Chapter 44: Nursing Management: Liver, Pancreas, and Biliary Tract Problems Nursing School Test Banks

Chapter 44: Nursing Management: Liver, Pancreas, and Biliary Tract Problems

Test Bank

MULTIPLE CHOICE

1. A 24-year-old female contracts hepatitis from contaminated food. During the acute (icteric) phase of the patients illness, the nurse would expect serologic testing to reveal

a.

antibody to hepatitis D (anti-HDV).

b.

hepatitis B surface antigen (HBsAg).

c.

anti-hepatitis A virus immunoglobulin G (anti-HAV IgG).

d.

anti-hepatitis A virus immunoglobulin M (anti-HAV IgM).

ANS: D

Hepatitis A is transmitted through the oral-fecal route, and antibody to HAV IgM appears during the acute phase of hepatitis A. The patient would not have antigen for hepatitis B or antibody for hepatitis D. Anti-HAV IgG would indicate past infection and lifelong immunity.

DIF: Cognitive Level: Apply (application) REF: 1007

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

2. Administration of hepatitis B vaccine to a healthy 18-year-old patient has been effective when a specimen of the patients blood reveals

a.

HBsAg.

b.

anti-HBs.

c.

anti-HBc IgG.

d.

anti-HBc IgM.

ANS: B

The presence of surface antibody to HBV (anti-HBs) is a marker of a positive response to the vaccine. The other laboratory values indicate current infection with HBV.

DIF: Cognitive Level: Analyze (analysis) REF: 1008

TOP: Nursing Process: Evaluation MSC: NCLEX: Health Promotion and Maintenance

3. A 36-year-old male patient in the outpatient clinic is diagnosed with acute hepatitis C (HCV) infection. Which action by the nurse is appropriate?

a.

Schedule the patient for HCV genotype testing.

b.

Administer the HCV vaccine and immune globulin.

c.

Teach the patient about ribavirin (Rebetol) treatment.

d.

Explain that the infection will resolve over a few months.

ANS: A

Genotyping of HCV has an important role in managing treatment and is done before drug therapy is initiated. Because most patients with acute HCV infection convert to the chronic state, the nurse should not teach the patient that the HCV will resolve in a few months. Immune globulin or vaccine is not available for HCV. Ribavirin is used for chronic HCV infection.

DIF: Cognitive Level: Apply (application) REF: 1010

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

4. The nurse will plan to teach the patient diagnosed with acute hepatitis B about

a.

side effects of nucleotide analogs.

b.

measures for improving the appetite.

c.

ways to increase activity and exercise.

d.

administering a-interferon (Intron A).

ANS: B

Maintaining adequate nutritional intake is important for regeneration of hepatocytes. Interferon and antivirals may be used for chronic hepatitis B, but they are not prescribed for acute hepatitis B infection. Rest is recommended.

DIF: Cognitive Level: Apply (application) REF: 1015

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

5. The nurse administering a-interferon and ribavirin (Rebetol) to a patient with chronic hepatitis C will plan to monitor for

a.

leukopenia.

b.

hypokalemia.

c.

polycythemia.

d.

hypoglycemia.

ANS: A

Therapy with ribavirin and a-interferon may cause leukopenia. The other problems are not associated with this drug therapy.

DIF: Cognitive Level: Apply (application) REF: 1013

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

6. Which information given by a 70-year-old patient during a health history indicates to the nurse that the patient should be screened for hepatitis C?

a.

The patient had a blood transfusion in 2005.

b.

The patient used IV drugs about 20 years ago.

c.

The patient frequently eats in fast-food restaurants.

d.

The patient traveled to a country with poor sanitation.

ANS: B

Any patient with a history of IV drug use should be tested for hepatitis C. Blood transfusions given after 1992 (when an antibody test for hepatitis C became available) do not pose a risk for hepatitis C. Hepatitis C is not spread by the oral-fecal route and therefore is not caused by contaminated food or by traveling in underdeveloped countries.

DIF: Cognitive Level: Apply (application) REF: 1009

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance

7. A 55-year-old patient admitted with an abrupt onset of jaundice and nausea has abnormal liver function studies but serologic testing is negative for viral causes of hepatitis. Which question by the nurse is most appropriate?

a.

Is there any history of IV drug use?

b.

Do you use any over-the-counter drugs?

c.

Are you taking corticosteroids for any reason?

d.

