NUR 213 Test 1
1. After teaching a client who has alcohol-induced cirrhosis, a nurse as- sesses the client's
understanding. Which statement made by the client indi-cates a need for additional teaching?
a. "I cannot drink any alcohol at all anymore."
b. "I need to avoid protein in my diet."
c. "I should not take over-the-counter medications."
d. "I should eat small, frequent, balanced meals.": b. "I need to avoid protein inmy diet."
Based on the degree of liver involvement and decreased function, protein intake may have to
be decreased. However, some protein is necessary for the synthesis ofalbumin and normal
healing. The other statements indicate accurate understandingof self-care measures for this
client
2. A nurse cares for a client with hepatopulmonary syndrome who is expe- riencing dyspnea
with oxygen saturations at 92%. The client states, "I do notwant to wear the oxygen because it
causes my nose to bleed. Get out of my room and leave me alone!" Which action should the
nurse take?
a. Instruct the client to sit in as upright a position as possible.
b. Add humidity to the oxygen and encourage the client to wear it.
c. Document the client's refusal, and call the health care provider.
d. Contact the provider to request an extra dose of the client's diuretic.: a.Instruct the client to
sit in as upright a position as possible.
The client with hepatopulmonary syndrome is often dyspneic. Because the oxygensaturation
is not significantly low, the nurse should first allow the client to sit upright
to see if that helps. If the client remains dyspneic, or if the oxygen saturation dropsfurther, the
nurse should investigate adding humidity to the oxygen and seeing whether the client will
tolerate that. The other two options may be beneficial, but they are not the best choices. If the
client is comfortable, his or her agitation will decrease; this will improve respiratory status.
3. A nurse cares for a client who is scheduled for a paracentesis. Which intervention should
the nurse delegate to an unlicensed assistive personnel(UAP)?
a. Have the client sign the informed consent form.
b. Assist the client to void before the procedure.
c. Help the client lie flat in bed on the right side.
d. Get the client into a chair after the procedure.: b. Assist the client to void beforethe procedure.
For safety, the client should void just before a paracentesis. The nurse or the providershould have
the client sign the consent form. The proper position for a paracentesisis sitting upright in bed
or, alternatively, sitting on the side of the bed and leaning over the bedside table. The client
will be on bedrest after the procedure.
,4. A nurse cares for a client who has chronic cirrhosis from substance abuse.The client states,
"All of my family hates me." How should the nurse respond?
a. "You should make peace with your family."
b. "This is not unusual. My family hates me too."
c. "I will help you identify a support system."
d. "You must attend Alcoholics Anonymous.": c. "I will help you identify a supportsystem."
Clients who have chronic cirrhosis may have alienated relatives over the years because of
substance abuse. The nurse should assist the client to identify a friend,neighbor, or person in
his or her recovery group for support. The nurse should
not minimize the client's concerns by brushing off the client's comment. AttendingAA may be
appropriate, but this response doesn't address the client's concern.
Making peace with the client's family may not be possible. This statement is notclient-
centered.
5. A nurse cares for a client with hepatitis C. The client's brother states, "I do not want to
contract this infection, so I will not go into his hospital room." Howshould the nurse respond?
a. "If you wear a gown and gloves, you will not get this virus."
b. "Viral hepatitis is not spread through casual contact."
c. "This virus is only transmitted through a fecal specimen."
d. "I can give you an update on your brother's status from here.": b. "Viralhepatitis is not
spread through casual contact."
Although family members may be afraid that they will contract hepatitis C, the nurseshould
educate the client's family about how the virus is spread. Viral hepatitis,
or hepatitis C, is spread via blood-to-blood transmission and is associated with illicit IV drug
needle sharing, blood and organ transplantation, accidental needle sticks, unsanitary tattoo
equipment, and sharing of intranasal cocaine paraphernalia.Wearing a gown and gloves will not
decrease the transmission of this virus. HepatitisC is not spread through casual contact or a fecal
specimen. The nurse would be violating privacy laws by sharing the client's status with the
brother.
6. An infection control nurse develops a plan to decrease the number of health care
professionals who contract viral hepatitis at work. Which ideasshould the nurse include in this
plan? (Select all that apply.)
a. Policies related to consistent use of Standard Precautions
b. Hepatitis vaccination mandate for workers in high-risk areas
c. Implementation of a needleless system for intravenous therapy
d. Number of sharps used in client care reduced where possible
e. Postexposure prophylaxis provided in a timely manner: A,C,D,E
Nurses should always use Standard Precautions for client care, and policies shouldreflect this.
