TEST 7: The Client with Biliary Tract Disorders

Question 1

The Client with Cholecystitis
1. A client has undergone a laparoscopic cholecystectomy. Which of the following instructions
should the nurse include in the discharge teaching?
1. Empty the bile bag daily.
2. Breathe deeply into a paper bag when nauseated.
3. Keep adhesive dressings in place for 6 weeks.
4. Report bile-colored drainage from any incision.

Answer 1

The Client with Cholecystitis
1. 4. There should be no bile-colored drainage coming from any of the incisions postoperatively.
A laparoscopic cholecystectomy does not involve a bile bag. Breathing deeply into a paper bag will
prevent a person from passing out due to hyperventilation; it does not alleviate nausea. If the adhesive
dressings have not already fallen off, they are removed by the surgeon in 7 to 10 days, not 6 weeks.
CN: Management of care; CL: Create

Question 2

2. A 40-year-old client is admitted to the hospital with a diagnosis of acute cholecystitis. The
   nurse should contact the physician to question which of the following prescriptions?
3. IV fluid therapy of normal saline solution to be infused at 100 mL/h until further prescriptions.
4. Administer morphine sulfate 10 mg IM every 4 hours as needed for severe abdominal pain.
5. Nothing by mouth (NPO) until further prescriptions.
6. Insert a nasogastric tube and connect to low intermittent suction.

Answer 2

2. 2. A nurse should question the prescription for morphine sulfate because it is believed to cause
      biliary spasm. Thus, the preferred opioid analgesic to treat cholecystitis is meperidine (Demerol).
      Elderly clients should not be given meperidine because of the risk of acute confusion and seizures in
      this population. An alternative pain medication will be necessary. IV fluid therapy is used to maintain
      fluid and electrolyte balance that may result from NPO status and gastric suctioning. NPO status and
      gastric decompression prevent further gallbladder stimulation.
      CN: Safety and infection control; CL: Synthesize

Question 3

3. A client is admitted to the hospital with a diagnosis of cholecystitis from cholelithiasis. The
   client has severe abdominal pain and nausea, and has vomited several times. Based on these data,
   which nursing action would have the highest priority for intervention at this time?
4. Manage anxiety.
5. Restore fluid loss.
6. Manage the pain.
7. Replace nutritional loss.

Answer 3

3. 3. The priority for nursing care at this time is to decrease the client’s severe abdominal pain.
      The pain, which is frequently accompanied by nausea and vomiting, is caused by biliary spasm.
      Opioid analgesics are given to relieve the severe pain and spasm of cholecystitis. Relief of pain may
      decrease nausea and vomiting and thereby decrease the client’s likelihood of developing further
      complications, such as severe fluid loss and inadequate nutrition. There are no data to suggest that the
      client is anxious.
      CN: Physiological adaptation; CL: Analyze

Question 4

4. A client's stools are light gray in color. The nurse should assess the client further for which of
the following? Select all that apply.
1. Intolerance to fatty foods.
2. Fever.
3. Jaundice.
4. Respiratory distress.
5. Pain at McBurney's point.
6. Peptic ulcer disease.

Answer 4

4. 1, 2, 3. Bile is created in the liver, stored in the gallbladder, and released into the duodenum,
   giving stool its brown color. A bile duct obstruction can cause pale-colored stools. Other symptoms
   associated with cholelithiasis are right upper quadrant tenderness, fever from inflammation or
   infection, jaundice from elevated serum bilirubin levels, and nausea or right upper quadrant pain after
   a fatty meal. Pain at McBurney’s point lies between the umbilicus and right iliac crest and is
   associated with appendicitis. A bleeding ulcer produces black, tarry stools. Respiratory distress is
   not a symptom of cholelithiasis.
   CN: Physiological adaptation; CL: Analyze

Question 5

5. A client who has been scheduled to have a choledocholithotomy expresses anxiety about
   having surgery. Which nursing intervention would be the most appropriate to achieve the outcome of
   anxiety reduction?
6. Providing the client with information about what to expect postoperatively.
7. Telling the client it is normal to be afraid.
8. Reassuring the client by saying that surgery is a common procedure.
9. Stressing the importance of following the physician’s instructions after surgery

Answer 5

5. 1. Providing information can help to answer the client’s questions and decrease anxiety. Fear of
      the unknown can increase anxiety. Telling the client not to be afraid, that the procedure is common, or
      to follow her physician’s prescriptions will not necessarily decrease anxiety.
      CN: Psychosocial adaptation; CL: Synthesize

Question 6

6. A client has an open cholecystectomy with bile duct exploration. Following surgery, the client
   has a t-tube. To evaluate the effectiveness of the t-tube, the nurse should:
7. Irrigate the tube with 20 mL of normal saline every 4 hours.
8. Unclamp the t-tube and empty the contents every day.
9. Assess the color and amount of drainage every shift.
10. Monitor the multiple incision sites for bile drainage.

Answer 6

6. 3. A t-tube is inserted in the common bile duct to maintain patency until edema from the duct
      exploration subsides. The bile color should be gold to dark green and the amount of drainage should
      be closely monitored to ensure tube patency. Irrigation is not routinely done, unless prescribed using a
      smaller volume of fluid. The t-tube is not clamped in the early postop period to allow for continuous
      drainage. An open cholecystectomy has one right subcostal incision, whereas a laparoscopic
      cholecystectomy has multiple small incisions.
      CN: Physiological adaptation; CL: Evaluate

Question 7

7. At 8 AM , the nurse reviews the amount of t-tube drainage for a client who underwent an open
cholecystectomy yesterday. After reviewing the output record (see chart), the nurse should:
12 pm - 50 ml
4 pm - 60 ml
8 pm - 60 ml
12 am - 70 ml
4 am - 70 ml
8 am - 10 ml

1. Report the 24-hour drainage amount at 12 noon.
2. Clamp the t-tube.
3. Evaluate the tube for patency.
4. Irrigate the t-tube.

Answer 7

7. 3. The t-tube should drain approximately 300 to 500 mL in the first 24 hours, and after 3 to 4
      days the amount should decrease to less than 200 mL in 24 hours. With the sudden decrease in
      drainage at 8 AM , the nurse should immediately assess the tube for obstruction of flow that can be
      caused by kinks in the tube or the client lying on the tube. Drainage color must also be assessed for
      signs of bleeding. The tube should not be irrigated or clamped without a prescription.
      CN: Physiological adaptation; CL: Synthesize

Question 8

8. The nurse measures the amount of bile drainage from a t-tube and records it by which one of
   the following methods?
9. Adding it to the client’s urine output.
10. Charting it separately on the output record.
11. Adding it to the amount of wound drainage.
12. Subtracting it from the total intake for each day.

Answer 8

8. 2. T-tube bile drainage is recorded separately on the output record. Adding the t-tube drainage
      to the urine output or wound drainage makes it difficult to accurately determine the amounts of bile,
      urine, or drainage. The client’s total intake will be incorrect if drainage is subtracted from it.
      CN: Reduction of risk potential; CL: Apply

Question 9

9. The nurse is caring for a client who had an open cholecystectomy 24 hours ago. The client’s
   vital signs have been stable over the last 24 hours, with most recent temperature 37°C (98.6°F),
   blood pressure (BP) 118/76, respiratory rate (RR) 16/min, and heart rate (HR) 78 bpm, but are now
   changing. Which of the following indicate that the nurse should contact the physician?
10. Temperature 38.8°C (101.8°F), BP 140/86, HR 94 bpm, RR 24/min.
11. Temperature 38.2°C (100.7°F), BP 118/68, HR 84 bpm, RR 20/min.
12. Temperature 37.5°C (99.5°F), BP 126/80, HR 58 bpm, RR 16/min.
13. Temperature 36.4°C (97.5°F), BP 98/64, HR 98 bpm, RR 18/min.

