Exam 3 DM & Adrenal and Cirrhosis Events

Question 1

Which statement by a nurse to a patient newly diagnosed with type 2 diabetes is correct?

a. Insulin is not used to control blood glucose in patients with type 2 diabetes.
b. Complications of type 2 diabetes are less serious than those of type 1 diabetes.
c. Changes in diet and exercise may control blood glucose levels in type 2 diabetes.
d. Type 2 diabetes is usually diagnosed when the patient is admitted with a
hyperglycemic coma.

Answer 1

ANS: C

For some patients with type 2 diabetes, changes in lifestyle are sufficient to achieve blood glucose control. Insulin is frequently
used for type 2 diabetes, complications are equally severe as for type 1 diabetes, and type 2 diabetes is usually diagnosed with
routine laboratory testing or after a patient develops complications such as frequent yeast infections.

Question 2

A patient screened for diabetes at a clinic has a fasting plasma glucose level of 120 mg/dL (6.7 mmol/L). The nurse will plan to
teach the patient about

a. self-monitoring of blood glucose.
b. using low doses of regular insulin.
c. lifestyle changes to lower blood glucose.
d. effects of oral hypoglycemic medications.

Answer 2

ANS: C

The patient’s impaired fasting glucose indicates prediabetes, and the patient should be counseled about lifestyle changes to prevent
the development of type 2 diabetes. The patient with prediabetes does not require insulin or oral hypoglycemics for glucose control
and does not need to self-monitor blood glucose.

Question 3

A 28-yr-old male patient with type 1 diabetes reports how he manages his exercise and glucose control. Which behavior indicates
that the nurse should implement additional teaching?

a. The patient always carries hard candies when engaging in exercise.
b. The patient goes for a vigorous walk when his glucose is 200 mg/dL.
c. The patient has a peanut butter sandwich before going for a bicycle ride.
d. The patient increases daily exercise when ketones are present in the urine.

Answer 3

ANS: D

When the patient is ketotic, exercise may result in an increase in blood glucose level. Patients with type 1 diabetes should be taught
to avoid exercise when ketosis is present. The other statements are correct.

Question 4

The nurse is assessing a 22-yr-old patient experiencing the onset of symptoms of type 1 diabetes. To which question would the
nurse anticipate a positive response?

a. “Are you anorexic?”
b. “Is your urine dark colored?”
c. “Have you lost weight lately?”
d. “Do you crave sugary drinks?”

Answer 4

ANS: C

Weight loss occurs because the body is no longer able to absorb glucose and starts to break down protein and fat for energy. The
patient is thirsty but does not necessarily crave sugar-containing fluids. Increased appetite is a classic symptom of type 1 diabetes.
With the classic symptom of polyuria, urine will be very dilute.

Question 5

A patient with type 2 diabetes is scheduled for a follow-up visit in the clinic several months from now. Which test will the nurse
schedule to evaluate the effectiveness of treatment for the patient?

a. Fasting blood glucose
b. Oral glucose tolerance
c. Glycosylated hemoglobin
d. Urine dipstick for glucose

Answer 5

ANS: C

The glycosylated hemoglobin (A1C) test shows the overall control of glucose over 90 to 120 days. A fasting blood level indicates
only the glucose level at one time. Urine glucose testing is not an accurate reflection of blood glucose level and does not reflect the
glucose over a prolonged time. Oral glucose tolerance testing is done to diagnose diabetes but is not used for monitoring glucose
control after diabetes has been diagnosed.

Question 6

The nurse is assessing a 55-yr-old female patient with type 2 diabetes who has a body mass index (BMI) of 31 kg/m2. Which goal in the plan of care is most important for this patient?

a. The patient will reach a glycosylated hemoglobin level of less than 7%.
b. The patient will follow a diet and exercise plan that results in weight loss.
c. The patient will choose a diet that distributes calories throughout the day.
d. The patient will state the reasons for eliminating simple sugars in the diet.

Answer 6

ANS: A

The complications of diabetes are related to elevated blood glucose and the most important patient outcome is the reduction of
glucose to near-normal levels. A BMI of 30?9?kg/m2 or above is considered obese, so the other outcomes are appropriate but are
not as high in priority.

Question 7

A patient who has type 1 diabetes plans to swim laps for an hour daily at 1:00 PM. The clinic nurse will plan to teach the patient to

a. check glucose level before, during, and after swimming.
b. delay eating the noon meal until after the swimming class.
c. increase the morning dose of neutral protamine Hagedorn (NPH) insulin.
d. time the morning insulin injection so that the peak occurs while swimming.

Answer 7

ANS: A

The change in exercise will affect blood glucose, and the patient will need to monitor glucose carefully to determine the need for
changes in diet and insulin administration. Because exercise tends to decrease blood glucose, patients are advised to eat before
exercising. Increasing the morning NPH or timing the insulin to peak during exercise may lead to hypoglycemia, especially with
the increased exercise.

Question 8

The nurse determines a need for additional instruction when the patient with newly diagnosed type 1 diabetes says which of the
following?

a. “I will need a bedtime snack because I take an evening dose of NPH insulin.”
b. “I can choose any foods, as long as I use enough insulin to cover the calories.”
c. “I can have an occasional beverage with alcohol if I include it in my meal plan.”
d. “I will eat something at meal times to prevent hypoglycemia, even if I am not
hungry. ”

Answer 8

ANS: B

Most patients with type 1 diabetes need to plan diet choices very carefully. Patients who are using intensified insulin therapy have
considerable flexibility in diet choices but still should restrict dietary intake of items such as fat, protein, and alcohol. The other
patient statements are correct and indicate good understanding of the diet instruction.

Question 9

To assist an older patient with diabetes to engage in moderate daily exercise, which action is most important for the nurse to take?

a. Determine what types of activities the patient enjoys.
b. Remind the patient that exercise improves self-esteem.
c. Teach the patient about the effects of exercise on glucose level.
d. Give the patient a list of activities that are moderate in intensity.

Answer 9

ANS: A

Because consistency with exercise is important, assessment for the types of exercise that the patient finds enjoyable is the most
important action by the nurse in ensuring adherence to an exercise program. The other actions may be helpful but are not the most
important in improving compliance.

Question 10

Which statement by the patient indicates a need for additional instruction in administering insulin?

a. “I need to rotate injection sites among my arms, legs, and abdomen each day.”
b. “I can buy the 0.5-mL syringes because the line markings will be easier to see.”
c. “I do not need to aspirate the plunger to check for blood before injecting insulin.”
d. “I should draw up the regular insulin first, after injecting air into the NPH bottle.”

Answer 10

ANS: A
Rotating sites is no longer recommended because there is more consistent insulin absorption when the same site is used
consistently. The other patient statements are accurate and indicate that no additional instruction is needed.

Question 11

Which patient action indicates good understanding of the nurse’s teaching about administration of aspart (NovoLog) insulin?

a. The patient avoids injecting the insulin into the upper abdominal area.
b. The patient cleans the skin with soap and water before insulin administration.
c. The patient stores the insulin in the freezer after administering the prescribed
dose.
d. The patient pushes the plunger down while removing the syringe from the
injection site.

Answer 11

ANS: B
Cleaning the skin with soap and water is acceptable. Insulin should not be frozen. The patient should leave the syringe in place for
about 5 seconds after injection to be sure that all the insulin has been injected. The upper abdominal area is one of the preferred
areas for insulin injection.

Question 12

A patient receives aspart (NovoLog) insulin at 8:00 AM. At which time would the nurse anticipate the highest risk for
hypoglycemia?

a. 10:00 AM
b. 12:00 AM
c. 2:00 PM
d. 4:00 PM

Answer 12

ANS: A

The rapid-acting insulins peak in 1 to 3 hours. The patient is not at a high risk for hypoglycemia at the other listed times, although
hypoglycemia may occur.

Question 13

Which patient action indicates a good understanding of the nurse’s teaching about the use of an insulin pump?

a. The patient programs the pump for an insulin bolus after eating.
b. The patient changes the location of the insertion site every week.
c. The patient takes the pump off at bedtime and starts it again each morning.
d. The patient plans a diet with more calories than usual when using the pump.

Answer 13

ANS: A

In addition to the basal rate of insulin infusion, the patient will adjust the pump to administer a bolus after each meal, with the dosage depending on the oral intake. The insertion site should be changed every 2 or 3 days. There is more flexibility in diet and exercise when an insulin pump is used, but it does not provide for consuming a higher calorie diet. The pump will deliver a basal insulin rate 24 hours a day.

Question 14

A patient with diabetes is starting on intensive insulin therapy. Which type of insulin will the nurse discuss using for mealtime coverage?

a. Lispro (Humalog)
b. Glargine (Lantus)
c. Detemir (Levemir)
d. NPH (Humulin N)

Answer 14

ANS: A

Rapid- or short-acting insulin is used for mealtime coverage for patients receiving intensive insulin therapy. NPH, glargine, or detemir will be used as the basal insulin.

Question 15

Which information will the nurse include when teaching a patient who has type 2 diabetes about glyburide ?

a. Glyburide decreases glucagon secretion from the pancreas.
b. Glyburide stimulates insulin production and release from the pancreas.
c. Glyburide should be taken even if the morning blood glucose level is low.
d. Glyburide should not be used for 48 hours after receiving IV contrast media.

Answer 15

ANS: B

The sulfonylureas stimulate the production and release of insulin from the pancreas. If the glucose level is low, the patient should contact the health care provider before taking glyburide because hypoglycemia can occur with this class of medication. Metformin should be held for 48 hours after administration of IV contrast media, but this is not necessary for glyburide. Glucagon secretion is not affected by glyburide.

Question 16

The nurse has been teaching a patient with type 2 diabetes about managing blood glucose levels and taking glipizide (Glucotrol). Which patient statement indicates a need for additional teaching?

a. “If I overeat at a meal, I will still take the usual dose of medication.”
b. “Other medications besides the Glucotrol may affect my blood sugar.”
c. “When I am ill, I may have to take insulin to control my blood sugar.”
d. “My diabetes won’t cause complications because I don’t need insulin.”

Answer 16

ANS: D

The patient should understand that type 2 diabetes places the patient at risk for many complications and that good glucose control is as important when taking oral agents as when using insulin. The other statements are accurate and indicate good understanding of the use of glipizide.

Question 17

When a patient who takes metformin (Glucophage) to manage type 2 diabetes develops an allergic rash from an unknown cause, the health care provider prescribes prednisone. The nurse will anticipate that the patient may

a. need a diet higher in calories while receiving prednisone.
b. develop acute hypoglycemia while taking the prednisone.
c. require administration of insulin while taking prednisone.
d. have rashes caused by metformin-prednisone interactions.