Have you recently traveled to a foreign country?

ANS: B

The patients symptoms, lack of antibodies for hepatitis, and the abrupt onset of symptoms suggest toxic hepatitis, which can be caused by commonly used over-the-counter drugs such as acetaminophen (Tylenol). Travel to a foreign country and a history of IV drug use are risk factors for viral hepatitis. Corticosteroid use does not cause the symptoms listed.

DIF: Cognitive Level: Apply (application) REF: 1027

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

8. Which data will the nurse monitor in relation to the 4+ pitting edema assessed in a patient with cirrhosis?

a.

Hemoglobin

b.

Temperature

c.

Activity level

d.

Albumin level

ANS: D

The low oncotic pressure caused by hypoalbuminemia is a major pathophysiologic factor in the development of edema. The other parameters should also be monitored, but they are not directly associated with the patients current symptoms.

DIF: Cognitive Level: Apply (application) REF: 1019

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

9. Which topic is most important to include in patient teaching for a 41-year-old patient diagnosed with early alcoholic cirrhosis?

a.

Maintaining good nutrition

b.

Avoiding alcohol ingestion

c.

Taking lactulose (Cephulac)

d.

Using vitamin B supplements

ANS: B

The disease progression can be stopped or reversed by alcohol abstinence. The other interventions may be used when cirrhosis becomes more severe to decrease symptoms or complications, but the priority for this patient is to stop the progression of the disease.

DIF: Cognitive Level: Apply (application) REF: 1015-1016

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

10. A serum potassium level of 3.2 mEq/L (3.2 mmol/L) is reported for a patient with cirrhosis who has scheduled doses of spironolactone (Aldactone) and furosemide (Lasix). due. Which action should the nurse take?

a.

Administer both drugs.

b.

Administer the spironolactone.

c.

Withhold the spironolactone and administer the furosemide.

d.

Withhold both drugs until discussed with the health care provider.

ANS: B

Spironolactone is a potassium-sparing diuretic and will help increase the patients potassium level. The nurse does not need to talk with the doctor before giving the spironolactone, although the health care provider should be notified about the low potassium value. The furosemide will further decrease the patients potassium level and should be held until the nurse talks with the health care provider.

DIF: Cognitive Level: Apply (application) REF: 1022

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

11. Which action should the nurse take to evaluate treatment effectiveness for a patient who has hepatic encephalopathy?

a.

Request that the patient stand on one foot.

b.

Ask the patient to extend both arms forward.

c.

Request that the patient walk with eyes closed.

d.

Ask the patient to perform the Valsalva maneuver.

ANS: B

Extending the arms allows the nurse to check for asterixis, a classic sign of hepatic encephalopathy. The other tests might also be done as part of the neurologic assessment but would not be diagnostic for hepatic encephalopathy.

DIF: Cognitive Level: Apply (application) REF: 1021

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

12. Which finding indicates to the nurse that lactulose (Cephulac) is effective for a 72-year-old man who has advanced cirrhosis?

a.

The patient is alert and oriented.

b.

The patient denies nausea or anorexia.

c.

The patients bilirubin level decreases.

d.

The patient has at least one stool daily.

ANS: A

The purpose of lactulose in the patient with cirrhosis is to lower ammonia levels and prevent encephalopathy. Although lactulose may be used to treat constipation, that is not the purpose for this patient. Lactulose will not decrease nausea and vomiting or lower bilirubin levels.

DIF: Cognitive Level: Apply (application) REF: 1023

TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

13. A 53-year-old patient is being treated for bleeding esophageal varices with balloon tamponade. Which nursing action will be included in the plan of care?

a.

Instruct the patient to cough every hour.

b.

Monitor the patient for shortness of breath.

c.

Verify the position of the balloon every 4 hours.

d.

Deflate the gastric balloon if the patient reports nausea.

ANS: B

The most common complication of balloon tamponade is aspiration pneumonia. In addition, if the gastric balloon ruptures, the esophageal balloon may slip upward and occlude the airway. Coughing increases the pressure on the varices and increases the risk for bleeding. Balloon position is verified after insertion and does not require further verification. The esophageal balloon is deflated every 8 to 12 hours to avoid necrosis, but if the gastric balloon is deflated, the esophageal balloon may occlude the airway.