Answer 9

9. 1. This client is exhibiting three of four signs of systemic inflammatory response syndrome
      (SIRS): temperature greater than 38°C (or less than 36°C), heart rate greater than 90 bpm, respiratory
      rate greater than 20 breaths/min. The fourth indicator is an abnormal white blood cell count (greater
      than 12,000 [12 × 10 9 /L], less than 4000 [4 × 10 9 /L] or greater than 10% [0.1 × 10 9 /L] bands). At
      least two of these variables are required to define SIRS.
      CN: Physiological integrity CL: Evaluate

Question 10

10. After a cholecystectomy, the client is to follow a low-fat diet. Which of the following foods
    would be most appropriate to include in a low-fat diet?
11. Cheese omelet.
12. Peanut butter.
13. Ham salad sandwich.
14. Roast beef.

Answer 10

10. 4. Lean meats, such as beef, lamb, veal, and well-trimmed lean ham and pork, are low in fat.
       Rice, pasta, and vegetables are low in fat when not served with butter, cream, or sauces. Fruits are
       low in fat. The amount of fat allowed in a client’s diet after a cholecystectomy will depend on the
       client’s ability to tolerate fat. Typically, the client does not require a special diet but is encouraged to
       avoid excessive fat intake. A cheese omelet and peanut butter have high fat content. Ham salad is high
       in fat from the fat in salad dressing.
       CN: Basic care and comfort; CL: Apply

Question 11

11. A client with cholecystitis continues to have severe right upper quadrant pain. The nurse
    obtains the following vital signs: temperature 38.4°C; pulse 114; respirations 22; blood pressure
    142/90. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for
    communication, the nurse recommends to the primary care provider for the client to receive:
12. Hydromorphone IV.2. Diltiazem PO.
13. Meperidine IM.
14. Promethazine IM.

Answer 11

11. 1. Hydromorphone should be considered for pain management. It should be administered
       intravenously for rapid action to address the severe pain the client is experiencing. Intramuscular
       injections are painful and slower acting. Since meperidine’s toxic metabolite can cause seizures, it is
       no longer the treatment choice for pain. Diltiazem, a calcium channel blocker, is not indicated.
       Elevation of heart rate and blood pressure is likely due to pain and fever. Promethazine is used to
       treat nausea.
       CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 12

The nurse prepares to administer promethazine (Phenergan) 35 mg IM as prescribed PRN for a client
with cholecystitis who has nausea. The ampule label reads that the medication is available in 25
mg/mL. How many milliliters should the nurse administer?
___________________________ mL.

Answer 12

12. 1.4 mL.

35 mg / X ml = 25 mg / 1 ml
X = 1.4 ml

The following formula is used to calculate the correct dosage:
CN: Pharmacological and parenteral therapies; CL: Apply

Question 13

13. A client undergoes a laparoscopic cholecystectomy. Which of the following dietary
    instructions should the nurse give the client immediately after surgery?
14. “You cannot eat or drink anything for 24 hours.”
15. “You may resume your normal diet the day after your surgery.”
16. “Drink liquids today and eat lightly for a few days.”
17. “You can progress from a liquid to a bland diet as tolerated.”

Answer 13

13. 3. Immediately after surgery, the client will drink liquids. A light diet can be resumed the day
       after surgery. There is no need for the client to remain on nothing-by-mouth status after surgery
       because peristaltic bowel activity should not be affected. The client will probably not be able to
       tolerate a full meal comfortably the day after surgery. There is no need for the client to stay on a bland
       diet after a laparoscopic cholecystectomy. The client should, however, avoid excessive fats.
       CN: Physiological adaptation; CL: Synthesize

Question 14

14. Which of the following discharge instructions would be appropriate for a client who has had
    a laparoscopic cholecystectomy and has sutures covered by steri-strips?
15. Avoid showering for 1 week hours after surgery.
16. Return to work within 1 week.
17. Leave steri-strips in place until you see the surgeon at the postoperative visit.
18. Use acetaminophen (Tylenol) to control any fever.

Answer 14

14. 3. After a laparoscopic cholecystectomy when there are sutures covered by a dressing or
       steri-strips, the client should not remove dressings from the puncture sites but should wait until
       visiting the surgeon. The client may shower 48 hours after surgery. A client can return to work within
       1 week, but only if approved by the surgeon and no strenuous activity is involved. The client should
       report any fever, which could be an indication of a complication.
       CN: Reduction of risk potential; CL: Synthesize

Question 15

15. After a client who has had a laparoscopic cholecystectomy receives discharge instructions,
    which of the following client statements would indicate that the teaching has been successful? Select
    all that apply.
16. “I can resume my normal diet when I want.”
17. “I need to avoid driving for about 4 weeks.”
18. “I may experience some pain in my right shoulder.”
19. “I should spend 2 to 3 days in bed before resuming activity.”
20. “I can take a shower 2 days later.”

Answer 15

15. 1, 3, 5. Following a laparoscopic cholecystectomy, the client can resume a normal diet as
    tolerated. The client may experience right shoulder pain from the gas that was used to inflate the
    abdomen during surgery. The puncture site should be cleansed daily with mild soap and water; if a
    band aid was applied after surgery it can be patted dry or removed and replaced. Driving can usually
    be resumed in 3 to 4 days following surgery, and there is no need for the client to maintain bed rest in
    the days following surgery. Light exercise such as walking can be resumed immediately.
    CN: Physiological adaptation; CL: Evaluate

Question 16

16. A client has been admitted to the medical surgical unit following an emergency
    cholecystectomy. There is a Jackson Pratt drain with a portable suction unit attached. After 4 hours,
    the drainage unit is full. The nurse should do which of the following?
17. Notify the surgeon.
18. Remove the drain and suction unit.
19. Check the dressing for bleeding.
20. Empty the drainage unit.

Answer 16

16. 4. Portable suction units should be emptied and drained every shift or when full. It is normal
       for the unit to fill within the first hours after surgery; the nurse does not need to contact the surgeon.
       There should not be bleeding on the dressing if the drainage system is emptied when full. The drain
       should not be removed until prescribed by the physician.
       CN: Management of care CL: Synthesize

Question 17

The Client with Pancreatitis
17. The client who has been hospitalized with pancreatitis does not drink alcohol because of her
religious convictions. She becomes upset when the physician persists in asking her about alcohol
intake. The nurse should explain that the reason for these questions is that:
1. There is a strong link between alcohol use and acute pancreatitis.
2. Alcohol intake can interfere with the tests used to diagnose pancreatitis.
3. Alcoholism is a major health problem, and all clients are questioned about alcohol intake.
4. The physician must obtain the pertinent facts, regardless of religious beliefs.