Needleless systems and reduction of sharps can help prevent hepatitis.Postexposure
,prophylaxis should be provided immediately. All health care workers should receive the
hepatitis vaccinations that are available.
7. A nurse assesses a client who has liver disease. Which laboratory findingsshould the nurse
recognize as potentially causing complications of this dis- order? (Select all that apply.)
a. Elevated aspartate transaminase
b. Elevated international normalized ratio (INR)
c. Decreased serum globulin levels
d. Decreased serum alkaline phosphatase
e. Elevated serum ammonia
f. Elevated prothrombin time (PT): B,E,F
Elevated INR and PT are indications of clotting disturbances and alert the nurse to the
increased possibility of hemorrhage. Elevated ammonia levels increase the
client's confusion. The other values are abnormal and associated with liver diseasebut do not
necessarily place the client at increased risk for complications.
8. A nurse delegates hygiene care for a client who has advanced cirrhosis toan unlicensed
nursing personnel (UAP). Which statements should the nurse include when delegating this
task to the UAP? (Select all that apply.)
a. "Apply lotion to the client's dry skin areas."
b. "Use a basin with warm water to bathe the client."
c. "For the client's oral care, use a soft toothbrush."
d. "Provide clippers so the client can trim the fingernails."
e. "Bathe with antibacterial and water-based soaps.": A,C,D
Clients with advanced cirrhosis often have pruritus. Lotion will help decrease itchi-ness from
dry skin. A soft toothbrush should be used to prevent gum bleeding, andthe client's nails should
be trimmed short to prevent the client from scratching himselfor herself. These clients should use
cool, not warm, water on their skin, and shouldnot use excessive amounts of soap.
9. A nurse assesses a male client who has symptoms of cirrhosis. Which questions should
the nurse ask to identify potential factors contributing tothis laboratory result? (Select all that
apply.)
a. "How frequently do you drink alcohol?"
b. "Have you ever had sex with a man?"
c. "Do you have a family history of cancer?"
d. "Have you ever worked as a plumber?"
e. "Were you previously incarcerated?": A,B,E
When assessing a client with suspected cirrhosis, the nurse should ask about alco-hol
consumption, including amount and frequency; sexual history and orientation (specifically
men having sex with men); illicit drug use; history of tattoos; and historyof military service,
, incarceration, or work as a firefighter, police officer, or health careprovider. A family history of
cancer and work as a plumber do not put the client at risk for cirrhosis.
10. A nurse plans care for a client who has hepatopulmonary syndrome. Which interventions
should the nurse include in this client's plan of care? (Select allthat apply.)
a. Oxygen therapy
b. Prone position
c. Feet elevated on pillows
d. Daily weights
e. Physical therapy: A,C,D
Care for a client who has hepatopulmonary syndrome should include oxygen ther-
apy, the head of bed elevated at least 30 degrees or as high as the client wants toimprove
breathing, elevated feet to decrease dependent edema, and daily weights.There is no need to
place the client in a prone position, on the client's stomach.
Although physical therapy may be helpful to a client who has been hospitalized for several
days, physical therapy is not an intervention specifically for hepatopulmonarysyndrome.
11. An emergency room nurse assesses a client with potential liver trauma. Which clinical
manifestations should alert the nurse to internal bleeding andhypovolemic shock? (Select all
that apply.)
a. Hypertension
b. Tachycardia
c. Flushed skin
d. Confusion
e. Shallow respirations: B,D
Symptoms of hemorrhage and hypovolemic shock include hypotension, tachycardia,tachypnea,
pallor, diaphoresis, cool and clammy skin, and confusion.
12. A nurse obtains a client's health history at a community health clinic. Whichstatement
alerts the nurse to provide health teaching to this client?
a. "I drink two glasses of red wine each week."
b. "I take a lot of Tylenol for my arthritis pain."
c. "I have a cousin who died of liver cancer."
d. "I got a hepatitis vaccine before traveling.": b. "I take a lot of Tylenol for myarthritis pain."
Acetaminophen (Tylenol) can cause liver damage if taken in large amounts. Clientsshould be
taught not to exceed 4000 mg/day of acetaminophen. The nurse should teach the client about
this limitation and should explore other drug options with theclient to manage his or her
arthritis pain. Two glasses of wine each week, a cousinwith liver cancer, and the hepatitis
vaccine do not place the client at risk for a liver disorder, and therefore do not require any
health teaching.
