Liver/Biliary NCLEX Questions

Liver/Biliary NCLEX Questions Leave the first rating Students also studied Terms in this set (26) Science MedicineNursing Save GI NCLEX Questions/Answers 26 terms wendilynhawk Preview Exam 4- Cirrhosis NCLEX Teacher 26 terms RegisteredNurse22 Preview

NCLEX Practice Questions: Liver, Bili...

20 terms JLT84Preview Hepatic 113 terms A_N The patient had a liver biopsy one hour ago. The nurse

should first:

• Auscultate lung sounds
• Check for fever
• Obtain a CBC
• Apply packing to the biopsy site
• Auscultate lung sounds

A client with cirrhosis is receiving lactulose. The nurse notes the client is more confused and has asterixis. The

nurse should:

• Assess for gastrointestinal (GI) bleeding
• Withhold the lactulose
• Increase protein in the diet
• Monitor serum bilirubin levels
• Assess for gastrointestinal (GI) bleeding

The nurse is assessing a client with cirrhosis who has developed hepatic encephalopathy. The nurse should notify the healthcare provider (HCP) of a decrease in which serum lab value that is a potential precipitating factor for hepatic encephalopathy?

• Aldosterone
• Creatinine
• Potassium
• Protein
• Potassium

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?

• "He must have eaten too many foods with salt in them.

Salt pulls water with it."

• "The swelling in his ankles must have moved up closer

to his heart so the fluid circulates better."

• "He must have forgotten to take his daily water pill."
• "Blood is not able to flow readily through the liver now,

and the liver cannot make protein to keep fluid inside the blood vessels."

• "Blood is not able to flow readily through the liver now, and the liver cannot

make protein to keep fluid inside the blood vessels." A nurse is developing a care plan for a client with hepatic encephalopathy. Which are goals for the care for this client?(Select all that apply)

• Prevent constipation
• Administer lactulose to reduce blood ammonia levels
• Monitor coordination when walking
• Check the pupil reaction
• Provide food and fluids high in carbohydrate
• Encourage physical activity
• Prevent constipation
• Administer lactulose to reduce blood ammonia levels
• Monitor coordination when walking
• Check the pupil reaction
• Provide food and fluids high in carbohydrate

The nurse is assessing a client who is in the early stages of cirrhosis of the liver. Which focused assessment is appropriate?

• Peripheral edema
• Ascites
• Anorexia
• Jaundice
• Anorexia

A client with cirrhosis begins to develop ascites.Spironolactone is prescribed to treat the ascites. The nurse should monitor the client closely for which drug related adverse effect?

• Constipation
• Hyperkalemia
• Irregular pulse
• Dysuria
• Hyperkalemia

What diet should be implemented for a client who is in the early stages of cirrhosis?

• High-calorie, high- CHO
• Low-protein, low-CHO
• Low-fat, low-protein
• High-CHO, low-sodium
• High-calorie, high- CHO

A client with jaundice has pruritus and areas of irritation from scratching. What measures can the nurse suggest the client use to prevent skin breakdown.(Select all that apply)

• Avoid lotions containing calamine
• Add baking soda to the water in a tub bath
• Keep nails short and clean
• Rub the skin when it itches with knuckles instead of

nails

• Massage skin with alcohol
• Increase sodium intake in the diet
• Add baking soda to the water in a tub bath
• Keep nails short and clean
• Rub the skin when it itches with knuckles instead of nails

Which health promotion activity should the nurse suggest that the client with cirrhosis add to the daily routine at home?

• Supplement the diet with daily multivitamins
• Abstain from drinking alcohol
• Take a sleeping pill at bedtime
• Limit contact with other people whenever possible
• Abstain from drinking alcohol

The nurse is reviewing the chart information for a client

with increased ascites. The data include the following:

• temperature 98.9F (37.2C)
• heart rate 118, shallow respirations 26/min
• BP 128/76 mmHg
• SpO2 89% on room air

The nurse should first:

• Assess heart sounds
• Obtain a prescription for blood cultures
• Prepare for a paracentesis
• Raise the bed of the bed
• Raise the bed of the bed

The nurse is caring for a client with esophageal varices.The nurse should discuss which laboratory finding with the HCP?

• Normal serum albumin
• Decreased ammonia
• Slightly decreased levels of calcium
• Elevated PT/INR
• Elevated PT/INR

A client with cirrhosis who has ascites receives 100ml of 25% serum albumin IV. Which finding would best indicate that the albumin is having its desired effect?

• Reduced ascites
• Increased serum albumin level
• Decreased anorexia
• Increased ease of breathing
• Reduced ascites

A client with an esophagogastric tamponade tube has a sudden drop in SpO2 and an increase in respiratory rate to 40 breaths/min. What should the nurse do in order form first to last?(All options must be used)

• Affirm airway obstruction by the tube
• Remove the tube
• Apply oxygen by face mask
• Deflate the tube by cutting with bedside scissors
• Affirm airway obstruction by the tube
• Deflate the tube by cutting with bedside scissors
• Remove the tube
• Apply oxygen by face mask

The nurse monitors a client with cirrhosis for the development of hepatic encephalopathy. Which would be an indication that hepatic encephalopathy is developing?

• Decreased mental status
• Elevated blood pressure
• Decreased urine output
• Labored respirations
• Decreased mental status

A client's serum ammonia level is elevated and the HCP prescribes 30ml of lactulose. Which effect is common for this drug?

• Increased urine output
• Improved level of consciousness
• Increased bowel movements
• Nausea and vomiting
• Increased bowel movements

The nurse has an order to administer 1.5 ounces of lactulose to a client that has cirrhosis. How many milliliters of lactulose should the nurse administer?(Record your answer using a whole number) 45mLs