Answer 17

hould not be removed until prescribed by the physician.
CN: Management of care CL: Synthesize
The Client with Pancreatitis
17. 1. Alcoholism is a major cause of acute pancreatitis in the United States and Canada. Because
some clients are reluctant to discuss alcohol use, staff may inquire about it in several ways.
Generally, alcohol intake does not interfere with the tests used to diagnose pancreatitis. Recent
ingestion of large amounts of alcohol, however, may cause an increased serum amylase level. Large
amounts of ethyl and methyl alcohol may produce an elevated urinary amylase concentration. All
clients are asked about alcohol and drug use on hospital admission, but this information is especially
pertinent for clients with pancreatitis. Physicians do need to seek facts, but this can be done while
respecting the client’s religious beliefs. Respecting religious beliefs is important in providing holistic
client care.
CN: Health promotion and maintenance; CL: Apply

Question 18

18. The nurse monitors the client with pancreatitis for early signs of shock. Which of the
    following conditions is primarily responsible for making it difficult to manage shock in pancreatitis?
19. Severity of intestinal hemorrhage.
20. Vasodilating effects of kinin peptides.
21. Tendency toward heart failure.
22. Frequent incidence of acute tubular necrosis.

Answer 18

18. 2. Life-threatening shock is a potential complication of pancreatitis. Kinin peptides activated
       by the trapped trypsin cause vasodilation and increased capillary permeability. These effects
       exacerbate shock and are not easily reversed with pharmacologic agents such as vasopressors.
       Hemorrhage may occur into the pancreas, but not in the intestines. Systemic complications include
       pulmonary complications, but not heart failure or acute tubular necrosis.
       CN: Physiological adaptation; CL: Analyze

Question 19

19. A client with acute pancreatitis has a blood pressure of 88/40, heart rate of 128 bpm,
    respirations of 28/min, and Grey Turner’s sign. What action should the nurse perform first?
20. Assess the urine output.
21. Place an intravenous line.
22. Position on the left side.
23. Insert a nasogastric tube.

Answer 19

19. 2. Grey Turner’s sign is a bluish discoloration in the flank area caused by retroperitoneal
       bleeding. The vital signs are showing hemodynamic instability. IV access should be obtained to
       provide immediate volume replacement. The urine output will provide information on the fluid status.
       A nasogastric tube is indicated for clients with uncontrolled nausea and vomiting or gastric
       distension. Repositioning the client may be considered for pain management once the client’s vital
       signs are stable.
       CN: Physiological adaptation; CL: Synthesize

Question 20

20. A client is admitted with acute necrotizing pancreatitis. Lab results have been obtained, and a
    peripheral IV has been inserted. Which of the following prescriptions from a health care provider
    should the nurse question?
21. Infuse a 500-mL normal saline bolus.
22. Calcium gluconate 90 mg in 100 mL NS.
23. Total parenteral nutrition (TPN) at 72 mL/h.
24. Placement of a Foley catheter.

Answer 20

20. 3. Clients with acute necrotizing pancreatitis should remain nothing by mouth (NPO) with
       early enteral feeding via the jejunum to maintain bowel integrity and immune function. TPN is
       considered if enteral feedings are contraindicated. Access is also needed for TPN, preferably via a
       central line. Hemodynamic instability can result from fluid volume loss and bleeding and requires
       fluid and electrolyte replacement. Fat necrosis occurring with acute pancreatitis can cause
       hypocalcemia requiring calcium replacement. A Foley catheter provides accurate output assessment
       to monitor for prerenal acute renal failure that can occur from hypovolemia.
       CN: Physiological adaptation; CL: Synthesize

Question 21

21. Which of the following medications would the nurse question for a client with acute
pancreatitis?
1. Furosemide (Lasix) 20 mg IV push.
2. Imipenem (Primaxin) 500 mg IV.
3. Morphine sulfate 2 mg IV push.
4. Famotidine (Pepcid) 20 mg IV push

Answer 21

21. 1. Furosemide (Lasix) can cause pancreatitis. Additionally, hypovolemia can develop with
       acute pancreatitis and Lasix will further delete fluid volume. Imipenem is indicated in the treatment of
       acute pancreatitis with necrosis and infection. Research no longer supports Meperidine (Demerol)
       over other opiates. Morphine and Dilaudid are opiates of choice in acute pancreatitis to get pain
       under control. Famotidine is a Histamine 2 receptor antagonist used to decrease acid secretion and
       prevent stress or peptic ulcers.
       CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 22

22. The nurse should monitor the client with acute pancreatitis for which of the following
complications?
1. Heart failure.
2. Duodenal ulcer.
3. Cirrhosis.
4. Pneumonia.

Answer 22

22. 4. The client with acute pancreatitis is prone to complications associated with the respiratory
       system. Pneumonia, atelectasis, and pleural effusion are examples of respiratory complications that
       can develop as a result of pancreatic enzyme exudate. Pancreatitis does not cause heart failure, ulcer
       formation, or cirrhosis.
       CN: Reduction of risk potential; CL: Analyze

Question 23

23. When providing care for a client hospitalized with acute pancreatitis who has acuteabdominal pain, which of the following nursing interventions would be most appropriate for this
    client? Select all that apply.
24. Placing the client in a side-lying position.
25. Administering morphine sulfate for pain as needed.
26. Maintaining the client on a high-calorie, high-protein diet.
27. Monitoring the client’s respiratory status.
28. Obtaining daily weights.

Answer 23

23. 1, 4, 5. The client with acute pancreatitis usually experiences acute abdominal pain. Placing
    the client in a side-lying position relieves the tension on the abdominal area and promotes comfort. A
    semi-Fowler’s position is also appropriate. The nurse should also monitor the client’s respiratory
    status because clients with pancreatitis are prone to develop respiratory complications. Daily weights
    are obtained to monitor the client’s nutritional and fluid volume status. While the client will likely
    need opioid analgesics to treat the pain, morphine sulfate is not appropriate as it stimulates spasm of
    the sphincter of Oddi, thus increasing the client’s discomfort. During the acute phase of the illness
    while the client is experiencing pain, the pancreas is rested by withholding food and drink. When the
    diet is reintroduced, it is a high-carbohydrate, low-fat, bland diet.
    CN: Physiological adaptation; CL: Synthesize

Question 24

24. The nurse notes that a client with acute pancreatitis occasionally experiences muscle
    twitching and jerking. How should the nurse interpret the significance of these symptoms?
25. The client may be developing hypocalcemia.
26. The client is experiencing a reaction to meperidine (Demerol).
27. The client has a nutritional imbalance.
28. The client needs a muscle relaxant to promote rest.

Answer 24

24. 1. Hypocalcemia develops in severe cases of acute pancreatitis. The exact cause is unknown.
       Signs and symptoms of hypocalcemia include jerking and muscle twitching, numbness of fingers and
       lips, and irritability. Meperidine (Demerol) may cause tremors or seizures as an adverse effect, but
       not muscle twitching. Muscle twitching is not caused by a nutritional deficit, nor does it indicate that
       the client needs a muscle relaxant.CN: Reduction of risk potential; CL: Analyze

Question 25

25. A client is receiving Propantheline bromide in the management of acute pancreatitis. Which
    of the following would indicate that the nurse should discuss withholding the medication with the
    physician?
26. Absent bowel sounds.
27. Increased urine output.
28. Diarrhea.
29. Decreased heart rate.

Answer 25

25. 1. Propantheline is an anticholinergic, antispasmodic medication that decreases vagal
       stimulation and pancreatic secretions. It is contraindicated in paralytic ileus; therefore, the nurse
       should be concerned with the absent bowel sounds. Side effects are urinary retention, constipation,
       and tachycardia.
       CN: Pharmacological and parenteral therapies; CL: Analyze

Question 26

26. Which of the following dietary instructions would be appropriate for the nurse to give a
    client who is recovering from acute pancreatitis?
27. Avoid crash dieting.
28. Restrict carbohydrate intake.
29. Eat six small meals a day.
30. Decrease sodium in the diet.