Answer 17

ANS: C
Glucose levels increase when patients are taking corticosteroids, and insulin may be required to control blood glucose. Hypoglycemia is not a side effect of prednisone. Rashes are not an adverse effect caused by taking metformin and prednisone simultaneously. The patient may have an increased appetite when taking prednisone but will not need a diet that is higher in calories.

Question 18

A hospitalized diabetic patient received 38 U of NPH insulin at 7:00 AM. At 1:00 PM, the patient has been away from the nursing unit for 2 hours, missing the lunch delivery while awaiting a chest x-ray. To prevent hypoglycemia, the best action by the nurse is to

a. save the lunch tray for the patient’s later return to the unit.
b. ask that diagnostic testing area staff to start a 5% dextrose IV.
c. send a glass of milk or orange juice to the patient in the diagnostic testing area.
d. request that if testing is further delayed, the patient be returned to the unit to eat.

Answer 18

ANS: D
Consistency for mealtimes assists with regulation of blood glucose, so the best option is for the patient to have lunch at the usual time. Waiting to eat until after the procedure is likely to cause hypoglycemia. Administration of an IV solution is unnecessarily invasive for the patient. A glass of milk or juice will keep the patient from becoming hypoglycemic but will cause a rapid rise in blood glucose because of the rapid absorption of the simple carbohydrate in these items.

Question 19

The nurse identifies a need for additional teaching when the patient who is self-monitoring blood glucose

a. washes the puncture site using warm water and soap.
b. chooses a puncture site in the center of the finger pad.
c. hangs the arm down for a minute before puncturing the site.
d. says the result of 120 mg indicates good blood sugar control.

Answer 19

ANS: B
The patient is taught to choose a puncture site at the side of the finger pad because there are fewer nerve endings along the side of the finger pad. The other patient actions indicate that teaching has been effective.

Question 20

The nurse is preparing to teach a 43-yr-old man who is newly diagnosed with type 2 diabetes about home management of the disease. Which action should the nurse take first?

a. Ask the patient’s family to participate in the diabetes education program.
b. Assess the patient’s perception of what it means to have diabetes mellitus.
c. Demonstrate how to check glucose using capillary blood glucose monitoring.
d. Discuss the need for the patient to actively participate in diabetes management.

Answer 20

ANS: B

Before planning teaching, the nurse should assess the patient’s interest in and ability to self-manage the diabetes. After assessing the patient, the other nursing actions may be appropriate, but planning needs to be individualized to each patient.

Question 21

An unresponsive patient with type 2 diabetes is brought to the emergency department and diagnosed with hyperosmolar hyperglycemic syndrome (HHS). The nurse will anticipate the need to

a. give 50% dextrose.
b. insert an IV catheter.
c. initiate O2 by nasal cannula.
d. administer glargine (Lantus) insulin.

Answer 21

ANS: B
HHS is initially treated with large volumes of IV fluids to correct hypovolemia. Regular insulin is administered, not a long-acting insulin. There is no indication that the patient requires O2. Dextrose solutions will increase the patient’s blood glucose and would be contraindicated.

Question 22

A 26-yr-old female with type 1 diabetes develops a sore throat and runny nose after caring for her sick toddler. The patient calls the clinic for advice about her symptoms and a blood glucose level of 210 mg/dL despite taking her usual glargine (Lantus) and lispro (Humalog) insulin. The nurse advises the patient to

a. use only the lispro insulin until the symptoms are resolved.
b. limit intake of calories until the glucose is less than 120 mg/dL.
c. monitor blood glucose every 4 hours and notify the clinic if it continues to rise.
d. decrease intake of carbohydrates until glycosylated hemoglobin is less than 7%.

Answer 22

ANS: C

Infection and other stressors increase blood glucose levels and the patient will need to test blood glucose frequently, treat elevations appropriately with lispro insulin, and call the health care provider if glucose levels continue to be elevated. Discontinuing the glargine will contribute to hyperglycemia and may lead to diabetic ketoacidosis (DKA). Decreasing carbohydrate or caloric intake is not appropriate because the patient will need more calories when ill. Glycosylated hemoglobin testing is not used to evaluate short-term alterations in blood glucose.

Question 23

The health care provider suspects the Somogyi effect in a 50-yr-old patient whose 6:00 AM blood glucose is 230 mg/dL. Which action will the nurse teach the patient to take?

a. Avoid snacking at bedtime.
b. Increase the rapid-acting insulin dose.
c. Check the blood glucose during the night
d. Administer a larger dose of long-acting insulin.

Answer 23

ANS: C
If the Somogyi effect is causing the patient’s increased morning glucose level, the patient will experience hypoglycemia between 2:00 and 4:00 AM. The dose of insulin will be reduced, rather than increased. A bedtime snack is used to prevent hypoglycemic episodes during the night.

Question 24

Which action should the nurse take after a patient treated with intramuscular glucagon for hypoglycemia regains consciousness?

a. Assess the patient for symptoms of hyperglycemia.
b. Give the patient a snack of peanut butter and crackers.
c. Have the patient drink a glass of orange juice or nonfat milk.
d. Administer a continuous infusion of 5% dextrose for 24 hours.

Answer 24

ANS: B
Rebound hypoglycemia can occur after glucagon administration, but having a meal containing complex carbohydrates plus protein and fat will help prevent hypoglycemia. Orange juice and nonfat milk will elevate blood glucose rapidly, but the cheese and crackers will stabilize blood glucose. Administration of IV glucose might be used in patients who were unable to take in nutrition orally. The patient should be assessed for symptoms of hypoglycemia after glucagon administration.

Question 25

Which question during the assessment of a patient who has diabetes will help the nurse identify autonomic neuropathy?

a. “Do you feel bloated after eating?”
b. “Have you seen any skin changes?”
c. “Do you need to increase your insulin dosage when you are stressed?”
d. “Have you noticed any painful new ulcerations or sores on your feet?”

Answer 25

ANS: A

Autonomic neuropathy can cause delayed gastric emptying, which results in a bloated feeling for the patient. The other questions are also appropriate to ask but would not help in identifying autonomic neuropathy.

Question 26

Which information will the nurse include in teaching a female patient who has peripheral arterial disease, type 2 diabetes, and sensory neuropathy of the feet and legs?

a. Choose flat-soled leather shoes.
b. Set heating pads on a low temperature.
c. Use callus remover for corns or calluses.
d. Soak feet in warm water for an hour each day.

Answer 26

ANS: A

The patient is taught to avoid high heels and that leather shoes are preferred. The feet should be washed, but not soaked, in warm water daily. Heating pad use should be avoided. Commercial callus and corn removers should be avoided. The patient should see a specialist to treat these problems.

Question 27

Which finding indicates a need to contact the health care provider before the nurse administers metformin (Glucophage)?

a. The patient’s blood glucose level is 174 mg/dL.
b. The patient is scheduled for a chest x-ray in an hour.
c. The patient has gained 2 lb (0.9 kg) in the past 24 hours.
d. The patient’s blood urea nitrogen (BUN) level is 52 mg/dL.

Answer 27

ANS: D
The BUN indicates possible renal failure, and metformin should not be used in patients with renal failure. The other findings are not contraindications to the use of metformin.

Question 28

A patient who has diabetes and reported burning foot pain at night receives a new prescription. Which information should the nurse teach the patient about amitriptyline ?

a. Amitriptyline decreases the depression caused by your foot pain.
b. Amitriptyline helps prevent transmission of pain impulses to the brain.
c. Amitriptyline corrects some of the blood vessel changes that cause pain.
d. Amitriptyline improves sleep and makes you less aware of nighttime pain.

Answer 28

ANS: B

Tricyclic antidepressants (TCAs) decrease the transmission of pain impulses to the spinal cord and brain. TCAs also improve sleep quality and are used for depression, but that is not the major purpose for their use in diabetic neuropathy. The blood vessel changes that contribute to neuropathy are not affected by TCAs.

Question 29

A patient who has type 2 diabetes is being prepared for an elective coronary angiogram. Which information would the nurse anticipate might lead to rescheduling the test?

a. The patient’s most recent A1C was 6.5%.
b. The patient’s blood glucose is 128 mg/dL.
c. The patient took the prescribed metformin today.
d. The patient took the prescribed captopril this morning.

Answer 29

ANS: C
To avoid lactic acidosis, metformin should be discontinued a day or 2 before the coronary angiogram and should not be used for 48 hours after IV contrast media are administered. The other patient data will also be reported but do not indicate any need to reschedule the procedure.

Question 30

. Which action by a patient indicates that the home health nurse’s teaching about glargine and regular insulin has been successful?

a. The patient administers the glargine 30 minutes before each meal.
b. The patient’s family prefills the syringes with the mix of insulins weekly.
c. The patient discards the open vials of glargine and regular insulin after 4 weeks.
d. The patient draws up the regular insulin and then the glargine in the same syringe.

Answer 30

ANS: C
Insulin can be stored at room temperature for 4 weeks. Glargine should not be mixed with other insulins or prefilled and stored. Short-acting regular insulin is administered before meals, and glargine is given once daily.

Question 31

A patient with diabetes rides a bicycle to and from work every day. Which site should the nurse teach the patient to use to administer the morning insulin?

a. thigh.
b. buttock.
c. abdomen.
d. upper arm.

Answer 31

ANS: C

Patients should be taught not to administer insulin into a site that will be exercised because exercise will increase the rate of absorption. The thigh, buttock, and arm are all exercised by riding a bicycle.

Question 32

The nurse is interviewing a new patient with diabetes who takes rosiglitazone (Avandia). Which information would the nurse anticipate resulting in the health care provider discontinuing the medication?

a. The patient’s blood pressure is 154/92.
b. The patient’s blood glucose is 86 mg/dL.
c. The patient reports a history of emphysema.
d. The patient has chest pressure when walking.

Answer 32

ANS: D
Rosiglitazone can cause myocardial ischemia. The nurse should immediately notify the health care provider and expect orders to discontinue the medication. A blood glucose level of 86 mg/dL indicates a positive effect from the medication. Hypertension and a history of emphysema do not contraindicate this medication.

Question 33

The nurse is taking a health history from a 29-yr-old pregnant patient at the first prenatal visit. The patient reports that she has no personal history of diabetes, but her mother has diabetes. Which action will the nurse plan to take?

a. Teach the patient about administering regular insulin.
b. Schedule the patient for a fasting blood glucose level.
c. Teach about an increased risk for fetal problems with gestational diabetes.
d. Schedule an oral glucose tolerance test for the twenty-fourth week of pregnancy.

