Hinkle 43

Question 1

A nurse is caring for a client with liver failure and is performing an assessment of the
client’s increased risk of bleeding. The nurse recognizes that this risk is related to the
client’s inability to synthesize prothrombin in the liver. What factor most likely
contributes to this loss of function?

A. Alterations in glucose metabolism
B. Retention of bile salts
C. Inadequate production of albumin by hepatocytes
D. Inability of the liver to use vitamin K

Answer 1

ANS: D

Rationale: Decreased production of several clotting factors may be partially due to
deficient absorption of vitamin K from the GI tract. This probably is caused by the inability
of liver cells to use vitamin K to make prothrombin. This bleeding risk is unrelated to the
roles of glucose, bile salts, or albumin

Question 2

2. A nurse is performing an admission assessment of a client with a diagnosis of cirrhosis.
   What technique should the nurse use to palpate the client’s liver?

A. Place hand under the right lower abdominal quadrant and press down lightly
with the other hand.
B. Place the left hand over the abdomen and behind the left side at the 11th rib.
C. Place hand under right lower rib cage and press down lightly with the other
hand.
D. Hold hand 90 degrees to right side of the abdomen and push down
firmly.

Answer 2

ANS: C

Rationale: To palpate the liver, the examiner places one hand under the right lower rib
cage and presses downward with light pressure with the other hand. The liver is not on
the left side or in the right lower abdominal quadrant.

Question 3

A client with portal hypertension has been admitted to the medical floor. The nurse
should prioritize what assessments?

A. Assessment of blood pressure and assessment for headaches and visual
changes
B. Assessments for signs and symptoms of venous thromboembolism
C. Daily weights and abdominal girth measurement
D. Blood glucose monitoring q4h

Answer 3

ANS: C

Rationale: Obstruction to blood flow through the damaged liver results in increased blood
pressure (portal hypertension) throughout the portal venous system. This can result in
varices and ascites in the abdominal cavity. Assessments related to ascites are daily
weights and abdominal girths. Portal hypertension is not synonymous with cardiovascular hypertension and does not create a risk for unstable blood glucose or VTE.

Question 4

A nurse educator is teaching a group of recent nursing graduates about their
occupational risks for contracting hepatitis B. What preventative measures should the
educator promote? Select all that apply.

A. Immunization
B. Use of standard precautions
C. Consumption of a vitamin-rich diet
D. Annual vitamin K injections
E. Annual vitamin B12 injections

Answer 4

ANS: A, B

Rationale: People who are at high occupational risk for contracting hepatitis B, including
nurses and other health care personnel exposed to blood or blood products, should
receive active immunization. The consistent use of standard precautions is also highly
beneficial. Vitamin supplementation is unrelated to an individual’s risk of HBV.

Question 5

A client who has undergone liver transplantation is ready to be discharged home. Which outcome of health education should the nurse prioritize?

A. The client will obtain measurement of drainage from the T-tube.
B. The client will exercise three times a week.
C. The client will take immunosuppressive agents as required.
D. The client will monitor for signs of liver dysfunction.

Answer 5

ANS: C

Rationale: The client is given written and verbal instructions about immunosuppressive
agent doses and dosing schedules. The client is also instructed on steps to follow to
ensure that an adequate supply of medication is available so that there is no chance
of running out of the medication or skipping a dose. Failure to take medications as
instructed may precipitate rejection. The nurse would not teach the client to measure
drainage from a T-tube as the client wouldn’t go home with a T-tube. The nurse may
teach the client about the need to exercise or what the signs of liver dysfunction are, but
the nurse would not stress these topics over the immunosuppressive drug regimen.

Question 6

A triage nurse in the emergency department is assessing a client who presented with
reports of general malaise. Assessment reveals the presence of jaundice and increased
abdominal girth. What assessment question best addresses the possible etiology of this
client’s presentation?

A. “How many alcoholic drinks do you typically consume in a week?”
B. “To the best of your knowledge, are your immunizations up to date?”
C. “Have you ever worked in an occupation where you might have been exposed to
toxins?”
D. “Has anyone in your family ever experienced symptoms similar to yours?”

Answer 6

ANS: A

Rationale: Signs or symptoms of hepatic dysfunction indicate a need to assess for alcohol
use. Immunization status, occupational risks, and family history are also relevant
considerations, but alcohol use is a more common etiologic factor in liver disease.