Answer 26

26. 1. Crash dieting or bingeing may cause an acute attack of pancreatitis and should be avoided.
       Carbohydrate intake should be increased because carbohydrates are less stimulating to the pancreas.
       There is no need to maintain a dietary pattern of six meals a day; the client can eat whenever desired.
       There is no need to place the client on a sodium-restricted diet because pancreatitis does not promote
       fluid retention.
       CN: Physiological adaptation; CL: Synthesize

Question 27

27. Pancreatic enzyme replacements are prescribed for the client with chronic pancreatitis. When
    should the nurse instruct the client to take them to obtain the most therapeutic effect?
28. Three times daily between meals.
29. With each meal and snack.
30. In the morning and at bedtime.
31. Every 4 hours, at specified times.

Answer 27

27. 2. In chronic pancreatitis, destruction of pancreatic tissue requires pancreatic enzyme
       replacement. Pancreatic enzymes are prescribed to facilitate the digestion of proteins and fats and
       should be taken in conjunction with every meal and snack. Specified hours or limited times for
       administration are ineffective because the enzymes must be taken in conjunction with food ingestion.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 28

28. The nurse should teach the client with chronic pancreatitis to monitor the effectiveness of
    pancreatic enzyme replacement therapy by doing which of the following?
29. Recording daily fluid intake.
30. Performing glucose fingerstick tests twice a day.
31. Observing stools for steatorrhea.
32. Testing urine for ketones.

Answer 28

28. 3. If the dosage and administration of pancreatic enzymes are adequate, the client’s stool will
       be relatively normal. Any increase in odor or fat content would indicate the need for dosage
       adjustment. Stable body weight would be another indirect indicator. Fluid intake does not affect
       enzyme replacement therapy. If diabetes has developed, the client will need to monitor glucose
       levels. However, glucose and ketone levels are not affected by pancreatic enzyme therapy and would
       not indicate effectiveness of the therapy.
       CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 29

The Client with Viral Hepatitis
29. The nurse is assessing a client with chronic hepatitis B who is receiving lamivudine. What
information is most important to communicate to the physician?
1. The client has had a 3-kg weight gain over 2 days.
2. The client has nausea.
3. The client now has a temperature of 99°F (37.2°C) orally.
4. The client has fatigue.

Answer 29

The Client with Viral Hepatitis
29. 1. The fluid weight gain is of concern since the drug should be used with caution with
impaired renal function. Dosage adjustment may be needed with renal insufficiency since the drug is
excreted in the urine. Nausea, mild temperature elevation, and fatigue are symptoms that should be
monitored, but are associated with hepatitis.
CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 30

30. The nurse is assessing a client with hepatitis and notices that the aspartate transaminase
    (AST) and alanine transaminase (ALT) lab values have increased. Which of the following statements
    by the client requires further instruction by the nurse?
31. “I require increased periods of rest.”
32. “I follow a low-fat, high-carbohydrate diet.”
33. “I eat dry toast to relieve my nausea.”
34. “I take acetaminophen (Tylenol) for arthritis pain.”

Answer 30

30. 4. Acetaminophen is toxic to the liver and should be avoided in a client with liver
       dysfunction. Increased periods of rest allow for liver regeneration. A low-fat, high-carbohydrate diet
       and dry toast to relieve nausea are appropriate.
       CN: Health promotion and maintenance; CL: Evaluate

Question 31

31. College freshmen are participating in a study abroad program. When teaching them about
    hepatitis B, the nurse should instruct the students on the need for:
32. Water sanitation.
33. Single dormitory rooms.
34. Vaccination for hepatitis D.
35. Safe sexual practices.

Answer 31

31. 4. Hepatitis B is considered a sexually transmitted disease and students should observe safe-
       sex practices. Poor sanitary conditions in underdeveloped countries relate to spread of hepatitis A
       and E. Focusing on routes of transmission and avoidance of infection can prevent the spread of
       hepatitis; isolation in single rooms is not required. There is no vaccine for hepatitis D.
       CN: Reduction of risk potential; CL: Synthesize

Question 32

32. Which of the following is normal for a client during the icteric phase of viral hepatitis?
33. Tarry stools.
34. Yellowed sclera.
35. Shortness of breath.
36. Light, frothy urine.

Answer 32

32. 2. Liver inflammation and obstruction block the normal flow of bile. Excess bilirubin turns the
       skin and sclera yellow and the urine dark and frothy. Profound anorexia is also common. Tarry stools
       are indicative of gastrointestinal bleeding and would not be expected in hepatitis. Light- or clay-
       colored stools may occur in hepatitis owing to bile duct obstruction. Shortness of breath would be
       unexpected.
       CN: Physiological adaptation; CL: Analyze

Question 33

33. The nurse is teaching a client with viral hepatitis about preventing transmission of the
    disease. The nurse should focus teaching on:
34. Proper food handling.
35. Insulin syringe disposal.
36. Alpha-interferon.
37. Use of condoms.

Answer 33

33. 1. The main route of transmission for hepatitis A is the oral-fecal route, rarely parenteral.
       Good handwashing before eating or preparing food (AF1). Percutaneous transmission is seen with
       hepatitis B, C, and D. Alpha-interferon is used for treatment of chronic hepatitis B and C.
       CN: Safety and infection control; CL: Synthesize

Question 34

34. A client has a positive serologic test for anti-HCV (hepatitis C virus). The nurse should
    instruct the client:
35. How to self-administer alpha interferon.
36. That the HCV will resolve in approximately 3 months.
37. That a follow-up appointment for HCV genotype testing is required.
38. To take alpha interferon as prescribed.

Answer 34

34. 3. Clients with hepatitis C should receive genotype testing to determine the most effective
       treatment approach, and it must be done prior to the start of drug treatment with alpha interferon.
       There are six types of hepatitis C genotypes and clients have different responses to drugs depending
       on their genotype. For example, clients with genotype 2 or 3 are three times more likely to respond to
       treatment than those with genotype 1. The recommended course of duration of treatment also depends
       on genotype. Clients with genotype 2 or 3 usually have a 24-week course of treatment, whereas a 48-
       week course is recommended for clients with genotype 1. HCV has a high possibility of converting to
       chronic HCV and will not resolve in 2 to 4 months.
       CN: Physiologic adaptation; CL: Apply

Question 35

35. A client with chronic hepatitis C is experiencing nausea, anorexia, and fatigue. During the
    health history the client states that he is homosexual, drinks one to two glasses of wine with dinner, is
    taking St. John’s Wort for a “bit of depression,” and takes Tylenol for frequent headaches. The nurseshould do which of the following? Select all that apply.
36. Instruct the client that the wine with meals can be beneficial for cardiovascular health.
37. Instruct the client to ask the health care provider about taking any other medications as they
    may interact with medications the client is currently taking.
38. Instruct the client to increase the protein in his diet and eat less frequently.
39. Advise the client of the need for additional testing for HIV.
40. Encourage the client to obtain sufficient rest.