Answer 33

ANS: B
Patients at high risk for gestational diabetes should be screened for diabetes on the initial prenatal visit. An oral glucose tolerance test may also be used to check for diabetes, but it would be done before the twenty-fourth week. Teaching plans would depend on the outcome of a fasting blood glucose test and other tests.

Question 34

A 27-yr-old patient admitted with diabetic ketoacidosis (DKA) has a serum glucose level of 732 mg/dL and serum potassium level of 3.1 mEq/L. Which action prescribed by the health care provider should the nurse take first?

a. Place the patient on a cardiac monitor.
b. Administer IV potassium supplements.
c. Ask the patient about home insulin doses.
d. Start an insulin infusion at 0.1 units/kg/hr.

Answer 34

ANS: A

Hypokalemia can lead to potentially fatal dysrhythmias such as ventricular tachycardia and ventricular fibrillation, which would be detected with electrocardiogram (ECG) monitoring. Because potassium must be infused over at least 1 hour, the nurse should initiate cardiac monitoring before infusion of potassium. Insulin should not be administered without cardiac monitoring because insulin infusion will further decrease potassium levels. Discussion of home insulin and possible causes can wait until the patient is stabilized.

Question 35

A patient with diabetic ketoacidosis is brought to the emergency department. Which prescribed action should the nurse implement first?

a. Infuse 1 L of normal saline per hour.
b. Give sodium bicarbonate 50 mEq IV push.
c. Administer regular insulin 10 U by IV push.
d. Start a regular insulin infusion at 0.1 units/kg/hr.

Answer 35

ANS: A

The most urgent patient problem is the hypovolemia associated with diabetic ketoacidosis (DKA), and the priority is to infuse IV fluids. The other actions can be done after the infusion of normal saline is initiated.

Question 36

A patient who was admitted with diabetic ketoacidosis secondary to a urinary tract infection has been weaned off an insulin drip 30 minutes ago. The patient reports feeling lightheaded and sweaty. Which action should the nurse take first?

a. Infuse dextrose 50% by slow IV push.
b. Administer 1 mg glucagon subcutaneously.
c. Obtain a glucose reading using a finger stick.
d. Have the patient drink 4 ounces of orange juice.

Answer 36

ANS: C
The patient’s clinical manifestations are consistent with hypoglycemia, and the initial action should be to check the patient’s glucose with a finger stick or order a stat blood glucose. If the glucose is low, the patient should ingest a rapid-acting carbohydrate, such as orange juice. Glucagon or dextrose 50% might be given if the patient’s symptoms become worse or if the patient is unconscious.

Question 37

A female patient is scheduled for an oral glucose tolerance test. Which information from the patient’s health history is important for the nurse to communicate to the health care provider regarding this test?

a. The patient uses oral contraceptives.
b. The patient runs several days a week.
c. The patient has been pregnant three times.
d. The patient has a family history of diabetes.

Answer 37

ANS: A

Oral contraceptive use may falsely elevate oral glucose tolerance test (OGTT) values. Exercise and a family history of diabetes both can affect blood glucose but will not lead to misleading information from the OGTT. History of previous pregnancies may provide informational about gestational glucose tolerance but will not lead to misleading information from the OGTT.

Question 38

Which laboratory value reported to the nurse by the unlicensed assistive personnel (UAP) indicates an urgent need for the nurse’s assessment of the patient?

a. Bedtime glucose of 140 mg/dL
b. Noon blood glucose of 52 mg/dL
c. Fasting blood glucose of 130 mg/dL
d. 2-hr postprandial glucose of 220 mg/dL

Answer 38

ANS: B

The nurse should assess the patient with a blood glucose level of 52 mg/dL for symptoms of hypoglycemia and give the patient a carbohydrate-containing beverage such as orange juice. The other values are within an acceptable range or not immediately dangerous for a patient with diabetes.

Question 39

When a patient with type 2 diabetes is admitted for a cholecystectomy, which nursing action can the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)?

a. Communicate the blood glucose level and insulin dose to the circulating nurse in
surgery.
b. Discuss the reason for the use of insulin therapy during the immediate
postoperative period.
c. Administer the prescribed lispro (Humalog) insulin before transporting the patient
to surgery.
d. Plan strategies to minimize the risk for hypoglycemia or hyperglycemia during
the postoperative period.

Answer 39

ANS: C
LPN/LVN education and scope of practice includes administration of insulin. Communication about patient status with other departments, planning, and patient teaching are skills that require RN education and scope of practice.

Question 40

An active 32-yr-old male who has type 1 diabetes is being seen in the endocrine clinic. Which finding indicates a need for the nurse to discuss a possible a change in therapy with the health care provider?

a. Hemoglobin A1C level of 6.2%
b. Blood pressure of 140/88 mmHg
c. Heart rate at rest of 58 beats/minute
d. High density lipoprotein (HDL) level of 65 mg/dL

Answer 40

ANS: B

To decrease the incidence of macrovascular and microvascular problems in patients with diabetes, the goal blood pressure is usually 130/80 mm Hg. An A1C less than 6.5%, a low resting heart rate (consistent with regular aerobic exercise in a young adult), and an HDL level of 65 mg/dL all indicate that the patient’s diabetes and risk factors for vascular disease are well controlled.

Question 41

A 30-yr-old patient has a new diagnosis of type 2 diabetes. The nurse will discuss the need to schedule a dilated eye examination

a. every 2 years.
b. as soon as possible.
c. when the patient is 39 years old.
d. within the first year after diagnosis.

Answer 41

ANS: B
Because many patients have some diabetic retinopathy when they are first diagnosed with type 2 diabetes, a dilated eye examination is recommended at the time of diagnosis and annually thereafter. Patients with type 1 diabetes should have dilated eye examinations starting 5 years after they are diagnosed and then annually.

Question 42

After the nurse has finished teaching a patient who has a new prescription for exenatide (Byetta), which patient statement indicates that the teaching has been effective?

a. “I may feel hungrier than usual when I take this medicine.”
b. “I will not need to worry about hypoglycemia with the Byetta.”
c. “I should take my daily aspirin at least an hour before the Byetta.”
d. “I will take the pill at the same time I eat breakfast in the morning.”

Answer 42

ANS: C
Because exenatide slows gastric emptying, oral medications should be taken at least 1 hour before the exenatide to avoid slowing absorption. Exenatide is injected and increases feelings of satiety. Hypoglycemia can occur with this medication.

Question 43

A few weeks after an 82-yr-old patient with a new diagnosis of type 2 diabetes has been placed on metformin (Glucophage) therapy and taught about appropriate diet and exercise, the home health nurse makes a visit. Which finding should the nurse promptly discuss with the health care provider?

a. Hemoglobin A1C level is 7.9%.
b. Last eye examination was 18 months ago.
c. Glomerular filtration rate is decreased.
d. Patient has questions about the prescribed diet.

Answer 43

ANS: C

The decrease in renal function may indicate a need to adjust the dose of metformin or change to a different medication. In older patients, the goal for A1C may be higher in order to avoid complications associated with hypoglycemia. The nurse will plan on scheduling the patient for an eye examination and addressing the questions about diet, but the area for prompt intervention is the patient’s decreased renal function.

Question 44

The nurse has administered 4 oz of orange juice to an alert patient whose blood glucose was 62 mg/dL. Fifteen minutes later, the blood glucose is 67 mg/dL. Which action should the nurse take next?

a. Give the patient 4 to 6 oz more orange juice.
b. Administer the PRN glucagon (Glucagon) 1 mg IM.
c. Have the patient eat some peanut butter with crackers.
d. Notify the health care provider about the hypoglycemia.

Answer 44

ANS: A
The “rule of 15” indicates that administration of quickly acting carbohydrates should be done two or three times for a conscious patient whose glucose remains less than 70 mg/dL before notifying the health care provider. More complex carbohydrates and fats may be used after the glucose has stabilized. Glucagon should be used if the patient’s level of consciousness decreases so that oral carbohydrates can no longer be given.

Question 45

Which nursing action can the nurse delegate to experienced unlicensed assistive personnel (UAP) who are working in the diabetic clinic?

a. Measure the ankle-brachial index.
b. Check for changes in skin pigmentation.
c. Assess for unilateral or bilateral foot drop.
d. Ask the patient about symptoms of depression.

Answer 45

ANS: A
Checking systolic pressure at the ankle and brachial areas and calculating the ankle-brachial index is a procedure that can be done by UAP who have been trained in the procedure. The other assessments require more education and critical thinking and should be done by the registered nurse (RN).

Question 46

After change-of-shift report, which patient will the nurse assess first?
a. A 19-yr-old patient with type 1 diabetes who was admitted with possible dawn
phenomenon
b. A 35-yr-old patient with type 1 diabetes whose most recent blood glucose reading
was 230 mg/dL
c. A 60-yr-old patient with hyperosmolar hyperglycemic syndrome who has poor
skin turgor and dry oral mucosa
d. A 68-yr-old patient with type 2 diabetes who has severe peripheral neuropathy
and complains of burning foot pain

Answer 46

ANS: C
The patient’s diagnosis of HHS and signs of dehydration indicate that the nurse should rapidly assess for signs of shock and determine whether increased fluid infusion is needed. The other patients also need assessment and intervention but do not have life-threatening complications.

Question 47

After change-of-shift report, which patient should the nurse assess first?

a. A 19-yr-old patient with type 1 diabetes who has a hemoglobin A1C of 12%
b. A 23-yr-old patient with type 1 diabetes who has a blood glucose of 40 mg/dL
c. A 40-yr-old patient who is pregnant and whose oral glucose tolerance test is 202
mg/dL
d. A 50-yr-old patient who uses exenatide (Byetta) and is complaining of acute
abdominal pain

Answer 47

ANS: B
Because the brain requires glucose to function, untreated hypoglycemia can cause unconsciousness, seizures, and death. The nurse will rapidly assess and treat the patient with low blood glucose. The other patients also have symptoms that require assessments or interventions, but they are not at immediate risk for life-threatening complications.

Question 48

To monitor for complications in a patient with type 2 diabetes, which tests will the nurse in the diabetic clinic schedule at least annually (select all that apply)?

a. Chest x-ray
b. Blood pressure
c. Serum creatinine
d. Urine for microalbuminuria
e. Complete blood count (CBC)
f. Monofilament testing of the foot

Answer 48

ANS: B, C, D, F
Blood pressure, serum creatinine, urine testing for microalbuminuria, and monofilament testing of the foot are recommended at least annually to screen for possible microvascular and macrovascular complications of diabetes. Chest x-ray and CBC might be ordered if the patient with diabetes presents with symptoms of respiratory or infectious problems but are not routinely included in screening.

