoir for platelets. When
viewing the laboratory re- the spleen is enlarged, as with splenomegaly, up
port, which of the follow- to 90 percent of a person's thrombocytes can be
ing results will the health- sequestered within the enlarged spleen.
care provider anticipate?
A.
Polycythemia
B.
Leukocytosis
C.
Thrombocytopenia
D.
Neutrophilia
4. A client diagnosed with B. Monitor the blood glucose
viral hepatitis devel-
ops liver failure and Interventions for this patient include blood glu-
hepatic encephalopathy. cose monitoring (because of decreased glycogen
Which of these mea- synthesis and storage), monitoring PT and INR
sures should the health- (because of decreased clotting factors), checking
care provider include in reflexes (because of the neurological effects of
this client's plan of care? increased ammonia), providing diet/feedings that
A. are low in protein (to decrease ammonia levels),
Provide high-protein and following standard precautions. The client
feedings should be weighed every day.
B.
Monitor the blood glu-
cose
C.
Institute droplet precau-
tions
D.
Weigh once a week
, NUR 414 Final Exam QUESTIONS AND CORRECT DETAILED ANSWER
WITH RATIONALES (VERIFIED ANSWERS)
Study online at https://quizlet.com/_epj8lc
5. A client with cirrho- A. Hyperkalemia
sis of the liver devel-
ops ascites, and the Spironolactone (Aldactone) is a potassium-spar-
health care provider pre- ing diuretic that is used to treat clients with as-
scribes spironolactone. cites; therefore, the nurse should monitor the
What should the nurse client for signs and symptoms of hyperkalemia.
monitor the client for? Bruising and purpura are associated with cir-
A. rhosis, not with the administration of spironolac-
Hyperkalemia tone. Spironolactone does not cause tachycardia.
B. Spironolactone does not cause hypoglycemia.
Tachycardia
C.
Hypoglycemia
D.
Ecchymosis
6. A health care provider C. Empty the bladder immediately before the pro-
schedules a paracentesis cedure.
for a client with ascites.
What should the nurse The bladder must be emptied immediately before
include in the client's the procedure to decrease the chance of punc-
teaching plan? ture with the trocar used in a paracentesis. A para-
A. centesis usually is performed with the client in the
Consume a diet low in fat Fowler position to assist the flow of fluid by gravity.
for three days before the Eating a diet low in fat for three days before the
procedure. procedure is not necessary for a paracentesis.
B. Staying on a liquid diet is not necessary for a
Stay on a liquid diet for paracentesis.
24 hours after the proce-
dure.
C.
Empty the bladder imme-
diately before the proce-
dure.
D.
Maintain a supine posi-
tion during the proce-
dure.