Answer 35

35. 2, 4, 5. Clients with chronic hepatitis C should abstain from alcohol as it can speed cirrhosis
    and end-stage liver disease. Clients should also check with their health care providers before taking
    any nonprescription or prescription medications, or herbal supplements. It is also important that
    clients who are infected with HCV be tested for HIV, as clients who have both HIV and HCV have a
    more rapid progression of liver disease than those who have HCV alone. Clients with HCV and
    nausea should be instructed to eat four to five times a day to help reduce anorexia and nausea. The
    client should obtain sufficient rest to manage the fatigue.
    CN: Physiologic adaptation; CL: Synthesize

Question 36

36. A client who is recovering from hepatitis A has fatigue and malaise. The client asks the nurse,
    “When will my strength return?” Which of the following responses by the nurse is most appropriate?
37. “Your fatigue should be gone by now. We will evaluate you for a secondary infection.”
38. “Your fatigue is an adverse effect of your drug therapy. It will disappear when your treatment
    regimen is complete.”
39. “It is important for you to increase your activity level. That will help decrease your fatigue.”
40. “It is normal for you to feel fatigued. The fatigue should go away in the next 2 to 4 months.”

Answer 36

36. 4. During the convalescent or posticteric stage of hepatitis, fatigue and malaise are the most
       common problems. These symptoms usually disappear within 2 to 4 months. Fatigue and malaise are
       not evidence of a secondary infection. Hepatitis A is not treated by drug therapy. It is important that
       the client continue to balance activity with periods of rest.
       CN: Reduction of risk potential; CL: Synthesize

Question 37

37. The nurse is developing a plan of care for the client with viral hepatitis. The nurse should
    instruct the client to:
38. Obtain adequate bed rest.
39. Increase fluid intake.
40. Take antibiotic therapy as prescribed.
41. Drink 8 oz (240 mL) of an electrolyte solution every day.

Answer 37

37. 1. Treatment of hepatitis consists primarily of bed rest with bathroom privileges. Bed rest is
       maintained during the acute phase to reduce metabolic demands on the liver, thus increasing its blood
       supply and promoting liver cell regeneration. When activity is gradually resumed, the client should be
       taught to rest before becoming overly tired. Although adequate fluid intake is important, it is not
       necessary to force fluids to treat hepatitis. Antibiotics are not used to treat hepatitis. Electrolyte
       imbalances are not typical of hepatitis.
       CN: Basic care and comfort; CL: Synthesize

Question 38

38. When planning care for a client with viral hepatitis, the nurse should review laboratory
    reports for which of the following abnormal laboratory values?
39. Prolonged prothrombin time.
40. Decreased blood glucose level.
41. Elevated serum potassium level.
42. Decreased serum calcium level.

Answer 38

38. 1. The prothrombin time may be prolonged because of decreased absorption of vitamin K and
       decreased production of prothrombin by the liver. The client should be assessed carefully forbleeding tendencies. Blood glucose and serum potassium and calcium levels are not affected by
       hepatitis.
       CN: Reduction of risk potential; CL: Analyze

Question 39

39. The nurse should teach the client with viral hepatitis to:
40. Limit caloric intake and reduce weight.
41. Increase carbohydrates and protein in the diet.
42. Avoid contact with others and sleep in a separate room.
43. Intensify routine exercise and increase strength.

Answer 39

39. 2. Low-fat, high-protein, high-carbohydrate diet is encouraged for a client with hepatitis to
       promote liver rejuvenation. Nutrition intake is important because clients may be anorexic and
       experience weight loss. Activity should be modified and adequate rest obtained to promote recovery.
       Social isolation should be avoided and education on preventing transmission should be provided; the
       client does not need to sleep in a separate room.
       CN: Health promotion and maintenance; CL: Synthesize

Question 40

40. The nurse develops a teaching plan for the client about how to prevent the transmission of
    hepatitis A. Which of the following discharge instructions is appropriate for the client?
41. Spray the house to eliminate infected insects.
42. Tell family members to try to stay away from the client.
43. Tell family members to wash their hands frequently.
44. Disinfect all clothing and eating utensils.

Answer 40

40. 3. The hepatitis A virus is transmitted via the fecal-oral route. It spreads through contaminated
       hands, water, and food, especially shellfish growing in contaminated water. Certain animal handlers
       are at risk for hepatitis A, particularly those handling primates. Frequent handwashing is probably the
       single most important preventive action. Insects do not transmit hepatitis A. Family members do not
       need to stay away from the client with hepatitis. It is not necessary to disinfect food and clothing.
       CN: Safety and infection control; CL: Synthesize

Question 41

41. The client with hepatitis is experiencing fatigue, weakness, and a general feeling of malaise.
    The client tires rapidly during morning care. The most appropriate goal for this client is to:
42. Increase mobility.
43. Learn new self-care skills.
44. Adapt to new levels of energy.4. Gradually increase activity tolerance.

Answer 41

41. 4. The most appropriate goal for this client with hepatitis is to increase activity gradually as
       tolerated. Periods of alternating rest and activity should be included in the plan of care. There is no
       evidence that the client is physically immobile, unable to provide self-care, or needs to adapt to new
       energy levels.
       CN: Basic care and comfort; CL: Analyze

Question 42

42. What would be the nurse’s best response to the client’s expressed feelings of isolation as a
    result of having hepatitis?
43. “Don’t worry. It’s normal to feel that way.”
44. “Your friends are probably afraid of contracting hepatitis from you.”
45. “I’m sure you’re imagining that!”
46. “Tell me more about your feelings of isolation.”

Answer 42

42. 4. The nurse should encourage the client to further verbalize feelings of isolation. Instead of
       dismissing these feelings or making assumptions about the cause of isolation, the nurse should allow
       clients to verbalize their fears and provide education on how to prevent infection transmission.
       CN: Psychosocial adaptation; CL: Synthesize

Question 43

43. Interferon alfa-2b (Intron A) has been prescribed to treat a client with chronic hepatitis B.
    The nurse should assess the client for which of the following adverse effects?
44. Retinopathy.
45. Constipation.
46. Flulike symptoms.
47. Hypoglycemia.

Answer 43

43. 3. Interferon alfa-2b (Intron A) most commonly causes flulike adverse effects, such as
       myalgia, arthralgia, headache, nausea, fever, and fatigue. Retinopathy is a potential adverse effect, but
       not a common one. Diarrhea may develop as an adverse effect. Clients are advised to administer the
       drug at bedtime and get adequate rest. Medications may be prescribed to treat the symptoms. The drug
       may also cause hematologic changes; therefore, laboratory tests such as a complete blood count and
       differential should be conducted monthly during drug therapy. Blood glucose laboratory values should
       be monitored for the development of hyperglycemia.
       CN: Pharmacological and parenteral therapies; CL: Analyze

Question 44

44. The nurse is preparing a community education program about preventing hepatitis B infection.
    Which of the following would be appropriate to incorporate into the teaching plan?
45. Hepatitis B is relatively uncommon among college students.
46. Frequent ingestion of alcohol can predispose an individual to development of hepatitis B.
47. Good personal hygiene habits are most effective at preventing the spread of hepatitis B.
48. The use of a condom is advised for sexual intercourse.