DIF: Cognitive Level: Apply (application) REF: 1025-1026

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

14. To detect possible complications in a patient with severe cirrhosis who has bleeding esophageal varices, it is most important for the nurse to monitor

a.

bilirubin levels.

b.

ammonia levels.

c.

potassium levels.

d.

prothrombin time.

ANS: B

The protein in the blood in the gastrointestinal (GI) tract will be absorbed and may result in an increase in the ammonia level because the liver cannot metabolize protein very well. The prothrombin time, bilirubin, and potassium levels should also be monitored, but they will not be affected by the bleeding episode.

DIF: Cognitive Level: Apply (application) REF: 1021

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

15. A 38-year-old patient with cirrhosis has ascites and 4+ edema of the feet and legs. Which nursing action will be included in the plan of care?

a.

Restrict daily dietary protein intake.

b.

Reposition the patient every 4 hours.

c.

Place the patient on a pressure-relieving mattress.

d.

Perform passive range of motion daily.

ANS: C

The pressure-relieving mattress will decrease the risk for skin breakdown for this patient. Adequate dietary protein intake is necessary in patients with ascites to improve oncotic pressure. Repositioning the patient every 4 hours will not be adequate to maintain skin integrity. Passive range of motion will not take the pressure off areas such as the sacrum that are vulnerable to breakdown.

DIF: Cognitive Level: Apply (application) REF: 1025

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

16. Which finding indicates to the nurse that a patients transjugular intrahepatic portosystemic shunt (TIPS) placed 3 months ago has been effective?

a.

Increased serum albumin level

b.

Decreased indirect bilirubin level

c.

Improved alertness and orientation

d.

Fewer episodes of bleeding varices

ANS: D

TIPS is used to lower pressure in the portal venous system and decrease the risk of bleeding from esophageal varices. Indirect bilirubin level and serum albumin levels are not affected by shunting procedures. TIPS will increase the risk for hepatic encephalopathy.

DIF: Cognitive Level: Apply (application) REF: 1022-1023

TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

17. To prepare a 56-year-old male patient with ascites for paracentesis, the nurse

a.

places the patient on NPO status.

b.

assists the patient to lie flat in bed.

c.

asks the patient to empty the bladder.

d.

positions the patient on the right side.

ANS: C

The patient should empty the bladder to decrease the risk of bladder perforation during the procedure. The patient would be positioned in Fowlers position and would not be able to lie flat without compromising breathing. Because no sedation is required for paracentesis, the patient does not need to be NPO.

DIF: Cognitive Level: Apply (application) REF: 1025

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

18. Which finding is most important for the nurse to communicate to the health care provider about a patient who received a liver transplant 1 week ago?

a.

Dry palpebral and oral mucosa

b.

Crackles at bilateral lung bases

c.

Temperature 100.8 F (38.2 C)

d.

No bowel movement for 4 days

ANS: C

The risk of infection is high in the first few months after liver transplant and fever is frequently the only sign of infection. The other patient data indicate the need for further assessment or nursing actions and might be communicated to the health care provider, but they do not indicate a need for urgent action.

DIF: Cognitive Level: Apply (application) REF: 1029

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

19. Which laboratory test result will the nurse monitor when evaluating the effects of therapy for a 62-year-old female patient who has acute pancreatitis?

a.

Calcium

b.

Bilirubin

c.

Amylase

d.

Potassium

ANS: C

Amylase is elevated in acute pancreatitis. Although changes in the other values may occur, they would not be useful in evaluating whether the prescribed therapies have been effective.

DIF: Cognitive Level: Apply (application) REF: 1031

TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

20. Which assessment finding would the nurse need to report most quickly to the health care provider regarding a patient with acute pancreatitis?

a.

Nausea and vomiting

b.

Hypotonic bowel sounds

c.

Abdominal tenderness and guarding

d.

Muscle twitching and finger numbness

ANS: D

Muscle twitching and finger numbness indicate hypocalcemia, which may lead to tetany unless calcium gluconate is administered. Although the other findings should also be reported to the health care provider, they do not indicate complications that require rapid action.

DIF: Cognitive Level: Apply (application) REF: 1033

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

21. The nurse will ask a 64-year-old patient being admitted with acute pancreatitis specifically about a history of

a.

diabetes mellitus.

b.

high-protein diet.

c.

cigarette smoking.

d.

alcohol consumption.

ANS: D

Alcohol use is one of the most common risk factors for pancreatitis in the United States. Cigarette smoking, diabetes, and high-protein diets are not risk factors.