Question 7

A nurse is participating in the emergency care of a client who has just developed
variceal bleeding. What intervention should the nurse anticipate?

A. Infusion of intravenous heparin
B. IV administration of albumin
C. STAT administration of vitamin K by the intramuscular route
D. IV administration of octreotide

Answer 7

ANS: D

Rationale: Octreotide—a synthetic analog of the hormone somatostatin—is effective in
decreasing bleeding from esophageal varices, and lacks the vasoconstrictive effects of
vasopressin. Because of this safety and efficacy profile, octreotide is considered the
preferred treatment regimen for immediate control of variceal bleeding. Vitamin K and
albumin are not given, and heparin would exacerbate, not alleviate, bleeding.

Question 8

A nurse is caring for a client with hepatic encephalopathy. While making the initial shift
assessment, the nurse notes that the client has a flapping tremor of the hands. The nurse
should document the presence of what sign of liver disease?

A. Asterixis
B. Constructional apraxia
C. Fetor hepaticus
D. Palmar erythema

Answer 8

ANS: A

Rationale: The nurse will document that a client exhibiting a flapping tremor of the hands
is demonstrating asterixis. While constructional apraxia is a motor disturbance, it is the
inability to reproduce a simple figure. Fetor hepaticus is a sweet, slightly fecal odor to
the

Question 9

A local public health nurse is informed that a cook in a local restaurant has been
diagnosed with hepatitis A. What should the nurse advise individuals to obtain who ate at
this restaurant and have never received the hepatitis A vaccine?

A. The hepatitis A vaccine
B. Albumin infusion
C. The hepatitis A and B vaccines
D. An immune globulin injection

Answer 9

ANS: D

Rationale: For people who have not been previously vaccinated, hepatitis A can be
prevented by the intramuscular administration of immune globulin during the incubation
period, if given within 2 weeks of exposure. Administration of the hepatitis A vaccine will
not protect the client exposed to hepatitis A, as protection will take a few weeks to
develop after the first dose of the vaccine. The hepatitis B vaccine provides protection
against the hepatitis B virus, but plays no role in protection for the client exposed to
hepatitis A. Albumin confers no therapeutic benefit.

Question 10

10. What health promotion teaching should the nurse prioritize to prevent drug-induced
    hepatitis?

A. Finish all prescribed courses of antibiotics, regardless of symptom resolution.
B. Adhere to dosing recommendations of over-the-counter analgesics.
C. Ensure that expired medications are disposed of safely.
D. Ensure that pharmacists regularly review drug regimens for potential
interactions.

Answer 10

ANS: B

Rationale: Although any medication can affect liver function, use of acetaminophen
(found in many over-the-counter medications used to treat fever and pain) has been
identified as the leading cause of acute liver failure. Finishing prescribed antibiotics and
avoiding expired medications are unrelated to this disease. Drug interactions are rarely
the cause of drug-induced hepatitis.

Question 11

Diagnostic testing has revealed that a client’s hepatocellular carcinoma (HCC) is
limited to one lobe. The nurse should anticipate that this client’s plan of care will focus on
what intervention?

A. Cryosurgery
B. Liver transplantation
C. Lobectomy
D. Laser hyperthermia

Answer 11

ANS: C

Rationale: Surgical resection is the treatment of choice when HCC is confined to one lobe
of the liver and the function of the remaining liver is considered adequate for postoperative recovery. Removal of a lobe of the liver (lobectomy) is the most common surgical procedure for excising a liver tumor. While cryosurgery and liver transplantation are other surgical options for management of liver cancer, these procedures are not performed at the same frequency as a lobectomy. Laser hyperthermia is a nonsurgical
treatment for liver cancer

Question 12

A client has been diagnosed with advanced stage breast cancer and will soon begin
aggressive treatment. What assessment findings would most strongly suggest that the
client may have developed liver metastases?

A. Persistent fever and cognitive changes
B. Abdominal pain and hepatomegaly
C. Peripheral edema unresponsive to diuresis
D. Spontaneous bleeding and jaundice

Answer 12

ANS: B

Rationale: The early manifestations of malignancy of the liver include pain—a continuous
dull ache in the right upper quadrant, epigastrium, or back. Weight loss, loss of strength,
anorexia, and anemia may also occur. The liver may be enlarged and irregular on
palpation. Jaundice is present only if the larger bile ducts are occluded by the pressure of
malignant nodules in the hilum of the liver. Fever, cognitive changes, peripheral edema,
and bleeding are atypical signs.