Answer 44

44. 4. Hepatitis B is spread through exposure to blood or blood products and through high-risk
       sexual activity. Hepatitis B is considered to be a sexually transmitted disease. High-risk sexual
       activities include sex with multiple partners, unprotected sex with an infected individual, male
       homosexual activity, and sexual activity with IV drug users. College students are at high risk for
       development of hepatitis B and are encouraged to be immunized. Alcohol intake by itself does not
       predispose an individual to hepatitis B, but it can lead to high-risk behaviors such as unprotected sex.
       Good personal hygiene alone will not prevent the transmission of hepatitis B.
       CN: Safety and infection control; CL: Create

Question 45

45. Which of the following expected outcomes would be appropriate for a client with viral
    hepatitis? The client will:
46. Demonstrate a decrease in fluid retention related to ascites.
47. Verbalize the importance of reporting bleeding gums or bloody stools.
48. Limit use of alcohol to two to three drinks per week.
49. Restrict activity to within the home to prevent disease transmission.

Answer 45

45. 2. The client should be able to verbalize the importance of reporting any bleeding tendencies
       that could be the result of a prolonged prothrombin time. Ascites is not typically a clinical
       manifestation of hepatitis; it is associated with cirrhosis. Alcohol use should be eliminated for at
       least 1 year after the diagnosis of hepatitis to allow the liver time to fully recover. There is no need
       for a client to be restricted to the home because hepatitis is not spread through casual contact between
       individuals.
       CN: Physiological adaptation; CL: Evaluate

Question 46

The Client with Cirrhosis
46. A client with cirrhosis is receiving lactulose. During the assessment, the nurse notes
increased confusion and asterixis. The nurse should:
1. Assess for gastrointestinal (GI) bleeding.
2. Hold the lactulose.
3. Increase protein in the diet.
4. Monitor serum bilirubin levels.

Answer 46

The Client with Cirrhosis
46. 1. Clients with cirrhosis can develop hepatic encephalopathy caused by increased ammonia
levels. Asterixis, a flapping tremor, is a characteristic symptom of increased ammonia levels.
Bacterial action on increased protein in the bowel will increase ammonia levels and cause the
encephalopathy to worsen. GI bleeding and protein consumed in the diet increase protein in the
intestine and can elevate ammonia levels. Lactulose is given to reduce ammonia formation in the
intestine and should not be held since neurological symptoms are worsening. Bilirubin is associated
with jaundice.
CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 47

47. The nurse is assessing a client with cirrhosis who has developed hepatic encephalopathy.
    The nurse should notify the physician of a decrease in which serum lab value that is a potential
    precipitating factor for hepatic encephalopathy?
48. Aldosterone.
49. Creatinine.
50. Potassium.
51. Protein.

Answer 47

47. 3. Hypokalemia is a precipitating factor in hepatic encephalopathy. A decrease in creatinine
       results from muscle atrophy; an increase in creatinine would indicate renal insufficiency. With liver
       dysfunction, increased aldosterone levels are seen. A decrease in serum protein will decrease colloid
       osmotic pressure and promote edema.
       CN: Physiological adaptation; CL: Synthesize

Question 48

48. A client has advanced cirrhosis of the liver. The client’s spouse asks the nurse why his
    abdomen is swollen, making it very difficult for him to fasten his pants. How should the nurse
    respond to provide the most accurate explanation of the disease process?
49. “He must have been eating too many foods with salt in them. Salt pulls water with it.”
50. “The swelling in his ankles must have moved up closer to his heart so the fluid circulates
    better.”
51. “He must have forgotten to take his daily water pill.”
52. “Blood is not able to flow readily through the liver now, and the liver cannot make protein to
    keep fluid inside the blood vessels.”

Answer 48

48. 4. Portal hypertension and hypoalbuminemia as a result of cirrhosis cause a fluid shift into the
       peritoneal space causing ascites. In a cardiac or kidney problem, not cirrhosis, sodium can promote
       edema formation and subsequent decreased urine output. Edema does not migrate upward toward the
       heart to enhance its circulation. Although diuretics promote the excretion of excess fluid, occasionally
       forgetting or omitting a dose will not yield the ascites found in cirrhosis of the liver.
       CN: Physiological adaptation; CL: Synthesize

Question 49

49. A nurse is developing a care plan for a client with hepatic encephalopathy. Which of the
    following are goals for the care for this client? Select all that apply.
50. Preventing constipation.
51. Administering lactulose to reduce blood ammonia levels.
52. Monitoring coordination while walking.
53. Checking the pupil reaction.
54. Providing food and fluids high in carbohydrate.
55. Encouraging physical activity.

Answer 49

49. 1, 2, 3, 4, 5. Constipation leads to increased ammonia production. Lactulose is a
    hyperosmotic laxative that reduces blood ammonia by acidifying the colon contents, which retards
    diffusion of nonionic ammonia from the colon to the blood while promoting its migration from the
    blood to the colon. Hepatic encephalopathy is considered a toxic or metabolic condition that causes
    cerebral edema; it affects a person’s coordination and pupil reaction to light and accommodation.
    Food and fluids high in carbohydrates should be given because the liver is not synthesizing and
    storing glucose. Because exercise produces ammonia as a byproduct of metabolism, physical activity
    should be limited, not encouraged.
    CN: Management of care; CL: Create

Question 50

50. The nurse is assessing a client who is in the early stages of cirrhosis of the liver. Which
focused assessment is appropriate?
1. Peripheral edema.
2. Ascites.
3. Anorexia.
4. Jaundice.

Answer 50

50. 3. Early clinical manifestations of cirrhosis are subtle and usually include gastrointestinal
       symptoms, such as anorexia, nausea, vomiting, and changes in bowel patterns. These changes are
       caused by the liver’s altered ability to metabolize carbohydrates, proteins, and fats. Peripheral edema,
       ascites, and jaundice are later signs of liver failure and portal hypertension.
       CN: Physiological adaptation; CL: Analyze

Question 51

51. A client with cirrhosis begins to develop ascites. Spironolactone (Aldactone) is prescribed
    to treat the ascites. The nurse should monitor the client closely for which of the following drug-
    related adverse effects?
52. Constipation.2. Hyperkalemia.
53. Irregular pulse.
54. Dysuria.

Answer 51

51. 2. Spironolactone (Aldactone) is a potassium-sparing diuretic; therefore, clients should be
       monitored closely for hyperkalemia. Other common adverse effects include abdominal cramping,
       diarrhea, dizziness, headache, and rash. Constipation and dysuria are not common adverse effects of
       spironolactone. An irregular pulse is not an adverse effect of spironolactone but could develop if
       serum potassium levels are not closely monitored.
       CN: Pharmacological and parenteral therapies; CL: Analyze

Question 52

52. What diet should be implemented for a client who is in the early stages of cirrhosis?
53. High-calorie, high-carbohydrate.
54. High-protein, low-fat.
55. Low-fat, low-protein.
56. High-carbohydrate, low-sodium.

Answer 52

52. 1. For clients who have cirrhosis without complications, a high-calorie, high-carbohydrate
       diet is preferred to provide an adequate supply of nutrients. In the early stages of cirrhosis, there is no
       need to restrict fat, protein, or sodium.
       CN: Physiological adaptation; CL: Apply

Question 53

53. A client with jaundice has pruritus and areas of irritation from scratching. What measures can
    the nurse discuss to prevent skin breakdown? Select all that apply.
54. Avoid lotions containing calamine.
55. Add baking soda to the water in a tub bath.
56. Keep nails short and clean.
57. Rub the skin when it itches with knuckles instead of nails.
58. Massage skin with alcohol.
59. Increase sodium intake in diet.