DIF: Cognitive Level: Understand (comprehension) REF: 1030

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

22. The nurse will teach a patient with chronic pancreatitis to take the prescribed pancrelipase (Viokase)

a.

at bedtime.

b.

in the morning.

c.

with each meal.

d.

for abdominal pain.

ANS: C

Pancreatic enzymes are used to help with digestion of nutrients and should be taken with every meal.

DIF: Cognitive Level: Apply (application) REF: 1032

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

23. The nurse recognizes that teaching a 44-year-old woman following a laparoscopic cholecystectomy has been effective when the patient states which of the following?

a.

I can expect yellow-green drainage from the incision for a few days.

b.

I can remove the bandages on my incisions tomorrow and take a shower.

c.

I should plan to limit my activities and not return to work for 4 to 6 weeks.

d.

I will always need to maintain a low-fat diet since I no longer have a gallbladder.

ANS: B

After a laparoscopic cholecystectomy, the patient will have Band-Aids in place over the incisions. Patients are discharged the same (or next) day and have few restrictions on activities of daily living. Drainage from the incisions would be abnormal, and the patient should be instructed to call the health care provider if this occurs. A low-fat diet may be recommended for a few weeks after surgery but will not be a life-long requirement.

DIF: Cognitive Level: Apply (application) REF: 1041

TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

24. The nurse is caring for a 73-year-old man who has cirrhosis. Which data obtained by the nurse during the assessment will be of most concern?

a.

The patient complains of right upper-quadrant pain with palpation.

b.

The patients hands flap back and forth when the arms are extended.

c.

The patient has ascites and a 2-kg weight gain from the previous day.

d.

The patients skin has multiple spider-shaped blood vessels on the abdomen.

ANS: B

Asterixis indicates that the patient has hepatic encephalopathy, and hepatic coma may occur. The spider angiomas and right upper quadrant abdominal pain are not unusual for the patient with cirrhosis and do not require a change in treatment. The ascites and weight gain indicate the need for treatment but not as urgently as the changes in neurologic status.

DIF: Cognitive Level: Apply (application) REF: 1021

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

25. A 49-year-old female patient with cirrhosis and esophageal varices has a new prescription for propranolol (Inderal). Which finding is the best indicator that the medication has been effective?

a.

The patient reports no chest pain.

b.

Blood pressure is 140/90 mm Hg.

c.

Stools test negative for occult blood.

d.

The apical pulse rate is 68 beats/minute.

ANS: C

Because the purpose of b-blocker therapy for patients with esophageal varices is to decrease the risk for bleeding from esophageal varices, the best indicator of the effectiveness for propranolol is the lack of blood in the stools. Although propranolol is used to treat hypertension, angina, and tachycardia, the purpose for use in this patient is to decrease the risk for bleeding from esophageal varices.

DIF: Cognitive Level: Apply (application) REF: 1022

TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

26. Which response by the nurse best explains the purpose of ranitidine (Zantac) for a patient admitted with bleeding esophageal varices?

a.

The medication will reduce the risk for aspiration.

b.

The medication will inhibit development of gastric ulcers.

c.

The medication will prevent irritation of the enlarged veins.

d.

The medication will decrease nausea and improve the appetite.

ANS: C

Esophageal varices are dilated submucosal veins. The therapeutic action of H2-receptor blockers in patients with esophageal varices is to prevent irritation and bleeding from the varices caused by reflux of acid gastric contents. Although ranitidine does decrease the risk for peptic ulcers, reduce nausea, and help prevent aspiration pneumonia, these are not the primary purposes for H2-receptor blockade in this patient.

DIF: Cognitive Level: Apply (application) REF: 1019

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

27. When taking the blood pressure (BP) on the right arm of a patient with severe acute pancreatitis, the nurse notices carpal spasms of the patients right hand. Which action should the nurse take next?

a.

Ask the patient about any arm pain.

b.

Retake the patients blood pressure.

c.

Check the calcium level in the chart.

d.

Notify the health care provider immediately.

ANS: C

The patient with acute pancreatitis is at risk for hypocalcemia, and the assessment data indicate a positive Trousseaus sign. The health care provider should be notified after the nurse checks the patients calcium level. There is no indication that the patient needs to have the BP rechecked or that there is any arm pain.