Question 13

A client is being discharged after a liver transplant and the nurse is performing
discharge education. When planning this client’s continuing care, the nurse should
prioritize what risk diagnosis?

A. Risk for infection related to immunosuppressant use
B. Risk for injury related to decreased hemostasis
C. Risk for unstable blood glucose related to impaired gluconeogenesis
D. Risk for contamination related to accumulation of ammonia

Answer 13

ANS: A

Rationale: Infection is the leading cause of death after liver transplantation. Pulmonary
and fungal infections are common; susceptibility to infection is increased by the
immunosuppressive therapy that is needed to prevent rejection. This risk exceeds the
threats of injury and unstable blood glucose. The diagnosis of Risk for Contamination
relates to environmental toxin exposure.

Question 14

A nurse is caring for a client with hepatic encephalopathy. The nurse’s assessment
reveals that the client exhibits episodes of confusion, is difficult to arouse from sleep and
has rigid extremities. Based on these clinical findings, the nurse should document what
stage of hepatic encephalopathy?

A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4

Answer 14

ANS: C

Rationale: Clients in the third stage of hepatic encephalopathy exhibit the following
symptoms: stuporous, difficult to arouse, sleep most of the time, exhibits marked
confusion, incoherent in speech, asterixis, increased deep tendon reflexes, rigidity of
extremities, marked EEG abnormalities. Clients in stages 1 and 2 exhibit clinical
symptoms that are not as advanced as found in stage 3, and clients in stage 4 are
comatose. In stage 4, there is an absence of asterixis, absence of deep tendon reflexes,
flaccidity of extremities, and EEG abnormalities.

Question 15

A client has developed hepatic encephalopathy secondary to cirrhosis and is receiving
care on the medical unit. The client’s current medication regimen includes lactulose four
times daily. What desired outcome should the nurse relate to this pharmacologic
intervention?

A. Two to three soft bowel movements daily
B. Significant increase in appetite and food intake
C. Absence of nausea and vomiting
D. Absence of blood or mucus in stool

Answer 15

ANS: A

Rationale: Lactulose is given to reduce serum ammonia levels. Two or three soft stools
per day are desirable; this indicates that lactulose is performing as intended. Lactulose
does not address the client’s appetite, symptoms of nausea and vomiting, or the
development of blood and mucus in the stool

Question 16

A nurse is performing an admission assessment for an 81-year-old client who
generally enjoys good health. When considering normal, age-related changes to hepatic
function, the nurse should anticipate what finding?

A. Similar liver size and texture as in younger adults
B. A nonpalpable liver
C. A slightly enlarged liver with palpably hard edges
D. A slightly decreased size of the liver

Answer 16

ANS: D

Rationale: The most common age-related change in the liver is a decrease in size and
weight. The liver is usually still palpable, however, and is not expected to have hardened
edges.

Question 17

A nurse is caring for a client with a blocked bile duct from a tumor. What
manifestation of obstructive jaundice should the nurse anticipate?

A. Watery, blood-streaked diarrhea
B. Orange and foamy urine
C. Increased abdominal girth
D. Decreased cognition

Answer 17

ANS: B

Rationale: If the bile duct is obstructed, the bile will be reabsorbed into the blood and
carried throughout the entire body. It is excreted in the urine, which becomes deep orange and foamy. Bloody diarrhea, ascites, and cognitive changes are not associated with obstructive jaundice.

Question 18

During a health education session, a participant has asked about the hepatitis E virus.
What prevention measure should the nurse recommend for preventing infection with this
virus?

A. Following proper hand-washing techniques
B. Avoiding chemicals that are toxic to the liver
C. Wearing a condom during sexual contact
D. Limiting alcohol intake

Answer 18

ANS: A

Rationale: Avoiding contact with the hepatitis E virus through good hygiene, including
hand-washing, is the major method of prevention. Hepatitis E is transmitted by the fecal–
oral route, principally through contaminated water in areas with poor sanitation.
Consequently, none of the other listed preventative measures is indicated.

Question 19

A client’s health care provider has ordered a “liver panel” in response to the client’s
development of jaundice. When reviewing the results of this laboratory testing, the nurse
should expect to review what blood tests? Select all that apply.