Answer 53

53. 2, 3, 4. Baking soda baths can decrease pruritis. Keeping nails short and rubbing with
    knuckles can decrease breakdown when scratching cannot be resisted, such as during sleep. Calamine
    lotions help relieve itching. Alcohol will increase skin dryness. Sodium in the diet will increase
    edema and weaken skin integrity.
    CN: Basic care and comfort; CL: Create

Question 54

54. Which of the following health promotion activities would be appropriate for the nurse to
    suggest that the client with cirrhosis add to the daily routine at home?
55. Supplement the diet with daily multivitamins.
56. Abstain from drinking alcohol.
57. Take a sleeping pill at bedtime.
58. Limit contact with other people whenever possible.

Answer 54

54. 2. General health promotion measures include maintaining good nutrition, avoiding infection,
       and abstaining from alcohol. Rest and sleep are essential, but an impaired liver may not be able to
       detoxify sedatives and barbiturates. Such drugs must be used cautiously, if at all, by clients with
       cirrhosis. The client does not need to limit contact with others but should exercise caution to stay
       away from ill people.
       CN: Health promotion and maintenance; CL: Synthesize

Question 55

55. The nurse is reviewing the chart information for a client with increased ascites. The data
    include the following: temperature 37.2°C, heart rate 118, shallow respirations 26, blood pressure
    128/76, and SpO 2 89% on room air. Which action should receive priority by the nurse?
56. Assess heart sounds.
57. Obtain a prescription for blood cultures.
58. Prepare for a paracentesis.
59. Raise the head of the bed.

Answer 55

55. 4. Elevating the head of the bed will allow for increased lung expansion by decreasing the
       ascites pressing on the diaphragm. The client requires reassessment. A paracentesis is reserved for
       symptomatic clients with ascites with impaired respiration or abdominal pain not responding to other
       measures such as sodium restriction and diuretics. There is no indication for blood cultures. Heart
       sounds are assessed with the routine physical assessment.
       CN: Physiological adaptation; CL: Synthesize

Question 56

56. Which of the following positions would be appropriate for a client with severe ascites?
57. Fowler’s.
58. Side-lying.
59. Reverse Trendelenburg.
60. Sims.

Answer 56

56. 1. Ascites can compromise the action of the diaphragm and increase the client’s risk of
       respiratory problems. Ascites also greatly increases the risk of skin breakdown. Frequent position
       changes are important, but the preferred position is Fowler’s. Placing the client in Fowler’s position
       helps facilitate the client’s breathing by relieving pressure on the diaphragm. The other positions do
       not relieve pressure on the diaphragm.
       CN: Reduction of risk potential; CL: Synthesize

Question 57

57. The client with cirrhosis receives 100 mL of 25% serum albumin IV. Which finding would
    best indicate that the albumin is having its desired effect?
58. Increased urine output.
59. Increased serum albumin level.
60. Decreased anorexia.
61. Increased ease of breathing.

Answer 57

57. 1. Normal serum albumin is administered to reduce ascites. Hypoalbuminemia, a mechanism
       underlying ascites formation, results in decreased colloid osmotic pressure. Administering serum
       albumin increases the plasma colloid osmotic pressure, which causes fluid to flow from the tissue
       space into the plasma. Increased urine output is the best indication that the albumin is having the
       desired effect. An increased serum albumin level and increased ease of breathing may indirectly
       imply that the administration of albumin is effective in relieving the ascites. However, it is not as
       direct an indicator as increased urine output. Anorexia is not affected by the administration of
       albumin.CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 58

58. A client with a Sengstaken-Blakemore tube has a sudden drop in SpO 2 and increase inrespiratory rate to 40 breaths/min. The nurse should do which of the following in order from first to
    last?
59. Affirm airway obstruction by the tube.
60. Remove the tube.
61. Deflate the tube by cutting with bedside scissors.
62. Apply oxygen via face mask.

Answer 58

58.
1. Affirm airway obstruction by the tube.
3. Deflate the tube by cutting with bedside scissors.
2. Remove the tube.
4. Apply oxygen via face mask.
The nurse should first assess the client to determine if the tube is obstructing the airway;
assessment is done by assessing air flow. Once obstruction is established, the tube should be deflated
and then quickly removed. A set of scissors should always be at the bedside to allow for emergency
deflation of the balloon. Oxygen via face mask should then be applied once the tube is removed.
CN: Safety and infection control; CL: Synthesize

Question 59

59. The health care provider instructs a client with alcohol-induced cirrhosis to stop drinking
    alcohol. The expected outcome of this intervention is:
60. Absence of delirium tremens.
61. Having a balanced diet.
62. Improved liver function.
63. Reduced weight.

Answer 59

59. 3. The goal of abstinence from alcohol in clients with alcohol-induced cirrhosis is to improve
       the liver function; most clients have improved liver function when they abstain from alcohol. Clients
       with cirrhosis do not necessarily have delirium tremens. Abstaining from alcohol may allow the
       client to improve nutritional status, but additional dietary counseling may be needed to achieve that
       goal. Clients with cirrhosis may have weight gain from ascites, but this is managed with diuretics.
       CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 60

60. The nurse monitors a client with cirrhosis for the development of hepatic encephalopathy.
    Which of the following would be an indication that hepatic encephalopathy is developing?
61. Decreased mental status.
62. Elevated blood pressure.
63. Decreased urine output.
64. Labored respirations.

Answer 60

60. 1. The client should be monitored closely for changes in mental status. Ammonia has a toxic
       effect on central nervous system tissue and produces an altered level of consciousness, marked by
       drowsiness and irritability. If this process is unchecked, the client may lapse into coma. Increasing
       ammonia levels are not detected by changes in blood pressure, urine output, or respirations.
       CN: Physiological adaptation; CL: Analyze

Question 61

61. A client’s serum ammonia level is elevated, and the physician prescribes 30 mL of lactulose.
    Which of the following is an adverse effect of this drug?
62. Increased urine output.
63. Improved level of consciousness.
64. Increased bowel movements.
65. Nausea and vomiting

Answer 61

61. 3. Lactulose increases intestinal motility, thereby trapping and expelling ammonia in the feces.
       An increase in the number of bowel movements is expected as an adverse effect. Lactulose does not
       affect urine output. Any improvements in mental status would be the result of increased ammonia
       elimination, not an adverse effect of the drug. Nausea and vomiting are not common adverse effects of
       lactulose.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 62

The nurse has a prescription to administer 2 oz of lactulose to a client who has cirrhosis. How many
milliliters of lactulose should the nurse administer?
_____________________ mL.

Answer 62

62. 60 mL
    The following formula is used to calculate the correct dosage:
    30 ml / 1 oz = X ml / 2 oz

CN: Pharmacological and parenteral therapies; CL: Apply

Question 63

63. A client is to be discharged with a prescription for lactulose. The nurse teaches the client and
    the client’s spouse how to administer this medication. Which of the following statements wouldindicate that the client has understood the information?
64. “I’ll take it with Maalox.”
65. “I’ll mix it with apple juice.”
66. “I’ll take it with a laxative.”
67. “I’ll mix the crushed tablets in some gelatin.”

