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)
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)
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
Test Bank - Lewis's Medical Surgical Nursing (11th Edition by Harding)
535
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)
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)
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)
Test Bank - Lewis's Medical Surgical Nursing (11th Edition by Harding)
536
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)
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)
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?
Test Bank - Lewis's Medical Surgical Nursing (11th Edition by Harding)
537
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)
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)
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.
Test Bank - Lewis's Medical Surgical Nursing (11th Edition by Harding)
538
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)
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)
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
Test Bank - Lewis's Medical Surgical Nursing (11th Edition by Harding)
539
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)
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)
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)
Test Bank - Lewis's Medical Surgical Nursing (11th Edition by Harding)
540
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 (PEGIntron, 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)
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)
OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
MULTIPLE RESPONSE
Test Bank - Lewis's Medical Surgical Nursing (11th Edition by Harding)
541
1.
After an unimmunized individual is exposed to hepatitis B through a needlestick 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 hepatis
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)
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)
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
Test Bank - Lewis's Medical Surgical Nursing (11th Edition by Harding)
535
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)
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)
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)
Test Bank - Lewis's Medical Surgical Nursing (11th Edition by Harding)
536
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)
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)
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?
Test Bank - Lewis's Medical Surgical Nursing (11th Edition by Harding)
537
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)
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)
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.
Test Bank - Lewis's Medical Surgical Nursing (11th Edition by Harding)
538
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)
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)
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
Test Bank - Lewis's Medical Surgical Nursing (11th Edition by Harding)
539
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)
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)
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)
Test Bank - Lewis's Medical Surgical Nursing (11th Edition by Harding)
540
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 (PEGIntron, 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)
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)
OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
MULTIPLE RESPONSE
Test Bank - Lewis's Medical Surgical Nursing (11th Edition by Harding)
541
1.
After an unimmunized individual is exposed to hepatitis B through a needle-stick injury, which actions will
the nurse plan to take (
s