A. Alanine aminotransferase (ALT)
B. C-reactive protein (CRP)
C. Gamma-glutamyl transferase (GGT)
D. Aspartate aminotransferase (AST)
E. B-type natriuretic peptide (BNP)

Answer 19

ANS: A, C, D

Rationale: Liver function testing includes GGT, ALT, and AST. CRP addresses the
presence of generalized inflammation and BNP is relevant to heart failure; neither is
included in a liver panel.

Question 20

A client with liver disease has developed ascites; the nurse is collaborating with the
client to develop a nutritional plan. The nurse should prioritize which of the following in
the client’s plan?

A. Increased potassium intake
B. Fluid restriction to 2 L per day
C. Reduction in sodium intake
D. High-protein, low-fat diet

Answer 20

ANS: C

Rationale: Clients with ascites require a sharp reduction in sodium intake. Potassium
intake should not be correspondingly increased. There is no need for fluid restriction or
increased protein intake.

Question 21

A nurse is amending a client’s plan of care in light of the fact that the client has
recently developed ascites. What should the nurse include in this client’s care plan?

A. Mobilization with assistance at least 4 times daily
B. Administration of beta-adrenergic blockers as prescribed
C. Vitamin B12 injections as prescribed
D. Administration of diuretics as prescribed

Answer 21

ANS: D

Rationale: Use of diuretics along with sodium restriction is successful in 90% of clients
with ascites. Beta-blockers are not used to treat ascites and bed rest is often more
beneficial than increased mobility. Vitamin B12 injections are not necessary.

Question 22

A nurse is caring for a client who has been admitted for the treatment of advanced
cirrhosis. What assessment should the nurse prioritize in this client’s plan of care?

A. Measurement of abdominal girth and body weight
B. Assessment for variceal bleeding
C. Assessment for signs and symptoms of jaundice
D. Monitoring of results of liver function testing

Answer 22

ANS: B

Rationale: Esophageal varices are a major cause of mortality in clients with
uncompensated cirrhosis. Consequently, this should be a focus of the nurse’s
assessments and should be prioritized over the other listed assessments, even though
each should be performed.

Question 23

A client with a diagnosis of cirrhosis has developed variceal bleeding and will
imminently undergo variceal banding. What psychosocial nursing diagnosis should the
nurse most likely prioritize during this phase of the client’s treatment?

A. Decisional conflict
B. Deficient knowledge
C. Death anxiety
D. Disturbed thought processes

Answer 23

ANS: C

Rationale: The sudden hemorrhage that accompanies variceal bleeding is intensely
anxiety-provoking. The nurse must address the client’s likely fear of death, which is a
realistic possibility. For most clients, anxiety is likely to be a more acute concern than lack
of knowledge or decisional conflict. The client may or may not experience disturbances in
thought processes.

Question 24

A client with a diagnosis of esophageal varices has undergone endoscopy to gauge
the progression of this complication of liver disease. Following the completion of this
diagnostic test, what nursing intervention should the nurse perform?

A. Keep client NPO until the results of test are known.
B. Keep client NPO until the client’s gag reflex returns.
C. Administer analgesia until post-procedure tenderness is relieved.
D. Give the client a cold beverage to promote swallowing ability.

Answer 24

ANS: B

Rationale: After the examination, fluids are not given until the client’s gag reflex returns.
Lozenges and gargles may be used to relieve throat discomfort if the client’s physical
condition and mental status permit. The result of the test is known immediately. Food
and fluids are contraindicated until the gag reflex returns.

Question 25

A client with esophageal varices is being cared for in the ICU. The varices have begun
to bleed. The client has Ringer lactate at 150 cc/hr infusing. The nurse should also
anticipate what intervention?

A. Positioning the client supine
B. Administering diuretics
C. Oxygen by nasal cannula
D. Administering volume expanders

Answer 25

ANS: D

Rationale: Because clients with bleeding esophageal varices have intravascular volume
depletion and are subject to electrolyte imbalance, IV fluids with electrolytes and volume
expanders are provided to restore fluid volume and replace electrolytes. Diuretics would
reduce vascular volume. Supine positioning could exacerbate bleeding because of the
effects of gravity. Nasal cannula are unlikely to meet the client’s oxygenation needs.

Question 26

A client with a history of injection drug use has been diagnosed with hepatitis C. When
collaborating with the care team to plan this client’s treatment, the nurse should
anticipate what intervention?