DIF: Cognitive Level: Apply (application) REF: 1033

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

28. A 67-year-old male patient with acute pancreatitis has a nasogastric (NG) tube to suction and is NPO. Which information obtained by the nurse indicates that these therapies have been effective?

a.

Bowel sounds are present.

b.

Grey Turner sign resolves.

c.

Electrolyte levels are normal.

d.

Abdominal pain is decreased.

ANS: D

NG suction and NPO status will decrease the release of pancreatic enzymes into the pancreas and decrease pain. Although bowel sounds may be hypotonic with acute pancreatitis, the presence of bowel sounds does not indicate that treatment with NG suction and NPO status has been effective. Electrolyte levels may be abnormal with NG suction and must be replaced by appropriate IV infusion. Although Grey Turner sign will eventually resolve, it would not be appropriate to wait for this to occur to determine whether treatment was effective.

DIF: Cognitive Level: Apply (application) REF: 1032

TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

29. Which assessment finding is of most concern for a 46-year-old woman with acute pancreatitis?

a.

Absent bowel sounds

b.

Abdominal tenderness

c.

Left upper quadrant pain

d.

Palpable abdominal mass

ANS: D

A palpable abdominal mass may indicate the presence of a pancreatic abscess, which will require rapid surgical drainage to prevent sepsis. Absent bowel sounds, abdominal tenderness, and left upper quadrant pain are common in acute pancreatitis and do not require rapid action to prevent further complications.

DIF: Cognitive Level: Apply (application) REF: 1031

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

30. Which action will be included in the care for a patient who has recently been diagnosed with asymptomatic nonalcoholic fatty liver disease (NAFLD)?

a.

Teach symptoms of variceal bleeding.

b.

Draw blood for hepatitis serology testing.

c.

Discuss the need to increase caloric intake.

d.

Review the patients current medication list.

ANS: D

Some medications can increase the risk for NAFLD, and they should be eliminated. NAFLD is not associated with hepatitis, weight loss is usually indicated, and variceal bleeding would not be a concern in a patient with asymptomatic NAFLD.

DIF: Cognitive Level: Apply (application) REF: 1016-1017

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

31. A 34-year old patient with chronic hepatitis C infection has several medications prescribed. Which medication requires further discussion with the health care provider before administration?

a.

Ribavirin (Rebetol, Copegus) 600 mg PO bid

b.

Pegylated a-interferon (PEG-Intron, Pegasys) SQ daily

c.

Diphenhydramine (Benadryl) 25 mg PO every 4 hours PRN itching

d.

Dimenhydrinate (Dramamine) 50 mg PO every 6 hours PRN nausea

ANS: B

Pegylated a-interferon is administered weekly. The other medications are appropriate for a patient with chronic hepatitis C infection.

DIF: Cognitive Level: Apply (application) REF: 1013

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

32. During change-of-shift report, the nurse learns about the following four patients. Which patient requires assessment first?

a.

40-year-old with chronic pancreatitis who has gnawing abdominal pain

b.

58-year-old who has compensated cirrhosis and is complaining of anorexia

c.

55-year-old with cirrhosis and ascites who has an oral temperature of 102 F (38.8 C)

d.

36-year-old recovering from a laparoscopic cholecystectomy who has severe shoulder pain

ANS: C

This patients history and fever suggest possible spontaneous bacterial peritonitis, which would require rapid assessment and interventions such as antibiotic therapy. The clinical manifestations for the other patients are consistent with their diagnoses and do not indicate complications are occurring.

DIF: Cognitive Level: Analyze (analysis) REF: 1021

OBJ: Special Questions: Multiple Patients

TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment

33. Which goal has the highest priority in the plan of care for a 26-year-old homeless patient admitted with viral hepatitis who has severe anorexia and fatigue?

a.

Increase activity level.

b.

Maintain adequate nutrition.

c.

Establish a stable environment.

d.

Identify sources of hepatitis exposure.

ANS: B

The highest priority outcome is to maintain nutrition because adequate nutrition is needed for hepatocyte regeneration. Finding a home for the patient and identifying the source of the infection would be appropriate activities, but they do not have as high a priority as ensuring adequate nutrition. Although the patients activity level will be gradually increased, rest is indicated during the acute phase of hepatitis.

DIF: Cognitive Level: Apply (application) REF: 1015

OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

34. Which action should the nurse in the emergency department take first for a new patient who is vomiting blood?

a.

Insert a large-gauge IV catheter.

b.

Draw blood for coagulation studies.

c.