Question 49

In which order will the nurse take these steps to prepare NPH 20 units and regular insulin 2 units using the same syringe? (Put a comma and a space between each answer choice [A, B, C, D, E]).

a. Rotate NPH vial.
b. Withdraw regular insulin.
c. Withdraw 20 units of NPH.
d. Inject 20 units of air into NPH vial.
e. Inject 2 units of air into regular insulin vial.

Answer 49

ANS:
A, D, E, B, C
When mixing regular insulin with NPH, it is important to avoid contact between the regular insulin and the additives in the NPH that slow the onset, peak, and duration of activity in the longer-acting insulin.

Question 50

A 40-yr-old patient with suspected acromegaly is seen at the clinic. To assist in making the diagnosis, which question should the nurse ask?

a. “Have you had a recent head injury?”
b. “Do you have to wear larger shoes now?”
c. “Is there a family history of acromegaly?”
d. “Are you experiencing tremors or anxiety?”

Answer 50

ANS: B
Acromegaly causes an enlargement of the hands and feet. Head injury and family history are not risk factors for acromegaly. Tremors and anxiety are not clinical manifestations of acromegaly.

Question 51

A 54-year-old patient admitted with diabetes mellitus, malnutrition, osteomyelitis, and alcohol abuse has a serum amylase level of 280 U/L and a serum lipase level of 310 U/L. To what diagnosis does the nurse attribute these findings?

A. Malnutrition
B. Osteomyelitis
C. Alcohol abuse
D. Diabetes mellitus

Answer 51

C. Alcohol abuse

The patient with alcohol abuse could develop pancreatitis as a complication, which would increase the serum amylase (normal 30-122 U/L) and serum lipase (normal 31-186 U/L) levels as shown.

Question 52

The health care provider orders lactulose for a patient with hepatic encephalopathy. The nurse will monitor for effectiveness of this medication for this patient by assessing what?

A. Relief of constipation
B. Relief of abdominal pain
C. Decreased liver enzymes
D. Decreased ammonia levels

Answer 52

D. Decreased ammonia levels

Hepatic encephalopathy is a complication of liver disease and is associated with elevated serum ammonia levels. Lactulose traps ammonia in the intestinal tract. Its laxative effect then expels the ammonia from the colon, resulting in decreased serum ammonia levels and correction of hepatic encephalopathy.

Question 53

The family of a patient newly diagnosed with hepatitis A asks the nurse what they can do to prevent becoming ill themselves. Which response by the nurse is most appropriate?

A. “The hepatitis vaccine will provide immunity from this exposure and future exposures.”
B. “I am afraid there is nothing you can do since the patient was infectious before admission.”
C. “You will need to be tested first to make sure you don’t have the virus before we can treat you.”
D. “An injection of immunoglobulin will need to be given to prevent or minimize the effects from this exposure.”

Answer 53

D. “An injection of immunoglobulin will need to be given to prevent or minimize the effects from this exposure.”

Immunoglobulin provides temporary (1-2 months) passive immunity and is effective for preventing hepatitis A if given within 2 weeks after exposure. It may not prevent infection in all persons, but it will at least modify the illness to a subclinical infection. The hepatitis vaccine is only used for preexposure prophylaxis.

Question 54

When planning care for a patient with cirrhosis, the nurse will give highest priority to which nursing diagnosis?

A. Impaired skin integrity related to edema, ascites, and pruritus
B. Imbalanced nutrition: less than body requirements related to anorexia
C. Excess fluid volume related to portal hypertension and hyperaldosteronism
D. Ineffective breathing pattern related to pressure on diaphragm and reduced lung volume

Answer 54

D. Ineffective breathing pattern related to pressure on diaphragm and reduced lung volume

Although all of these nursing diagnoses are appropriate and important in the care of a patient with cirrhosis, airway and breathing are always the highest priorities

Question 55

When caring for a patient with liver disease, the nurse recognizes the need to prevent bleeding resulting from altered clotting factors and rupture of varices. Which nursing interventions would be appropriate to achieve this outcome (select all that apply)?

A. Use smallest gauge needle possible when giving injections or drawing blood.
B. Teach patient to avoid straining at stool, vigorous blowing of nose, and coughing.
C. Advise patient to use soft-bristle toothbrush and avoid ingestion of irritating food.
D. Apply gentle pressure for the shortest possible time period after performing venipuncture.
E. Instruct patient to avoid aspirin and NSAIDs to prevent hemorrhage when varices are present.

Answer 55

A. Use smallest gauge needle possible when giving injections or drawing blood.
B. Teach patient to avoid straining at stool, vigorous blowing of nose, and coughing.
C. Advise patient to use soft-bristle toothbrush and avoid ingestion of irritating food.
E. Instruct patient to avoid aspirin and NSAIDs to prevent hemorrhage when varices are present.

Using the smallest gauge needle for injections will minimize the risk of bleeding into the tissues. Avoiding straining, nose blowing, and coughing will reduce the risk of hemorrhage at these sites. The use of a soft-bristle toothbrush and avoidance of irritating food will reduce injury to highly vascular mucous membranes. The nurse should apply gentle but prolonged pressure to venipuncture sites to minimize the risk of bleeding. Aspirin and NSAIDs should not be used in patients with liver disease because they interfere with platelet aggregation, thus increasing the risk for bleeding.

Question 56

A patient with type 2 diabetes and cirrhosis asks the nurse if it would be okay to take silymarin (milk thistle) to help minimize liver damage. The nurse responds based on what knowledge?

A. Milk thistle may affect liver enzymes and thus alter drug metabolism.
B. Milk thistle is generally safe in recommended doses for up to 10 years.
C. There is unclear scientific evidence for the use of milk thistle in treating cirrhosis.
D. Milk thistle may elevate the serum glucose levels and is thus contraindicated in diabetes.

Answer 56

A. Milk thistle may affect liver enzymes and thus alter drug metabolism.

There is good scientific evidence that there is no real benefit from using milk thistle to protect the liver cells from toxic damage in the treatment of cirrhosis. Milk thistle does affect liver enzymes and thus could alter drug metabolism. Therefore patients will need to be monitored for drug interactions. It is noted to be safe for up to 6 years, not 10 years, and it may lower, not elevate, blood glucose levels.

Question 57

When caring for a patient with a biliary obstruction, the nurse will anticipate administering which vitamin supplements (select all that apply)?

A. Vitamin A
B. Vitamin D
C. Vitamin E
D. Vitamin K
E. Vitamin B

Answer 57

A. Vitamin A Correct
B. Vitamin D Correct
C. Vitamin E Correct
D. Vitamin K Correct

Biliary obstruction prevents bile from entering the small intestine and thus prevents the absorption of fat-soluble vitamins. Vitamins A, D, E, and K are all fat-soluble and thus would need to be supplemented in a patient with biliary obstruction.

Question 58

A patient who has hepatitis B surface antigen (HBsAg) in the serum is being discharged with pain medication after knee surgery. Which medication order should the nurse question because it is most likely to cause hepatic complications?

A. Tramadol (Ultram)
B. Hydromorphone (Dilaudid)
C. Oxycodone with aspirin (Percodan)
D. Hydrocodone with acetaminophen (Vicodin)

Answer 58

D. Hydrocodone with acetaminophen (Vicodin)

The analgesic with acetaminophen should be questioned because this patient is a chronic carrier of hepatitis B and is likely to have impaired liver function. Acetaminophen is not suitable for this patient because it is converted to a toxic metabolite in the liver after absorption, increasing the risk of hepatocellular damage.

Question 59

The condition of a patient who has cirrhosis of the liver has deteriorated. Which diagnostic study would help determine if the patient has developed liver cancer?

A. Serum α-fetoprotein level
B. Ventilation/perfusion scan
C. Hepatic structure ultrasound
D. Abdominal girth measurement

Answer 59

C. Hepatic structure ultrasound

Hepatic structure ultrasound, CT, and MRI are used to screen and diagnose liver cancer. Serum α-fetoprotein level may be elevated with liver cancer or other liver problems. Ventilation/perfusion scans do not diagnose liver cancer. Abdominal girth measurement would not differentiate between cirrhosis and liver cancer.

Question 60

The patient with right upper quadrant abdominal pain has an abdominal ultrasound that reveals cholelithiasis. What should the nurse expect to do for this patient?

A. Prevent all oral intake.
B. Control abdominal pain.
C. Provide enteral feedings.
D. Avoid dietary cholesterol.

Answer 60

B. Control abdominal pain.

Patients with cholelithiasis can have severe pain, so controlling pain is important until the problem can be treated. NPO status may be needed if the patient will have surgery but will not be used for all patients with cholelithiasis. Enteral feedings should not be needed, and avoiding dietary cholesterol is not used to treat cholelithiasis.

Question 61

A patient with cholelithiasis needs to have the gallbladder removed. Which patient assessment is a contraindication for a cholecystectomy?

A. Low-grade fever of 100° F and dehydration
B. Abscess in the right upper quadrant of the abdomen
C. Activated partial thromboplastin time (aPTT) of 54 seconds

Answer 61

C. Activated partial thromboplastin time (aPTT) of 54 seconds

Multiple obstructions in the cystic and common bile duct
An aPTT of 54 seconds is above normal and indicates insufficient clotting ability. If the patient had surgery, significant bleeding complications postoperatively are very likely. Fluids can be given to eliminate the dehydration; the abscess can be assessed, and the obstructions in the cystic and common bile duct would be relieved with the cholecystectomy.

Question 62

When teaching the patient with acute hepatitis C (HCV), the patient demonstrates understanding when the patient makes which statement?

A. “I will use care when kissing my wife to prevent giving it to her.”
B. “I will need to take adofevir (Hepsera) to prevent chronic HCV.”
C. “Now that I have had HCV, I will have immunity and not get it again.”
D. “I will need to be checked for chronic HCV and other liver problems.”

Answer 62

D. “I will need to be checked for chronic HCV and other liver problems.”

The majority of patients who acquire HCV usually develop chronic infection, which may lead to cirrhosis or liver cancer. HCV is not transmitted via saliva, but percutaneously and via high-risk sexual activity exposure. The treatment for acute viral hepatitis focuses on resting the body and adequate nutrition for liver regeneration. Adofevir (Hepsera) is taken for severe hepatitis B (HBV) with liver failure. Chronic HCV is treated with pegylated interferon with ribavirin. Immunity with HCV does not occur as it does with HAV and HBV, so the patient may be reinfected with another type of HCV.

Question 63

The patient with cirrhosis has an increased abdominal girth from ascites. The nurse should know that this fluid gathers in the abdomen for which reasons (select all that apply)?