A. Administration of immune globulins
B. A regimen of antiviral medications
C. Rest and watchful waiting
D. Administration of fresh-frozen plasma (FFP)

Answer 26

ANS: B

Rationale: There is no benefit from rest, diet, or vitamin supplements in HCV treatment.
Studies have demonstrated that antiviral agents are most effective. Immune globulins
and FFP are not indicated.

Question 27

A group of nurses have attended an in-service on the prevention of occupationally
acquired diseases that affect health care providers. What action has the greatest
potential to reduce a nurse’s risk of acquiring hepatitis C in the workplace?

A. Disposing of sharps appropriately and not recapping needles
B. Performing meticulous hand hygiene at the appropriate moments in care
C. Adhering to the recommended schedule of immunizations
D. Wearing an N95 mask when providing care for clients on airborne precautions

Answer 27

ANS: A

Rationale: HCV is bloodborne. Consequently, prevention of needlestick injuries is paramount. Hand hygiene, immunizations and appropriate use of masks are important
aspects of overall infection control, but these actions do not directly mitigate the risk of
HCV.

Question 28

A client has been admitted to the critical care unit with a diagnosis of toxic hepatitis.
When planning the client’s care, the nurse should be aware of what potential clinical
course of this health problem? Place the following events in the correct sequence.
1. Fever rises.
2. Hematemesis.
3. Clotting abnormalities.
4. Vascular collapse.
5. Coma.

A. 1, 2, 5, 4, 3
B. 1, 2, 3, 4, 5
C. 2, 3, 1, 4, 5
D. 3, 1, 2, 5, 4

Answer 28

ANS: B

Rationale: Recovery from acute toxic hepatitis is rapid if the hepatotoxin is identified
early and removed or if exposure to the agent has been limited. Recovery is unlikely if
there is a prolonged period between exposure and onset of symptoms. There are no
effective antidotes. The fever rises; the client becomes toxic and prostrated. Vomiting
may be persistent, with the emesis containing blood. Clotting abnormalities may be
severe, and hemorrhages may appear under the skin. The severe GI symptoms may lead
to vascular collapse. Delirium, coma, and seizures develop, and within a few days the
client may die of fulminant hepatic failure unless he or she receives a liver transplant.

Question 29

A nurse is caring for a client with cirrhosis secondary to heavy alcohol use. The
nurse’s most recent assessment reveals subtle changes in the client’s cognition and
behavior. What is the nurse’s most appropriate response?

A. Ensure that the client’s sodium intake does not exceed recommended levels.
B. Report this finding to the primary provider due to the possibility of hepatic
encephalopathy.
C. Inform the primary provider that the client should be assessed for alcoholic
hepatitis.
D. Implement interventions aimed at ensuring a calm and therapeutic care
environment.

Answer 29

ANS: B

Rationale: Monitoring is an essential nursing function to identify early deterioration in
mental status. The nurse monitors the client’s mental status closely and reports changes
so that treatment of encephalopathy can be initiated promptly. This change in status is
likely unrelated to sodium intake and would not signal the onset of hepatitis. A supportive
care environment is beneficial, but does not address the client’s physiologic
deterioration

Question 30

A client with end-stage liver disease has developed hypervolemia. What nursing
interventions would be most appropriate when addressing the client’s fluid volume
excess? Select all that apply.

A. Administering diuretics
B. Administering calcium channel blockers
C. Implementing fluid restrictions
D. Implementing a 1500 kcal/day restriction
E. Enhancing client positioning

Answer 30

ANS: A, C, E

Rationale: Administering diuretics, implementing fluid restrictions, and enhancing client
positioning can optimize the management of fluid volume excess. Calcium channel
blockers and calorie restriction do not address this problem

Question 31

A client with liver cancer is being discharged home with a biliary drainage system in
place. The nurse should teach the client’s family how to safely perform which of the
following actions?

A. Aspirating bile from the catheter using a syringe
B. Removing the catheter when output is
C. Instilling antibiotics into the catheter
15 mL in 24 hours
D. Assessing the patency of the drainage catheter

Answer 31

ANS: D

Rationale: Families should be taught to provide basic catheter care, including assessment
of patency. Antibiotics are not instilled into the catheter and aspiration using a syringe is
contraindicated. The family would not independently remove the catheter; this would
be done by a member of the care team when deemed necessary.

Question 32

A client with cirrhosis has experienced a progressive decline in his health; and liver
transplantation is being considered by the interdisciplinary team. How will the client’s
prioritization for receiving a donor liver be determined?