Check blood pressure (BP), heart rate, and respirations.

d.

Place the patient in the supine position.

ANS: C

The nurses first action should be to determine the patients hemodynamic status by assessing vital signs. Drawing blood for coagulation studies and inserting an IV catheter are also appropriate. However, the vital signs may indicate the need for more urgent actions. Because aspiration is a concern for this patient, the nurse will need to assess the patients vital signs and neurologic status before placing the patient in a supine position.

DIF: Cognitive Level: Apply (application) REF: 1032-1033 | 1040

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

35. The nurse is planning care for a 48-year-old woman with acute severe pancreatitis. The highest priority patient outcome is

a.

maintaining normal respiratory function.

b.

expressing satisfaction with pain control.

c.

developing no ongoing pancreatic disease.

d.

having adequate fluid and electrolyte balance.

ANS: A

Respiratory failure can occur as a complication of acute pancreatitis, and maintenance of adequate respiratory function is the priority goal. The other outcomes would also be appropriate for the patient.

DIF: Cognitive Level: Apply (application) REF: 1031

OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

36. The nurse is caring for a 36-year-old patient with pancreatic cancer. Which nursing action is the highest priority?

a.

Offer psychologic support for depression.

b.

Offer high-calorie, high-protein dietary choices.

c.

Administer prescribed opioids to relieve pain as needed.

d.

Teach about the need to avoid scratching any pruritic areas.

ANS: C

Effective pain management will be necessary in order for the patient to improve nutrition, be receptive to teaching, or manage anxiety or depression.

DIF: Cognitive Level: Apply (application) REF: 1035-1036

OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

37. Which assessment information will be most important for the nurse to report to the health care provider about a patient with acute cholecystitis?

a.

The patients urine is bright yellow.

b.

The patients stools are tan colored.

c.

The patient has increased pain after eating.

d.

The patient complains of chronic heartburn.

ANS: B

Tan or grey stools indicate biliary obstruction, which requires rapid intervention to resolve. The other data are not unusual for a patient with this diagnosis, although the nurse would also report the other assessment information to the health care provider.

DIF: Cognitive Level: Apply (application) REF: 1037

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

38. A 51-year-old woman had an incisional cholecystectomy 6 hours ago. The nurse will place the highest priority on assisting the patient to

a.

choose low-fat foods from the menu.

b.

perform leg exercises hourly while awake.

c.

ambulate the evening of the operative day.

d.

turn, cough, and deep breathe every 2 hours.

ANS: D

Postoperative nursing care after a cholecystectomy focuses on prevention of respiratory complications because the surgical incision is high in the abdomen and impairs coughing and deep breathing. The other nursing actions are also important to implement but are not as high a priority as ensuring adequate ventilation.

DIF: Cognitive Level: Apply (application) REF: 1040

OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

39. For a patient with cirrhosis, which of the following nursing actions can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP)?

a.

Assessing the patient for jaundice

b.

Providing oral hygiene after a meal

c.

Palpating the abdomen for distention

d.

Assisting the patient to choose the diet

ANS: B

Providing oral hygiene is within the scope of UAP. Assessments and assisting patients to choose therapeutic diets are nursing actions that require higher-level nursing education and scope of practice and would be delegated to licensed practical/vocational nurses (LPNs/LVNs) or RNs.

DIF: Cognitive Level: Apply (application) REF: 15-16

OBJ: Special Questions: Delegation TOP: Nursing Process: Planning

MSC: NCLEX: Safe and Effective Care Environment

40. Which action will the nurse include in the plan of care for a patient who has been diagnosed with chronic hepatitis B?

a.

Advise limiting alcohol intake to 1 drink daily.

b.

Schedule for liver cancer screening every 6 months.

c.

Initiate administration of the hepatitis C vaccine series.

d.

Monitor anti-hepatitis B surface antigen (anti-HBs) levels annually.

ANS: B

Patients with chronic hepatitis are at higher risk for development of liver cancer, and should be screened for liver cancer every 6 to 12 months. Patients with chronic hepatitis are advised to completely avoid alcohol. There is no hepatitis C vaccine. Because anti-HBs is present whenever there has been a past hepatitis B infection or vaccination, there is no need to regularly monitor for this antibody.

DIF: Cognitive Level: Apply (application) REF: 1028

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

41. A patient born in 1955 had hepatitis A infection 1 year ago. According to Centers for Disease Control and Prevention (CDC) guidelines, which action should the nurse include in care when the patient is seen for a routine annual physical exam?

a.