A. There is decreased colloid oncotic pressure from the liver’s inability to synthesize albumin.
B. Hyperaldosteronism related to damaged hepatocytes increases sodium and fluid retention.
C. Portal hypertension pushes proteins from the blood vessels, causing leaking into the peritoneal cavity.
D. Osmoreceptors in the hypothalamus stimulate thirst, which causes the stimulation to take in fluids orally.
E. Overactivity of the enlarged spleen results in increased removal of blood cells from the circulation, which decreases the vascular pressure.

Answer 63

A. There is decreased colloid oncotic pressure from the liver’s inability to synthesize albumin. Correct
B. Hyperaldosteronism related to damaged hepatocytes increases sodium and fluid retention. Correct
C. Portal hypertension pushes proteins from the blood vessels, causing leaking into the peritoneal cavity. Correct

The ascites related to cirrhosis are caused by decreased colloid oncotic pressure from the lack of albumin from liver inability to synthesize it and the portal hypertension that shifts the protein from the blood vessels to the peritoneal cavity, and hyperaldosteronism which increases sodium and fluid retention. The intake of fluids orally and the removal of blood cells by the spleen do not directly contribute to ascites.

Question 64

The patient with cirrhosis is being taught self-care. Which statement indicates the patient needs more teaching?

A. “If I notice a fast heart rate or irregular beats, this is normal for cirrhosis.”
B. “I need to take good care of my belly and ankle skin where it is swollen.”
C. “A scrotal support may be more comfortable when I have scrotal edema.”
D. “I can use pillows to support my head to help me breathe when I am in bed.”

Answer 64

A. “If I notice a fast heart rate or irregular beats, this is normal for cirrhosis.” Correct

If the patient with cirrhosis experiences a fast or irregular heart rate, it may be indicative of hypokalemia and should be reported to the health care provider, as this is not normal for cirrhosis. Edematous tissue is subject to breakdown and needs meticulous skin care. Pillows and a semi-Fowler’s or Fowler’s position will increase respiratory efficiency. A scrotal support may improve comfort if there is scrotal edema.

Question 65

The patient with a history of lung cancer and hepatitis C has developed liver failure and is considering liver transplantation. After the comprehensive evaluation, the nurse knows that which factor discovered may be a contraindication for liver transplantation?

A. Has completed a college education
B. Has been able to stop smoking cigarettes
C. Has well-controlled type 1 diabetes mellitus
D. The chest x-ray showed another lung cancer lesion.

Answer 65

D. The chest x-ray showed another lung cancer lesion. Correct

Contraindications for liver transplant include severe extrahepatic disease, advanced hepatocellular carcinoma or other cancer, ongoing drug and/or alcohol abuse, and the inability to comprehend or comply with the rigorous post-transplant course.

Question 66

The patient with sudden pain in the left upper quadrant radiating to the back and vomiting was diagnosed with acute pancreatitis. What intervention(s) should the nurse expect to include in the patient’s plan of care?

A. Immediately start enteral feeding to prevent malnutrition.
B. Insert an NG and maintain NPO status to allow pancreas to rest.
C. Initiate early prophylactic antibiotic therapy to prevent infection.
D. Administer acetaminophen (Tylenol) every 4 hours for pain relief.

Answer 66

B. Insert an NG and maintain NPO status to allow pancreas to rest. Correct

Initial treatment with acute pancreatitis will include an NG tube if there is vomiting and being NPO to decrease pancreatic enzyme stimulation and allow the pancreas to rest and heal. Fluid will be administered to treat or prevent shock. The pain will be treated with IV morphine because of the NPO status. Enteral feedings will only be used for the patient with severe acute pancreatitis in whom oral intake is not resumed. Antibiotic therapy is only needed with acute necrotizing pancreatitis and signs of infection.

Question 67

The patient with suspected pancreatic cancer is having many diagnostic studies done. Which one can be used to establish the diagnosis of pancreatic adenocarcinoma and for monitoring the response to treatment?

A. Spiral CT scan
B. A PET/CT scan Incorrect
C. Abdominal ultrasound
D. Cancer-associated antigen 19-9

Answer 67

D. Cancer-associated antigen 19-9 Correct

The cancer-associated antigen 19-9 (CA 19-9) is the tumor marker used for the diagnosis of pancreatic adenocarcinoma and for monitoring the response to treatment. Although a spiral CT scan may be the initial study done and provides information on metastasis and vascular involvement, this test and the PET/CT scan or abdominal ultrasound do not provide additional information.

Question 68

When providing discharge teaching for the patient after a laparoscopic cholecystectomy, what information should the nurse include?

A. A lower-fat diet may be better tolerated for several weeks. Correct
B. Do not return to work or normal activities for 3 weeks.
C. Bile-colored drainage will probably drain from the incision.
D. Keep the bandages on and the puncture site dry until it heals.

Answer 68

A. A lower-fat diet may be better tolerated for several weeks.

Although the usual diet can be resumed, a low-fat diet is usually better tolerated for several weeks following surgery. Normal activities can be gradually resumed as the patient tolerates. Bile-colored drainage or pus, redness, swelling, severe pain, and fever may all indicate infection. The bandage may be removed the day after surgery, and the patient can shower.

Question 69

The nurse is caring for a woman recently diagnosed with viral hepatitis A. Which individual should the nurse refer for an immunoglobin (IG) injection?

A. A caregiver who lives in the same household with the patient
B. A friend who delivers meals to the patient and family each week
C. A relative with a history of hepatitis A who visits the patient daily
D. A child living in the home who received the hepatitis A vaccine 3 months ago

Answer 69

A. A caregiver who lives in the same household with the patient

IG is recommended for persons who do not have anti-HAV antibodies and are exposed as a result of close contact with persons who have HAV or foodborne exposure. Persons who have received a dose of HAV vaccine more than 1 month previously or who have a history of HAV infection do not require IG.

Question 70

The nurse provides discharge instructions for a 64-year-old woman with ascites and peripheral edema related to cirrhosis. Which statement, if made by the patient, indicates teaching was effective?

A. “It is safe to take acetaminophen up to four times a day for pain.”
B. “Lactulose (Cephulac) should be taken every day to prevent constipation.”
C. “Herbs and other spices should be used to season my foods instead of salt.”
D. “I will eat foods high in potassium while taking spironolactone (Aldactone).”

Answer 70

C. “Herbs and other spices should be used to season my foods instead of salt.”

A low-sodium diet is indicated for the patient with ascites and edema related to cirrhosis. Table salt is a well-known source of sodium and should be avoided. Alternatives to salt to season foods include the use of seasonings such as garlic, parsley, onion, lemon juice, and spices. Pain medications such as acetaminophen, aspirin, and ibuprofen should be avoided as these medications may be toxic to the liver. The patient should avoid potentially hepatotoxic over-the-counter drugs (e.g., acetaminophen) because the diseased liver is unable to metabolize these drugs. Spironolactone is a potassium-sparing diuretic. Lactulose results in the acidification of feces in bowel and trapping of ammonia, causing its elimination in feces.

Question 71

The nurse is caring for a 55-year-old man patient with acute pancreatitis resulting from gallstones. Which clinical manifestation would the nurse expect the patient to exhibit?

A. Hematochezia
B. Left upper abdominal pain
C. Ascites and peripheral edema
D. Temperature over 102o F (38.9o C)

Answer 71

B. Left upper abdominal pain

Abdominal pain (usually in the left upper quadrant) is the predominant manifestation of acute pancreatitis. Other manifestations of acute pancreatitis include nausea and vomiting, low-grade fever, leukocytosis, hypotension, tachycardia, and jaundice. Abdominal tenderness with muscle guarding is common. Bowel sounds may be decreased or absent. Ileus may occur and causes marked abdominal distention. Areas of cyanosis or greenish to yellow-brown discoloration of the abdominal wall may occur. Other areas of ecchymoses are the flanks (Grey Turner’s spots or sign, a bluish flank discoloration) and the periumbilical area (Cullen’s sign, a bluish periumbilical discoloration).

Question 72

The nurse is caring for a group of patients. Which patient is at highest risk for pancreatic cancer?

A. A 38-year-old Hispanic female who is obese and has hyperinsulinemia
B. A 23-year-old who has cystic fibrosis-related pancreatic enzyme insufficiency
C. A 72-year-old African American male who has smoked cigarettes for 50 years
D. A 19-year-old who has a 5-year history of uncontrolled type 1 diabetes mellitus

Answer 72

C. A 72-year-old African American male who has smoked cigarettes for 50 years

Risk factors for pancreatic cancer include chronic pancreatitis, diabetes mellitus, age, cigarette smoking, family history of pancreatic cancer, high-fat diet, and exposure to chemicals such as benzidine. African Americans have a higher incidence of pancreatic cancer than whites. The most firmly established environmental risk factor is cigarette smoking. Smokers are two or three times more likely to develop pancreatic cancer as compared with nonsmokers. The risk is related to duration and number of cigarettes smoked.

Question 73

The nurse instructs a 50-year-old woman about cholestyramine to reduce pruritis caused by gallbladder disease. Which statement by the patient to the nurse indicates she understands the instructions?

A. “This medication will help me digest fats and fat-soluble vitamins.”
B. “I will apply the medicated lotion sparingly to the areas where I itch.”
C. “The medication is a powder and needs to be mixed with milk or juice.”
D. “I should take this medication on an empty stomach at the same time each day.”

Answer 73

C. “The medication is a powder and needs to be mixed with milk or juice.”

For treatment of pruritus, cholestyramine may provide relief. This is a resin that binds bile salts in the intestine, increasing their excretion in the feces. Cholestyramine is in powder form and should be mixed with milk or juice before oral administration.

Question 74

A patient with hepatitis A is in the acute phase. The nurse plans care for the patient based on the knowledge that

a. pruritus is a common problem with jaundice in this phase.
b. the patient is most likely to transmit the disease during this phase.
c. gastrointestinal symptoms are not as severe in hepatitis A as they are in hepatitis B.
d. extrahepatic manifestations of glomerulonephritis and polyarteritis are common in this phase.

Answer 74

A. pruritus is a common problem with jaundice in this phase.

Rationale: The acute phase of jaundice may be icteric or anicteric. Jaundice results when bilirubin diffuses into the tissues. Pruritus sometimes accompanies jaundice. Pruritus is the result of an accumulation of bile salts beneath the skin.

Question 75

A patient with acute hepatitis B is being discharged in 2 days. In the discharge teaching plan the nurse should include instructions to

a. avoid alcohol for the first 3 weeks.
b. use a condom during sexual intercourse.
c. have family members get an injection of immunoglobulin.
d. follow a low-protein, moderate-carbohydrate, moderate-fat diet. (Lewis 1042)

Answer 75

b. use a condom during sexual intercourse.