A. By considering the client’s age and prognosis
B. By objectively determining the client’s medical need
C. By objectively assessing the client’s willingness to adhere to
post-transplantation care
D. By systematically ruling out alternative treatment options

Answer 32

ANS: B

Rationale: The client would undergo a classification of the degree of medical need
through an objective determination known as the Model of End-Stage Liver Disease
(MELD) classification, which stratifies the level of illness of those awaiting a liver
transplant. This algorithm considers multiple variables, not solely age, prognosis,
potential for adherence, and the rejection of alternative options.

Question 33

A nurse has entered the room of a client with cirrhosis and found the client on the
floor. The client reports falling when transferring to the commode. The client’s vital signs
are within reference ranges and the nurse observes no apparent injuries. What is the
nurse’s most appropriate action?

A. Remove the client’s commode and supply a bedpan.
B. Complete an incident report and submit it to the unit supervisor.
C. Have the client assessed by the primary provider due to the risk of internal
bleeding.
D. Perform a focused abdominal assessment in order to rule out injury.

Answer 33

ANS: C

Rationale: A fall would necessitate thorough medical assessment due to the client’s risk
of bleeding. The nurse’s abdominal assessment is an appropriate action, but is not wholly
sufficient to rule out internal injury. Medical assessment is a priority over removing the
commode or filling out an incident report, even though these actions are appropriate.

Question 34

A client with liver cancer is being discharged home with a hepatic artery catheter in
place. The nurse should be aware that this catheter will facilitate which of the following?

A. Continuous monitoring for portal hypertension
B. Administration of immunosuppressive drugs during the first weeks after transplantation
C. Real-time monitoring of vascular changes in the hepatic system
D. Delivery of a continuous chemotherapeutic dose

Answer 34

ANS: D

Rationale: In most cases, the hepatic artery catheter has been inserted surgically and has a prefilled infusion pump that delivers a continuous chemotherapeutic dose until completed. The hepatic artery catheter does not monitor portal hypertension, deliver immunosuppressive drugs, or monitor vascular changes in the hepatic system.

Question 35

A nurse on a solid organ transplant unit is planning the care of a client who will soon
be admitted upon immediate recovery following liver transplantation. What aspect of
nursing care is the nurse’s priority?

A. Implementation of infection-control measures
B. Close monitoring of skin integrity and color
C. Frequent assessment of the client’s psychosocial status
D. Administration of antiretroviral medications

Answer 35

ANS: A

Rationale: Infection control is paramount following liver transplantation. This is a priority
over skin integrity and psychosocial status, even though these are valid areas of
assessment and intervention. Antiretrovirals are not indicated.

Question 36

A 55-year-old female client with hepatocellular carcinoma (HCC) is undergoing
radiofrequency ablation. The nurse should recognize what goal of this treatment?
A. Destruction of the client’s liver tumor
B. Restoration of portal vein patency
C. Destruction of a liver abscess
D. Reversal of metastasis

Answer 36

ANS: A

Rationale: Using radiofrequency ablation, a tumor up to 5 cm in size can be destroyed in
one treatment session. This technique does not address circulatory function or abscess
formation. It does not allow for the reversal of metastasis.

Question 37

A nurse is caring for a client with severe hemolytic jaundice. Laboratory tests show
free bilirubin to be 24 mg/dL (408 mmol/L). For what complication is this client at risk?

A. Chronic jaundice
B. Pigment stones in portal circulation
C. Central nervous system damage
D. Hepatomegaly

Answer 37

ANS: C

Rationale: Prolonged jaundice, even if mild, predisposes to the formation of pigment
stones in the gallbladder, and extremely severe jaundice (levels of free bilirubin
exceeding 20 to 25 mg/dL) poses a risk for CNS damage. There are not specific risks of
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hepatomegaly or chronic jaundice resulting from high bilirubin.

Question 38

The nurse’s review of a client’s most recent laboratory results indicates a bilirubin
level of 3.0 mg/dL (51 mmol/L). The nurse assesses the client for:

A. jaundice.
B. bleeding.
C. malnutrition.
D. hypokalemia.

Answer 38

ANS: A

Rationale: Jaundice becomes clinically evident when the serum bilirubin level exceeds 2.0
mg/dL (34 mmol/L). Elevated bilirubin levels are not associated with hypokalemia,
malnutrition or bleeding, though these complications may result from the underlying liver
disorder.