Start the hepatitis B immunization series.

b.

Teach the patient about hepatitis A immune globulin.

c.

Ask whether the patient has been screened for hepatitis C.

d.

Test for anti-hepatitis-A virus immune globulin M (anti-HAV-IgM).

ANS: C

Current CDC guidelines indicate that all patients who were born between 1945 and 1965 should be screened for hepatitis C because many individuals who are positive have not been diagnosed. Although routine hepatitis B immunization is recommended for infants, children, and adolescents, vaccination for hepatitis B is recommended only for adults at risk for blood-borne infections. Because the patient has already had hepatitis A, immunization and anti-HAV IgM levels will not be needed.

DIF: Cognitive Level: Analyze (analysis) REF: 1015

TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance

42. A 23-year-old has been admitted with acute liver failure. Which assessment data are most important for the nurse to communicate to the health care provider?

a.

Asterixis and lethargy

b.

Jaundiced sclera and skin

c.

Elevated total bilirubin level

d.

Liver 3 cm below costal margin

ANS: A

The patients findings of asterixis and lethargy are consistent with grade 2 hepatic encephalopathy. Patients with acute liver failure can deteriorate rapidly from grade 1 or 2 to grade 3 or 4 hepatic encephalopathy and need early transfer to a transplant center. The other findings are typical of patients with hepatic failure and would be reported but would not indicate a need for an immediate change in the therapeutic plan.

DIF: Cognitive Level: Apply (application) REF: 1021

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

43. A 36-year-old female patient is receiving treatment for chronic hepatitis C with pegylated interferon (PEG-Intron, Pegasys), ribavirin (Rebetol), and telaprevir (Incivek). Which finding is most important to communicate to the health care provider?

a.

Weight loss of 2 lb (1 kg)

b.

Positive urine pregnancy test

c.

Hemoglobin level of 10.4 g/dL

d.

Complaints of nausea and anorexia

ANS: B

Because ribavirin is teratogenic, the medication will need to be discontinued immediately. Anemia, weight loss, and nausea are common adverse effects of the prescribed regimen and may require actions such as patient teaching, but they would not require immediate cessation of the therapy.

DIF: Cognitive Level: Apply (application) REF: 1013

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

44. A nurse is considering which patient to admit to the same room as a patient who had a liver transplant 3 weeks ago and is now hospitalized with acute rejection. Which patient would be the best choice?

a.

Patient who is receiving chemotherapy for liver cancer

b.

Patient who is receiving treatment for acute hepatitis C

c.

Patient who has a wound infection after cholecystectomy

d.

Patient who requires pain management for chronic pancreatitis

ANS: D

The patient with chronic pancreatitis does not present an infection risk to the immunosuppressed patient who had a liver transplant. The other patients either are at risk for infection or currently have an infection, which will place the immunosuppressed patient at risk for infection.

DIF: Cognitive Level: Analyze (analysis) REF: 1029

OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Planning

MSC: NCLEX: Safe and Effective Care Environment

45. In reviewing the medical record shown in the accompanying figure for a patient admitted with acute pancreatitis, the nurse sees that the patient has a positive Cullens sign. Indicate the area where the nurse will assess for this change.

a.

1

b.

2

c.

3

d.

4

ANS: C

The area around the umbilicus should be indicated. Cullens sign consists of ecchymosis around the umbilicus. Cullens sign occurs because of seepage of bloody exudates from the inflamed pancreas and indicates severe acute pancreatitis.

DIF: Cognitive Level: Understand (comprehension) REF: 1031

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

MULTIPLE RESPONSE

1. After an unimmunized individual is exposed to hepatitis B through a needle-stick injury, which actions will the nurse plan to take (select all that apply)?

a.

Administer hepatitis B vaccine.

b.

Test for antibodies to hepatitis B.

c.

Teach about a-interferon therapy.

d.

Give hepatitis B immune globulin.

e.

Teach about choices for oral antiviral therapy.

ANS: A, B, D

The recommendations for hepatitis B exposure include both vaccination and immune globulin administration. In addition, baseline testing for hepatitis B antibodies will be needed. Interferon and oral antivirals are not used for hepatitis B prophylaxis.

DIF: Cognitive Level: Apply (application) REF: 1014-1015

TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment

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