Rationale: Hepatitis B virus may be transmitted by mucosal exposure to infected blood, blood products, or other body fluids (e.g., semen, vaginal secretions, saliva). Hepatitis B is a sexually transmitted disease that is acquired through unprotected sex with an infected person. Condom use should be taught to patients to prevent transmission of hepatitis B.

Question 76

A patient has been told that she has elevated liver enzymes caused by nonalcoholic fatty liver disease (NAFLD). The nursing teaching plan should include

a. having genetic testing done.
b. recommending a heart-healthy diet.
c. the necessity to reduce weight rapidly.
d. avoiding alcohol until liver enzymes return to normal.

Answer 76

b. recommending a heart-healthy diet.

Rationale: Nonalcoholic fatty liver disease (NAFLD) can progress to liver cirrhosis. There is no definitive treatment, and therapy is directed at reduction of risk factors, which include treatment of diabetes, reduction in body weight, and elimination of harmful medications. For patients who are overweight, weight reduction is important. Weight loss improves insulin sensitivity and reduces liver enzyme levels. No specific dietary therapy is recommended. However, a heart-healthy diet as recommended by the American Heart Association is appropriate.

Question 77

The patient with advanced cirrhosis asks why his abdomen is so swollen. The nurse’s response is based on the knowledge that

a. a lack of clotting factors promotes the collection of blood in the abdominal cavity.
b. portal hypertension and hypoalbuminemia cause a fluid shift into the peritoneal space.
c. decreased peristalsis in the GI tract contributes to gas formation and distention of the bowel.
d. bile salts in the blood irritate the peritoneal membranes, causing edema and pocketing of fluid.

Answer 77

b. portal hypertension and hypoalbuminemia cause a fluid shift into the peritoneal space.

Rationale: Ascites is the accumulation of serous fluid in the peritoneal or abdominal cavity and is a common manifestation of cirrhosis. With portal hypertension, proteins shift from the blood vessels through the larger pores of the sinusoids (capillaries) into the lymph space. When the lymphatic system is unable to carry off the excess proteins and water, those substances leak through the liver capsule into the peritoneal cavity. Osmotic pressure of the proteins pulls additional fluid into the peritoneal cavity. A second mechanism of ascites formation is hypoalbuminemia, which results from the inability of the liver to synthesize albumin. Hypoalbuminemia results in decreased colloidal oncotic pressure. A third mechanism is hyperaldosteronism, which occurs when aldosterone is not metabolized by damaged hepatocytes. The increased level of aldosterone causes increases in sodium reabsorption by the renal tubules. Sodium retention and an increase in antidiuretic hormone levels cause additional water retention.

Question 78

In planning care for a patient with metastatic liver cancer, the nurse should include interventions that

a. focus primarily on symptomatic and comfort measures.
b. reassure the patient that chemotherapy offers a good prognosis.
c. promote the patient’s confidence that surgical excision of the tumor will be successful.
d. provide information necessary for the patient to make decisions regarding liver transplantation.

Answer 78

a. focus primarily on symptomatic and comfort measures.

Rationale: Nursing intervention for a patient with liver cancer focuses on keeping the patient as comfortable as possible. The prognosis for patients with liver cancer is poor. The cancer grows rapidly, and death may occur within 4 to 7 months as a result of hepatic encephalopathy or massive blood loss from gastrointestinal (GI) bleeding.

Question 79

Nursing management of the patient with acute pancreatitis includes (select all that apply)

a. checking for signs of hypocalcemia.
b. providing a diet low in carbohydrates.
c. giving insulin based on a sliding scale.
d. observing stools for signs of steatorrhea.
e. monitoring for infection, particularly respiratory tract infection.

Answer 79

a. checking for signs of hypocalcemia.
e. monitoring for infection, particularly respiratory tract infection.

Rationale: During the acute phase, it is important to monitor vital signs. Hemodynamic stability may be compromised by hypotension, fever, and tachypnea. Intravenous fluids are ordered, and the response to therapy is monitored. Fluid and electrolyte balances are closely monitored. Frequent vomiting, along with gastric suction, may result in decreased levels of chloride, sodium, and potassium. Because hypocalcemia can occur in acute pancreatitis, the nurse should observe for symptoms of tetany, such as jerking, irritability, and muscular twitching. Numbness or tingling around the lips and in the fingers is an early indicator of hypocalcemia. The patient should be assessed for Chvostek’s sign or Trousseau’s sign. A patient with acute pancreatitis should be observed for fever and other manifestations of infection. Respiratory infections are common because the retroperitoneal fluid raises the diaphragm, which causes the patient to take shallow, guarded abdominal breaths.

Question 80

A patient with pancreatic cancer is admitted to the hospital for evaluation of possible treatment options. The patient asks the nurse to explain the Whipple procedure that the surgeon has described. The explanation includes the information that a Whipple procedure involves

a. creating a bypass around the obstruction caused by the tumor by joining the gallbladder to the jejunum.
b. resection of the entire pancreas and the distal portion of the stomach, with anastomosis of the common bile duct and the stomach into the duodenum.
c. removal of part of the pancreas, part of the stomach, the duodenum, and the gallbladder, with joining of the pancreatic duct, the common bile duct, and the stomach into the jejunum.
d. radical removal of the pancreas, the duodenum, and the spleen, and attachment of the stomach to the jejunum, which requires oral supplementation of pancreatic digestive enzymes and insulin replacement therapy.

Answer 80

c. removal of part of the pancreas, part of the stomach, the duodenum, and the gallbladder, with joining of the pancreatic duct, the common bile duct, and the stomach into the jejunum.

Rationale: The classic operation for pancreatic cancer is a radical pancreaticoduodenectomy, or Whipple procedure. This entails resection of the proximal pancreas (i.e., proximal pancreatectomy), the adjoining duodenum (i.e., duodenectomy), the distal portion of the stomach (i.e., partial gastrectomy), and the distal segment of the common bile duct. The pancreatic duct, common bile duct, and stomach are anastomosed to the jejunum.

Question 81

The nursing management of the patient with cholecystitis associated with cholelithiasis is based on the knowledge that

a. shock-wave therapy should be tried initially.
b. once gallstones are removed, they tend not to recur.
c. the disorder can be successfully treated with oral bile salts that dissolve gallstones.
d. laparoscopic cholecystectomy is the treatment of choice in most patients who are symptomatic.

Answer 81

d. laparoscopic cholecystectomy is the treatment of choice in most patients who are symptomatic.

Rationale: Laparoscopic cholecystectomy is the treatment of choice for symptomatic cholelithiasis.

Question 82

Teaching in relation to home management after a laparoscopic cholecystectomy should include

a. keeping the bandages on the puncture sites for 48 hours.
b. reporting any bile-colored drainage or pus from any incision.
c. using over-the-counter antiemetics if nausea and vomiting occur.
d. emptying and measuring the contents of the bile bag from the T tube every day.

Answer 82

b. reporting any bile-colored drainage or pus from any incision.

Rationale: The following discharge instructions are taught to the patient and caregiver after a laparoscopic cholecystectomy: First, remove the bandages on the puncture site the day after surgery and shower. Second, notify the surgeon if any of the following signs and symptoms occur: redness, swelling, bile-colored drainage or pus from any incision; and severe abdominal pain, nausea, vomiting, fever, or chills. Third, gradually resume normal activities. Fourth, return to work within 1 week of surgery. Fifth, resume a usual diet, but a low-fat diet is usually better tolerated for several weeks after surgery.

Question 83

Which information will the nurse include when teaching a 50-yr-old male patient about somatropin (Genotropin)?

a. The medication will be needed for 3 to 6 months.
b. Inject the medication subcutaneously every day.
c. Blood glucose levels may decrease when taking the medication.
d. Stop taking the medication if swelling of the hands or feet occurs.

Answer 83

ANS: B Inject the medication subcutaneously every day.

Somatropin is injected subcutaneously on a daily basis, preferably in the evening. The patient will need to continue on somatropin for life. If swelling or other common adverse effects occur, the health care provider should be notified. Growth hormone will increase blood glucose levels.

Question 84

The nurse determines that demeclocycline is effective for a patient with syndrome of inappropriate antidiuretic hormone (SIADH) based on finding that the patient’s

a. weight has increased.
b. urinary output is increased.
c. peripheral edema is increased.
d. urine specific gravity is increased.

Answer 84

ANS: B urinary output is increased.

Demeclocycline blocks the action of antidiuretic hormone (ADH) on the renal tubules and increases urine output. An increase in weight or an increase in urine specific gravity indicates that the SIADH is not corrected. Peripheral edema does not occur with SIADH. A sudden weight gain without edema is a common clinical manifestation of this disorder.

Question 85

The nurse determines that additional instruction is needed for a patient with chronic syndrome of inappropriate antidiuretic hormone (SIADH) when the patient makes which statement?

a. “I need to shop for foods low in sodium and avoid adding salt to food.”
b. “I should weigh myself daily and report any sudden weight loss or gain.”
c. “I need to limit my fluid intake to no more than 1 quart of liquids a day.”
d. “I should eat foods high in potassium because diuretics cause potassium loss.”

Answer 85

a. “I need to shop for foods low in sodium and avoid adding salt to food.”

Patients with SIADH are at risk for hyponatremia, and a sodium supplement may be prescribed. The other patient statements are correct and indicate successful teaching has occurred.

Question 86

A 56-yr-old patient who is disoriented and reports a headache and muscle cramps is hospitalized with possible syndrome of inappropriate antidiuretic hormone (SIADH). The nurse would expect the initial laboratory results to include a(n)

a. elevated hematocrit.
b. decreased serum sodium.
c. increased serum chloride.
d. low urine specific gravity.

Answer 86

b. decreased serum sodium

When water is retained, the serum sodium level will drop below normal, causing the clinical manifestations reported by the patient. The hematocrit will decrease because of the dilution caused by water retention. Urine will be more concentrated with a higher specific gravity. The serum chloride level will usually decrease along with the sodium level.

Question 87

An expected patient problem for a patient admitted to the hospital with symptoms of diabetes insipidus is

a. excess fluid volume related to intake greater than output.
b. impaired gas exchange related to fluid retention in lungs.
c. sleep pattern disturbance related to frequent waking to void.
d. risk for impaired skin integrity related to generalized edema.

Answer 87

c. sleep pattern disturbance related to frequent waking to void.

Nocturia occurs as a result of the polyuria caused by diabetes insipidus. Edema, excess fluid volume, and fluid retention are not expected.

Question 88

Which information will the nurse teach a patient who has been newly diagnosed with Graves’ disease?

a. Exercise is contraindicated to avoid increasing metabolic rate.
b. Restriction of iodine intake is needed to reduce thyroid activity.
c. Antithyroid medications may take several months for full effect.
d. Surgery will eventually be required to remove the thyroid gland.

