Hepaitits & Cirrhosis Saunder's Q&A

Hepaitits & Cirrhosis Saunder's Q&A Leave the first rating Students also studied Terms in this set (5) Science MedicineNursing Save Saunders NCLEX Questions-Gastroi...78 terms kirstin_whitcomb Preview Exam 4- Cirrhosis NCLEX Teacher 26 terms RegisteredNurse22 Preview 75 Free NCLEX Questions - c/o Brilli...75 terms carey47Preview NCLEX 13 terms wha A client admitted to the hospital with a diagnosis of cirrhosis demonstrates massive ascites causing dyspnea.The nurse performs which intervention as a priority measure to assist the client with this complication?

• Repositions side to side every 2 hours
• Elevates the head of the bed 60 degrees
• Auscultates the lung fields every 4 hours
• Encourages deep breathing exercises every 2 hours
• Elevates the head of the bed 60 degrees

Rationale: The client is having difficulty breathing because of upward pressure on the diaphragm from the ascitic fluid in the abdomen. Elevating the head of the bed enlists the aid of gravity in relieving pressure on the diaphragm. Although assessment is the first step of the nursing process, the stem of the question identifies the assessment findings ascites and difficulty breathing, so the best answer is to intervene based on the assessment data, by elevating the head of the bed to make the client's breathing easier. The other options are general measures in the care of a client with ascites, but the priority measure is the one that relieves diaphragmatic pressure thus assisting effective respirations.The nurse is assigned to care for a client being admitted with a diagnosis of cirrhosis and ascites. Which dietary measure would the nurse expect to be prescribed for the client?

• Sodium restriction
• Increased fat intake
• Decreased carbohydrates
• Calorie restriction of 1500 daily
• Sodium restriction

Rationale: If the client has ascites, sodium and possibly fluids would be restricted in the diet. The client should maintain a normal amount of fat intake. The diet should supply sufficient carbohydrates to maintain weight and spare protein. The total daily calories should range between 2000 and 3000. The diet should provide ample protein to rebuild tissue but not an amount that will precipitate hepatic encephalopathy.

A client diagnosed with cirrhosis of the liver is receiving oral triamterene daily. Which sign/symptom would indicate to the nurse that the client is experiencing an adverse effect of the medication?

• Dry skin
• Excitability
• Constipation
• Hyperkalemia
• Hyperkalemia

Rationale: Triamterene is a potassium-sparing diuretic. Adverse effects include

hyperkalemia, dehydration, hyponatremia, and lethargy. Although the concern with most diuretics is hypokalemia, this is a potassium-sparing medication, which means that the concern with the administration of this medication is hyperkalemia.Other effects include nausea, vomiting, cramping, diarrhea, headache, ataxia, drowsiness, confusion, and fever.An assessment of a client has confirmed the presences of ascites and slight jaundice and cirrhosis is suspected. The nurse would assess for the chronic use of which medication to suggest a cause for these assessment findings?

• Cimetidine
• Acetaminophen
• Docusate sodium
• Acetylsalicylic acid
• Acetaminophen

Rationale: Acetaminophen is an analgesic and a potentially hepatotoxic

medication. Use of this medication and other hepatotoxic agents should be investigated whenever a client presents with symptoms compatible with liver disease (such as ascites and jaundice). Hepatotoxicity is not an adverse effect of the medications identified in the other options.The nurse preparing to administer medications to a client diagnosed with hepatic encephalopathy expects to note which medication prescription?

• Docusate
• Lactulose syrup
• Magnesium hydroxide
• Psyllium hydrophilic mucilloid
• Lactulose syrup

Rationale: Lactulose syrup is a hyperosmotic laxative agent that has the adjunct benefit of lowering serum ammonia levels. This occurs because the medication lowers bowel pH, which aids in the conversion of ammonia in the gut to the ammonium ion, which is poorly absorbed. Docusate is a stool softener.Magnesium hydroxide is a saline laxative. Psyllium hydrophilic mucilloid is a bulk laxative.