1. After teaching a client who has alcohol-induced cirrhosis, a nurse as- sesses the client's
understanding. Which statement made by the client indi-cates a need for additional teaching?
a. "I cannot drink any alcohol at all anymore."
b. "I need to avoid protein in my diet."
c. "I should not take over-the-counter medications."
d. "I should eat small, frequent, balanced meals.": b. "I need to avoid protein inmy diet."
Based on the degree of liver involvement and decreased function, protein intake may have to
be decreased. However, some protein is necessary for the synthesis ofalbumin and normal
healing. The other statements indicate accurate understandingof self-care measures for this
client
2. A nurse cares for a client with hepatopulmonary syndrome who is expe- riencing dyspnea
with oxygen saturations at 92%. The client states, "I do notwant to wear the oxygen because it
causes my nose to bleed. Get out of my room and leave me alone!" Which action should the
nurse take?
a. Instruct the client to sit in as upright a position as possible.
b. Add humidity to the oxygen and encourage the client to wear it.
c. Document the client's refusal, and call the health care provider.
d. Contact the provider to request an extra dose of the client's diuretic.: a.Instruct the client to
sit in as upright a position as possible.
The client with hepatopulmonary syndrome is often dyspneic. Because the oxygensaturation
is not significantly low, the nurse should first allow the client to sit upright
to see if that helps. If the client remains dyspneic, or if the oxygen saturation dropsfurther, the
nurse should investigate adding humidity to the oxygen and seeing whether the client will
tolerate that. The other two options may be beneficial, but they are not the best choices. If the
client is comfortable, his or her agitation will decrease; this will improve respiratory status.
3. A nurse cares for a client who is scheduled for a paracentesis. Which intervention should
the nurse delegate to an unlicensed assistive personnel(UAP)?
a. Have the client sign the informed consent form.
b. Assist the client to void before the procedure.
c. Help the client lie flat in bed on the right side.
d. Get the client into a chair after the procedure.: b. Assist the client to void beforethe procedure.
For safety, the client should void just before a paracentesis. The nurse or the providershould have
the client sign the consent form. The proper position for a paracentesisis sitting upright in bed
or, alternatively, sitting on the side of the bed and leaning over the bedside table. The client
will be on bedrest after the procedure.
,4. A nurse cares for a client who has chronic cirrhosis from substance abuse.The client states,
"All of my family hates me." How should the nurse respond?
a. "You should make peace with your family."
b. "This is not unusual. My family hates me too."
c. "I will help you identify a support system."
d. "You must attend Alcoholics Anonymous.": c. "I will help you identify a supportsystem."
Clients who have chronic cirrhosis may have alienated relatives over the years because of
substance abuse. The nurse should assist the client to identify a friend,neighbor, or person in
his or her recovery group for support. The nurse should
not minimize the client's concerns by brushing off the client's comment. AttendingAA may be
appropriate, but this response doesn't address the client's concern.
Making peace with the client's family may not be possible. This statement is notclient-
centered.
5. A nurse cares for a client with hepatitis C. The client's brother states, "I do not want to
contract this infection, so I will not go into his hospital room." Howshould the nurse respond?
a. "If you wear a gown and gloves, you will not get this virus."
b. "Viral hepatitis is not spread through casual contact."
c. "This virus is only transmitted through a fecal specimen."
d. "I can give you an update on your brother's status from here.": b. "Viralhepatitis is not
spread through casual contact."
Although family members may be afraid that they will contract hepatitis C, the nurseshould
educate the client's family about how the virus is spread. Viral hepatitis,
or hepatitis C, is spread via blood-to-blood transmission and is associated with illicit IV drug
needle sharing, blood and organ transplantation, accidental needle sticks, unsanitary tattoo
equipment, and sharing of intranasal cocaine paraphernalia.Wearing a gown and gloves will not
decrease the transmission of this virus. HepatitisC is not spread through casual contact or a fecal
specimen. The nurse would be violating privacy laws by sharing the client's status with the
brother.
6. An infection control nurse develops a plan to decrease the number of health care
professionals who contract viral hepatitis at work. Which ideasshould the nurse include in this
plan? (Select all that apply.)
a. Policies related to consistent use of Standard Precautions
b. Hepatitis vaccination mandate for workers in high-risk areas
c. Implementation of a needleless system for intravenous therapy
d. Number of sharps used in client care reduced where possible
e. Postexposure prophylaxis provided in a timely manner: A,C,D,E
Nurses should always use Standard Precautions for client care, and policies shouldreflect this.