Answer 88

c. Antithyroid medications may take several months for full effect.

Medications used to block the synthesis of thyroid hormones may take 2 to 3 months before the full effect is seen. Large doses of iodine are used to inhibit the synthesis of thyroid hormones. Exercise using large muscle groups is encouraged to decrease the irritability and hyperactivity associated with high levels of thyroid hormones. Radioactive iodine is the most common treatment for Graves’ disease, although surgery may be used.

Question 89

A patient is being admitted with a diagnosis of Cushing syndrome. Which findings will the nurse expect during the assessment?

a. Chronically low blood pressure
b. Bronzed appearance of the skin
c. Purplish streaks on the abdomen
d. Decreased axillary and pubic hair

Answer 89

c. Purplish streaks on the abdomen

Purplish-red striae on the abdomen are a common clinical manifestation of Cushing syndrome. Hypotension and bronzed-appearing skin are manifestations of Addison’s disease. Decreased axillary and pubic hair occur with androgen deficiency.

Question 90

A 44-yr-old female patient with Cushing syndrome is admitted for adrenalectomy. Which intervention by the nurse will be most helpful for the patient problem of disturbed body image related to changes in appearance?

a. Reassure the patient that the physical changes are very common in patients with
Cushing syndrome.
b. Discuss the use of diet and exercise in controlling the weight gain associated with
Cushing syndrome.
c. Teach the patient that the metabolic impact of Cushing syndrome is of more
importance than appearance.
d. Remind the patient that most of the physical changes caused by Cushing
syndrome will resolve after surgery.

Answer 90

d. Remind the patient that most of the physical changes caused by Cushing
syndrome will resolve after surgery.

The most reassuring and accurate communication to the patient is that the physical and emotional changes caused by the Cushing syndrome will resolve after hormone levels return to normal postoperatively. Reassurance that the physical changes are expected or that there are more serious physiologic problems associated with Cushing syndrome are not therapeutic responses. The patient’s physiological changes are caused by the high hormone levels, not by the patient’s diet or exercise choices.

Question 91

Which finding indicates to the nurse that the current therapies are effective for a patient with acute adrenal insufficiency?

a. Increasing serum sodium levels
b. Decreasing blood glucose levels
c. Decreasing serum chloride levels
d. Increasing serum potassium levels

Answer 91

a. Increasing serum sodium levels

Clinical manifestations of Addison’s disease include hyponatremia and an increase in sodium level indicates improvement. The other values indicate that treatment has not been effective.

Question 92

The nurse admits a patient to the hospital in Addisonian crisis. Which patient statement supports the need to plan additional teaching?

a. “I frequently eat at restaurants, and my food has a lot of added salt.”
b. “I had the flu earlier this week, so I couldn’t take the hydrocortisone.”
c. “I always double my dose of hydrocortisone on the days that I go for a long run.”
d. “I take twice as much hydrocortisone in the morning dose as I do in the
afternoon. ”

Answer 92

b. “I had the flu earlier this week, so I couldn’t take the hydrocortisone.”

The need for hydrocortisone replacement is increased with stressors such as illness, and the patient needs to be taught to call the health care provider because medication and IV fluids and electrolytes may need to be given. The other patient statements indicate appropriate management of the Addison’s disease.

Question 93

A 29-yr-old woman with systemic lupus erythematosus has been prescribed 2 weeks of high-dose prednisone therapy. Which information about the prednisone is most important for the nurse to include?

a. “Weigh yourself daily to monitor for weight gain.”
b. “The prednisone dose should be decreased gradually.”
c. “A weight-bearing exercise program will help minimize risk for osteoporosis.”
d. “Call the health care provider if you have mood changes with the prednisone.”

Answer 93

b. “The prednisone dose should be decreased gradually.”

Acute adrenal insufficiency may occur if exogenous corticosteroids are suddenly stopped. Mood alterations and weight gain are possible adverse effects of corticosteroid use, but these are not life-threatening effects. Osteoporosis occurs when patients take corticosteroids for longer periods.

Question 94

The nurse providing care for a patient who has an adrenocortical adenoma causing hyperaldosteronism should

a. monitor the blood pressure every 4 hours.
b. elevate the patient’s legs to relieve edema.
c. monitor blood glucose level every 4 hours.
d. order the patient a potassium-restricted diet.

Answer 94

a. monitor the blood pressure every 4 hours.

Hypertension caused by sodium retention is a common complication of hyperaldosteronism. Hyperaldosteronism does not cause an elevation in blood glucose. The patient will be hypokalemic and require potassium supplementation before surgery. Edema does not usually occur with hyperaldosteronism.

Question 95

After a patient with a pituitary adenoma has had a hypophysectomy, the nurse will teach about the need for

a. sodium restriction to prevent fluid retention.
b. insulin to maintain normal blood glucose levels.
c. oral corticosteroids to replace endogenous cortisol.
d. chemotherapy to prevent malignant tumor recurrence.

Answer 95

c. oral corticosteroids to replace endogenous cortisol.

Antidiuretic hormone (ADH), cortisol, and thyroid hormone replacement will be needed for life after hypophysectomy. Without the effects of adrenocorticotropic hormone (ACTH) and cortisol, the blood glucose and serum sodium will be low unless cortisol is replaced. An adenoma is a benign tumor, and chemotherapy will not be needed.

Question 96

Which intervention will the nurse include in the plan of care for a patient with syndrome of inappropriate antidiuretic hormone (SIADH)?

a. Encourage fluids to 2 to 3 L/day.
b. Monitor for increasing peripheral edema.
c. Offer the patient hard candies to suck on.
d. Keep head of bed elevated to 30 degrees.

Answer 96

c. Offer the patient hard candies to suck on.

Sucking on hard candies decreases thirst for a patient on fluid restriction. Patients with SIADH are on fluid restrictions of 800 to 1000 mL/day. Peripheral edema is not seen with SIADH. The head of the bed is elevated no more than 10 degrees to increase left atrial filling pressure and decrease antidiuretic hormone (ADH) release.

Question 97

The nurse is caring for a patient following an adrenalectomy. The highest priority in the immediate postoperative period is to

a. protect the patient’s skin.
b. monitor for signs of infection.
c. balance fluids and electrolytes.
d. prevent emotional disturbances.

Answer 97

c. balance fluids and electrolytes.

After adrenalectomy, the patient is at risk for circulatory instability caused by fluctuating hormone levels, and the focus of care is to assess and maintain fluid and electrolyte status through the use of IV fluids and corticosteroids. The other goals are also important for the patient but are not as immediately life threatening as the circulatory collapse that can occur with fluid and electrolyte disturbances.

Question 98

The nurse is caring for a patient admitted with diabetes insipidus (DI). Which information is most important to report to the health care provider?

a. The patient is confused and lethargic.
b. The patient reports a recent head injury.
c. The patient has a urine output of 400 mL/hr.
d. The patient’s urine specific gravity is 1.003.

Answer 98

a. The patient is confused and lethargic.

The patient’s confusion and lethargy may indicate hypernatremia and should be addressed quickly. In addition, patients with DI compensate for fluid losses by drinking copious amounts of fluids, but a patient who is lethargic will be unable to drink enough fluids and will become hypovolemic. A high urine output, low urine specific gravity, and history of a recent head injury are consistent with diabetes insipidus, but they do not require immediate nursing action to avoid life-threatening complications.

Question 99

Which assessment finding of a 42-yr-old patient who had a bilateral adrenalectomy requires the most rapid action by the nurse?

a. The blood glucose is 192 mg/dL.
b. The lungs have bibasilar crackles.
c. The patient reports 6/10 incisional pain.
d. The blood pressure (BP) is 88/50 mm Hg.

Answer 99

d. The blood pressure (BP) is 88/50 mm Hg.

The decreased BP indicates possible adrenal insufficiency. The nurse should immediately notify the health care provider so that corticosteroid medications can be administered. The nurse should also address the elevated glucose, incisional pain, and crackles with appropriate collaborative or nursing actions, but prevention and treatment of acute adrenal insufficiency are the priorities after adrenalectomy.

Question 100

A patient is admitted with diabetes insipidus. Which action will be appropriate for the registered nurse (RN) to delegate to an experienced licensed practical/vocational nurse (LPN/LVN)?

a. Titrate the infusion of 5% dextrose in water.
b. Administer prescribed subcutaneous DDAVP.
c. Assess the patient’s overall hydration status every 8 hours.
d. Teach the patient how to use desmopressin (DDAVP) nasal spray.

Answer 100

b. Administer prescribed subcutaneous DDAVP.

Administration of medications is included in LPN/LVN education and scope of practice. Assessments, patient teaching, and titrating fluid infusions are more complex skills and should be done by the RN.

Question 101

Which information is most important for the nurse to communicate rapidly to the health care provider about a patient admitted with possible syndrome of inappropriate antidiuretic hormone (SIADH)?

a. The patient has a recent weight gain of 9 lb.
b. The patient complains of dyspnea with activity.
c. The patient has a urine specific gravity of 1.025.
d. The patient has a serum sodium level of 118 mEq/L.

Answer 101

d. The patient has a serum sodium level of 118 mEq/L.

A serum sodium of less than 120 mEq/L increases the risk for complications such as seizures and needs rapid correction. The other data are not unusual for a patient with SIADH and do not indicate the need for rapid action.

Question 102

After receiving change-of-shift report about the following four patients, which patient should the nurse assess first?

a. A 31-yr-old female patient with Cushing syndrome and a blood glucose level of
244 mg/dL
b. A 70-yr-old female patient taking levothyroxine (Synthroid) who has an irregular pulse of 134
c. A 53-yr-old male patient who has Addison’s disease and is due for a prescribed
dose of hydrocortisone (Solu-Cortef).
d. A 22-yr-old male patient admitted with syndrome of inappropriate antidiuretic
hormone (SIADH) who has a serum sodium level of 130 mEq/L

Answer 102

b. A 70-yr-old female patient taking levothyroxine (Synthroid) who has an irregular pulse of 134

Initiation of thyroid replacement in older adults may cause angina and cardiac dysrhythmias. The patient’s high pulse rate needs rapid investigation by the nurse to assess for and intervene with any cardiac problems. The other patients also require nursing assessment and/or actions but are not at risk for life-threatening complications.

Question 103

Which finding by the nurse when assessing a patient with a large pituitary adenoma is most important to report to the health care provider?

a. Changes in visual field
b. Milk leaking from breasts
c. Blood glucose 150 mg/dL
d. Nausea and projectile vomiting

Answer 103

d. Nausea and projectile vomiting

Nausea and projectile vomiting may indicate increased intracranial pressure, which will require rapid actions for diagnosis and treatment. Changes in the visual field, elevated blood glucose, and galactorrhea are common with pituitary adenoma, but these do not require rapid action to prevent life-threatening complications.