Answer 63

63. 2. The taste of lactulose is a problem for some clients. Mixing it with fruit juice, water, ormilk can make it more palatable. Lactulose should not be given with antacids, which may inhibit its
       action. Lactulose should not be taken with a laxative because diarrhea is an adverse effect of the drug.
       Lactulose comes in the form of syrup for oral or rectal administration.
       CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 64

64. The nurse is providing discharge instructions for a client with cirrhosis. Which of the
    following statements best indicates that the client has understood the teaching?
65. “I should eat a high-protein, high-carbohydrate diet to provide energy.”
66. “It is safer for me to take acetaminophen (Tylenol) for pain instead of aspirin.”
67. “I should avoid constipation to decrease chances of bleeding.”
68. “If I get enough rest and follow my diet, it is possible for my cirrhosis to be cured.”

Answer 64

64. 3. Clients with cirrhosis should be instructed to avoid constipation and straining at stool to
       prevent hemorrhage. The client with cirrhosis has bleeding tendencies because of the liver’s inability
       to produce clotting factors. A low-protein and high-carbohydrate diet is recommended. Clients with
       cirrhosis should not take acetaminophen (Tylenol), which is potentially hepatotoxic. Aspirin also
       should be avoided if esophageal varices are present. Cirrhosis is a chronic disease.
       CN: Reduction of risk potential; CL: Evaluate

Question 65

65. The nurse is preparing a client for a paracentesis. The nurse should:
66. Have the client void immediately before the procedure.
67. Place the client in a side-lying position.
68. Initiate an IV line to administer sedatives.
69. Place the client on nothing-by-mouth (NPO) status 6 hours before the procedure.

Answer 65

65. 1. Immediately before a paracentesis, the client should empty the bladder to prevent
       perforation. The client will be placed in a high Fowler’s position or seated on the side of the bed for
       the procedure. IV sedatives are not usually administered. The client does not need to be NPO.
       CN: Reduction of risk potential; CL: Synthesize

Question 66

66. A client with ascites and peripheral edema is at risk for impaired skin integrity. To prevent
    skin breakdown, the nurse should:
67. Institute range-of-motion (ROM) exercise every 4 hours.
68. Massage the abdomen once a shift.
69. Use an alternating air pressure mattress.
70. Elevate the lower extremities.

Answer 66

66. 3. Edematous tissue is easily traumatized and must receive meticulous care. An alternating air
       pressure mattress will help decrease pressure on the edematous tissue. ROM exercises are important
       to maintain joint function, but they do not necessarily prevent skin breakdown. When abdominal skin
       is stretched taut due to ascites, it must be cleaned very carefully. The abdomen should not be
       massaged. Elevation of the lower extremities promotes venous return and decreases swelling.
       CN: Reduction of risk potential; CL: Synthesize

Question 67

Managing Care Quality and Safety
67. The nurse is planning a staff development program on how to care for clients with hepatitis
A. Which of the following precautions should the nurse indicate as essential when caring for clients
with hepatitis A?
1. Gowning when entering a client’s room.
2. Wearing a mask when providing care.
3. Assigning the client to a private room.
4. Wearing gloves when giving direct care.

Answer 67

Managing Care Quality and Safety
67. 4. Contact precautions are recommended for clients with hepatitis A. This includes wearing
gloves for direct care. A gown is not required unless substantial contact with the client is anticipated.
It is not necessary to wear a mask. The client does not need a private room unless incontinent of stool.
CN: Safety and infection control; CL: Create

Question 68

68. After completing assessment rounds, which of the following should the nurse discuss with the
    physician first?
69. A client with cirrhosis who is depressed and has refused to eat for the past 2 days.
70. A client with stable vital signs that has been receiving IV cipro following a cholecystectomy
    for 1 day and has developed a rash on the chest and arms.
71. A client with pancreatitis whose family requests to speak with the physician regarding the
    treatment plan.
72. A client with hepatitis whose pulse was 84 and regular and is now 118 and irregular.

Answer 68

68. 4. A change in a client’s baseline vital signs should be brought to the physician’s attention
       immediately. In this case, the client’s heart rate has increased and the rhythm appears to have changed;
       the physician may prescribe an ECG to determine if treatment is necessary. The nurse should also
       have a complete set of current vital signs as well as a physical assessment before providing the
       physician information using the SBAR format. The nutritional as well as psychological needs of a
       client must be addressed but are not first priority. A rash that develops after a new antibiotic is
       started must be brought to the physician’s attention; however, this client is stable and is not the first
       priority. The nurse is responsible to facilitate discussion between the client, the client’s family, and
       the physician but only after all of the immediate physical and psychological needs of all clients have
       been met.
       CN: Reduction of risk potential; CL: Synthesize

Question 69

69. The nurse’s assignment consists of the following four clients. From highest to lowest priority,
    in which order should the nurse assess the clients after receiving morning report?
70. The client with cirrhosis who became confused and disoriented during the night.
71. The client who is 1 day postoperative following a cholecystectomy and has a t-tube inserted.
72. The client with acute pancreatitis who is requesting pain medication.
73. The client with hepatitis B who has questions about discharge instructions.

Answer 69

69.
1. The client with cirrhosis who became confused and disoriented during the night.3. The client with acute pancreatitis who is requesting pain medication.
2. The client who is 1 day postoperative following a cholecystectomy and has a t-tube inserted.
4. The client with hepatitis B who has questions about discharge instructions.
The nurse should first assess the client with cirrhosis to ensure the client’s safety and assess the
client for the onset of hepatic encephalopathy. The nurse should then assess the client with acute
pancreatitis who is requesting pain medication and administer the needed medication. The nurse
should next assess the client who underwent a cholecystectomy and is 1 day postoperative to make
sure that the t-tube is draining and that the client is performing postoperative breathing exercises. This
client’s safety is not at risk and the client is not reporting having pain. The nurse can speak last with
the client with hepatitis B who has questions about discharge instructions because this client’s issues
are not urgent.
CN: Management of care; CL: Synthesize

Question 70

70. The nurse should institute which of the following measures to prevent transmission of the
    hepatitis C virus to health care personnel?
71. Administering hepatitis C vaccine to all health care personnel.
72. Decreasing contact with blood and blood-contaminated fluids.
73. Wearing gloves when emptying the bedpan.
74. Wearing a gown and mask when providing direct care.

Answer 70

70. 2. Hepatitis C is usually transmitted through blood exposure or needlesticks. A hepatitis C
       vaccine is currently under development, but it is not available for use. The first line of defense
       against hepatitis B is the hepatitis B vaccine. Hepatitis C is not transmitted through feces or urine.
       Wearing a gown and mask will not prevent transmission of the hepatitis C virus if the caregiver
       comes in contact with infected blood or needles.
       CN: Safety and infection control; CL: Apply

Question 71

71. The nurse is taking care of a client who has an IV infusion pump. The pump alarm rings. Whatshould the nurse do in order from first to last?
72. Silence the pump alarm.
73. Determine if the infusion pump is plugged into an electrical outlet.
74. Assess the client’s access site for infiltration or inflammation.
75. Assess the tubing for hindrances to flow of solution.

Answer 71

71.
1. Silence the pump alarm.
3. Assess the client’s access site for infiltration or inflammation.
4. Assess the tubing for hindrances to flow of solution.
2. Determine if the infusion pump is plugged into an electrical outlet.
Silencing the alarm will eliminate a stress to the client and allow the nurse to focus on the task at
hand. The nurse should then assess the access site to note if the needle is inserted in the vein or if
there is tissue trauma, infiltration, or inflammation. Next, the nurse should check for kinks in the
tubing. Finally, the nurse can plug the pump into the wall to allow the battery to become recharged.
CN: Pharmacological and parenteral therapies; CL: Synthesize