Needleless systems and reduction of sharps can help prevent hepatitis.Postexposure
,prophylaxis should be provided immediately. All health care workers should receive the
hepatitis vaccinations that are available.
7. A nurse assesses a client who has liver disease. Which laboratory findingsshould the nurse
recognize as potentially causing complications of this dis- order? (Select all that apply.)
a. Elevated aspartate transaminase
b. Elevated international normalized ratio (INR)
c. Decreased serum globulin levels
d. Decreased serum alkaline phosphatase
e. Elevated serum ammonia
f. Elevated prothrombin time (PT): B,E,F
Elevated INR and PT are indications of clotting disturbances and alert the nurse to the
increased possibility of hemorrhage. Elevated ammonia levels increase the
client's confusion. The other values are abnormal and associated with liver diseasebut do not
necessarily place the client at increased risk for complications.
8. A nurse delegates hygiene care for a client who has advanced cirrhosis toan unlicensed
nursing personnel (UAP). Which statements should the nurse include when delegating this
task to the UAP? (Select all that apply.)
a. "Apply lotion to the client's dry skin areas."
b. "Use a basin with warm water to bathe the client."
c. "For the client's oral care, use a soft toothbrush."
d. "Provide clippers so the client can trim the fingernails."
e. "Bathe with antibacterial and water-based soaps.": A,C,D
Clients with advanced cirrhosis often have pruritus. Lotion will help decrease itchi-ness from
dry skin. A soft toothbrush should be used to prevent gum bleeding, andthe client's nails should
be trimmed short to prevent the client from scratching himselfor herself. These clients should use
cool, not warm, water on their skin, and shouldnot use excessive amounts of soap.
9. A nurse assesses a male client who has symptoms of cirrhosis. Which questions should
the nurse ask to identify potential factors contributing tothis laboratory result? (Select all that
apply.)
a. "How frequently do you drink alcohol?"
b. "Have you ever had sex with a man?"
c. "Do you have a family history of cancer?"
d. "Have you ever worked as a plumber?"
e. "Were you previously incarcerated?": A,B,E
When assessing a client with suspected cirrhosis, the nurse should ask about alco-hol
consumption, including amount and frequency; sexual history and orientation (specifically
men having sex with men); illicit drug use; history of tattoos; and historyof military service,
, incarceration, or work as a firefighter, police officer, or health careprovider. A family history of
cancer and work as a plumber do not put the client at risk for cirrhosis.
10. A nurse plans care for a client who has hepatopulmonary syndrome. Which interventions
should the nurse include in this client's plan of care? (Select allthat apply.)
a. Oxygen therapy
b. Prone position
c. Feet elevated on pillows
d. Daily weights
e. Physical therapy: A,C,D
Care for a client who has hepatopulmonary syndrome should include oxygen ther-
apy, the head of bed elevated at least 30 degrees or as high as the client wants toimprove
breathing, elevated feet to decrease dependent edema, and daily weights.There is no need to
place the client in a prone position, on the client's stomach.
Although physical therapy may be helpful to a client who has been hospitalized for several
days, physical therapy is not an intervention specifically for hepatopulmonarysyndrome.
11. An emergency room nurse assesses a client with potential liver trauma. Which clinical
manifestations should alert the nurse to internal bleeding andhypovolemic shock? (Select all
that apply.)
a. Hypertension
b. Tachycardia
c. Flushed skin
d. Confusion
e. Shallow respirations: B,D
Symptoms of hemorrhage and hypovolemic shock include hypotension, tachycardia,tachypnea,
pallor, diaphoresis, cool and clammy skin, and confusion.
12. A nurse obtains a client's health history at a community health clinic. Whichstatement
alerts the nurse to provide health teaching to this client?
a. "I drink two glasses of red wine each week."
b. "I take a lot of Tylenol for my arthritis pain."
c. "I have a cousin who died of liver cancer."
d. "I got a hepatitis vaccine before traveling.": b. "I take a lot of Tylenol for myarthritis pain."
Acetaminophen (Tylenol) can cause liver damage if taken in large amounts. Clientsshould be
taught not to exceed 4000 mg/day of acetaminophen. The nurse should teach the client about
this limitation and should explore other drug options with theclient to manage his or her
arthritis pain. Two glasses of wine each week, a cousinwith liver cancer, and the hepatitis
vaccine do not place the client at risk for a liver disorder, and therefore do not require any
health teaching.