Question 104

Which information obtained by the nurse in the endocrine clinic about a patient who has been taking prednisone 40 mg daily for 3 weeks is most important to report to the health care provider?

a. Patient’s blood pressure is 148/94 mm Hg.
b. Patient has bilateral 2+ pitting ankle edema.
c. Patient stopped taking the medication 2 days ago.
d. Patient has not been taking the prescribed vitamin D.

Answer 104

c. Patient stopped taking the medication 2 days ago.

Sudden cessation of corticosteroids after taking the medication for a week or more can lead to adrenal insufficiency, with problems such as severe hypotension and hypoglycemia. The patient will need immediate evaluation by the health care provider to prevent or treat adrenal insufficiency. The other information will also be reported but does not require rapid treatment.

Question 105

After obtaining the information shown in the accompanying figure regarding a patient with Addison’s disease, which prescribed action will the nurse take first

a.
Give 4 oz of fruit juice orally.
b.
Recheck the blood glucose level.
c.
Infuse 5% dextrose and 0.9% saline.
d.
Administer oxygen therapy as needed

Answer 105

c.
Infuse 5% dextrose and 0.9% saline.

The patient’s poor skin turgor, hypotension, and hyponatremia indicate an Addisonian crisis. Immediate correction of the hypovolemia and hyponatremia is needed. The other actions may also be needed but are not the initial action for the patient

Question 106

The nurse is reviewing the record of a client with a dx of cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence?

Dorsiflex the foot
Measure abdominal girth
Ask pt to extend the arms
Instruct pt to lean forward

Answer 106

Ask the pt to extend the arms

Asterixis is irregular flapping movements of the fingers and wrists when the hands and arms are outstretched, with the palms down, wrists bent up, and fingers spread. It is the most common and reliable sign that hepati encephalopathy is developing.

Question 107

The nurse is reviewing the lab results for a pt with cirrhosis and notes that the ammonia level is elevated. Which diet does the nurse anticipate to be presribed for this pt?

Low-protein
High-protein
Moderate-fat
High-carb

Answer 107

Low-protein diet

Protein provided by the diet is transported to the liver via the portal vein. The liver breaks down protein, which results in the formation of ammonia.

Question 108

During assessment of a pt with obstructive jaundice, the nurse would expect to find:

clay colored stools
dark urine and stool
pyrexia and pruritis
elevated urinary urobilinogen

Answer 108

clay colored stool

Question 109

A pt has been told she has NAFLD. The nursing teaching plan should include

a. having genetic testing done
b. recommend a heart healthy diet
c. the necessity to reduce weight rapidly
d. avoiding alcohol until liver enzymes return to normal

Answer 109

b. recommend a heart healthy diet

NAFLD can progress to cirrhosis. NO definitive treatment; therapy directed at reducing risk like diabetes, body weight, and harmful medications.

Question 110

The pt with advanced cirrhosis asks why his abdomen is so swollen. The nurse’s best response is based on the knowledge that

a. a lack of clotting factors promotes the collection of blood in the abdominal cavity
b. portal hypertension and hypoalbuminemia cause fluid shift into the peritoneal space.
c. decreased peristalsis in the GI tract contributes to gas formation and distention of the bowel
d. bile salts in the blood irritate the peritoneal membranes, causing edema and pocketing of fluid.

Answer 110

b. portal hypertension and hypoalbuminemia cause fluid shift into the peritoneal space.

Question 111

When caring for a pt with liver disease, the nurse recognizes the need to prevent bleeding resulting from altered clotting factors and rupture of varices. Which nursing interventions would be appropriate to achieve this outcome? Select all that apply.

a. use smallest gauge needle possible when giving injections or drawing blood.
b. teach pt to avoid straining at stool, vigorous blowing of nose, and coughing
c. advise pt to use soft-bristle toothbrush and avoid ingestion of irritating food.
d. apply gentle pressure for the shortest possible time period after performing venipuncture
e. instruct pt to avoid aspirin and NSAIDs to prevent hemorrhage when varices are present.

Answer 111

A, B, C, E

• small gauge minimize risk of bleeding into tissues.
• avoiding strain reduces hemorrhage
• soft bristle reduce injury to highly vascular mucous membranes
• apply gentle but prolonged pressure to venipuncture
• aspirin and NSAIDs should not be used in pt with liver disease b/c they interfere w/ platelet aggregation, increasing bleeding risk

Question 112

Ms. Charlotte is​ 66-years-old and admits to being an alcoholic for most of her adult life. She is brought to the emergency department with bleeding esophageal varices. Which therapy should be the most effective for Ms. Charlotte at this​ time?

​Beta-blocker

Minnesota tube

Paracentesis

Transjugular intrahepatic portosystemic shunt​ (TIPS)

Answer 112

Minnesota tube

While a​ beta-blocker can be used for esophageal​ varices, the best therapy at this time is a balloon tamponade​ (either a​ Sengstaken-Blakemore or Minnesota​ tube). A paracentesis is done to relieve severe ascites. A transjugular intrahepatic portosystemic shunt​ (TIPS) relieves portal hypertension and reduces the onset of esophageal varices and ascites.

Question 113

The nurse observes a distinct change in the Mr.​ Dontay’s level of consciousness during a routine assessment during a scheduled physical examination. Mr. Dontay is 55 years​ old, a recovering​ alcoholic, and has a primary diagnosis of cirrhosis. Which intervention is appropriate for Mr. Dontay while providing​ care?

Encouraging large meals

Measuring abdominal girth

Providing a diet high in sodium

Using hot water for bathing

Answer 113

Measuring abdominal girth

The client with cirrhosis is at risk for​ ascites; therefore it is important to measure the​ client’s abdominal girth while providing care. The nurse should encourage small​ meals, provide a diet low in​ sodium, and use warm water for bathing.

Question 114

A client is at risk for infectious sepsis through which portals of​ entry? ​(Select all that​ apply.)

Peptic ulcerations

Surgical wounds

Sexually transmitted infections

Pulse oximetry monitoring

Intravenous catheters

Answer 114

Peptic ulcerations
Surgical wounds
Sexually transmitted infections
Intravenous catheters

Portals of entry for infection that may lead to sepsis​ include, but are not limited​ to, intravenous​ catheters, surgical​ wounds, sexually transmitted​ infections, and peptic ulcerations. Pulse oximetry is not an invasive procedure and is not a portal of entry for infectious sepsis.

Question 115

What is the purpose of liver functions tests in diagnosing​ cirrhosis?

To determine the presence of anemia

To determine the prothrombin time

To determine glucose and lipid metabolism

To determine the degree of elevation of liver enzymes

Answer 115

To determine the degree of elevation of liver enzymes

The purpose of liver functions tests in diagnosing cirrhosis is to determine the degree of elevation of liver enzymes.

A CBC is used to determine the presence of anemia.

Coagulation studies are used to determine the prothrombin time.

Serum glucose and cholesterol levels are used to determine the effect cirrhosis is having on glucose and lipid metabolism.

Question 116

Which therapy for cirrhosis is considered nutritional​ therapy?

Increasing fluid intake

Restricting sodium intake

Administering vitamin K

Recommending antacids

Answer 116

Restricting sodium intake

Nutritional support for cirrhosis includes restricting sodium intake to 2 g per day. Administering vitamin K and recommending antacids is pharmacologic therapy. Decreasing fluid​ intake, not increasing​ it, is considered a nutritional therapy for cirrhosis.

Question 117

The nurse assesses for which item during the health history for a client with​ cirrhosis?

Skin color

Mental status

Weight loss

Vital signs

Answer 117

Weight loss

For a client with​ cirrhosis, the nurse assesses recent weight loss during the heath history portion of the nursing assessment. Vital​ signs, mental​ status, and skin color are assessed during the physical examination portion of the nursing assessment.

Question 118

Which nursing diagnosis is not appropriate for a client with​ cirrhosis?

Decreased fluid volume

Diminished protection

Impaired nutrition

Impaired skin integrity

Answer 118

Decreased fluid volume

Appropriate nursing diagnoses for a client with cirrhosis include impaired skin​ integrity, diminished protection and impaired nutrition.​ Increased, not​ decreased, fluid volume is appropriate for a client with cirrhosis.

Question 119

A nurse is caring for a client with cirrhosis. Which assessment finding warrants immediate​ attention?

Pulse of 60 bpm

Oxygen saturation of​ 92%

Blood pressure of​ 110/72 mmHg

Abdominal distention

Answer 119

Abdominal distention

Rationale
Abdominal​ distention, which is an imbalance of fluid within the portal​ system, might mean ascites in a client with cirrhosis. The vital signs are all within normal limits

Question 120

A client diagnosed with liver cirrhosis is being treated for an infection. For which complication should the nurse monitor the​ client?

Portal hypertension

Hepatic encephalopathy

Esophageal varices

Wilson disease

Answer 120

Hepatic encephalopathy

Hepatic encephalopathy may be aggravated by sepsis secondary to​ infection, due to increased buildup of toxic​ substances, in clients with cirrhosis. Portal​ hypertension, esophageal​ varices, and Wilson disease (an inherited disorder that causes too much copper to accumulate in the organs) are not caused or aggravated by infection.

Question 121

For which manifestation should the nurse assess in a client with hepatorenal​ syndrome?

Fever

Esophageal varices

Sodium retention

Asterixis

Answer 121

Sodium retention

Hepatorenal syndrome causes sodium​ retention, oliguria, and hypotension. Asterixis develops with hepatic​ encephalopathy, and fever with bacterial peritonitis. Esophageal varices are a complication of cirrhosis.

Question 122

Which nursing diagnosis supports a medical diagnosis of​ cirrhosis?

Increased risk for acute confusion

Anxiety

Activity intolerance

Fatigue

Answer 122

Increased risk for acute confusion

Clients with cirrhosis deal with a variety of​ problems, but​ fatigue, activity​ intolerance, and anxiety are not among them. A few nursing diagnoses that are appropriate include impaired skin​ integrity, increased risk for acute​ confusion, diminished​ protection, increased fluid​ volume, and reduced​ nutrition, less than body requirements.

Question 123

Which laboratory test is prescribed for a client with suspected​ cirrhosis?

O2 level

CO2 level

WBC count

Liver biopsy

Answer 123

Liver biopsy

Liver biopsy helps distinguish cirrhosis from other forms of liver disease. The O2 ​level, CO2 ​level, and WBC count are not relevant to establishing the diagnosis of cirrhosis.