28. The client asks how he contracted hepatitis A. He
reports all of the following. Which one is most
likely related to hepatitis A?
2. He ate oysters his roommate brought home from
a fishing trip.
3. He stepped on a nail two weeks ago.
4. He donated blood two weeks before he got sick.
29. A client has had a liver biopsy. After the
procedure, the nurse should position him on his
right side with a pillow under his rib cage. What is
the primary reason for this position?
1. To immobilize the diaphragm
2. To facilitate full chest expansion
3. To minimize the danger of aspiration
4. To reduce the likelihood of bleeding
30. A client with cirrhosis is about to have a
paracentesis for relief of ascites. Which activity is
essential prior to the procedure?
1. Administer thorough mouth care.
2. Ask the client to empty his bladder.
3. Be sure his bowels have moved recently.
4. Have the client bathe with betadine.
31. The client has severe liver disease. Which of
the following observations is most indicative of
serious problems?
1. The client has generalized urticaria.
2. The client is “confused” and can no longer
write his name legibly.
3. The client is jaundiced.
4. The client has ecchymotic areas on his arms.
Nursing Care of Clients with Disorders
of the Gallbladder
A 45-year-old client is suspected of having cholecystitis.
119. When describing the discomfort to the nurse, the
client is most likely to indicate that the pain worsens at
which time?
[ ] 1. Shortly after eating
[ ] 2. When the stomach is empty
[ ] 3. After periods of activity
[ ] 4. Before rising in the morning
120. If this client is typical of others with cholecystitis,
besides localized pain, the client may describe feeling pain
that is referred to which area?
[ ] 1. Right shoulder
[ ] 2. Midepigastrium
[ ] 3. Neck or jaw
[ ] 4. Left upper arm
121. If the cause of the client’s infl amed gallbladder is
gallstones, the nurse would anticipate the laboratory data
to indicate which fi nding?
[ ] 1. Low red blood cell count
[ ] 2. Low hemoglobin level
[ ] 3. Elevated cholesterol level
[ ] 4. Elevated serum albumin level
122. If gallstones obstruct the fl ow of bile, how would
the nurse expect the client’s stools to appear?
[ ] 1. Black and tarry
[ ] 2. Light clay-colored
[ ] 3. Brown with bloody mucus
[ ] 4. Greenish yellow
123. When the dietitian has fi nished instructing the client
about a low-fat diet, the nurse knows that the client
requires additional teaching based on which statement?
[ ] 1. “I can eat chicken that has been broiled.”
[ ] 2. “Because fi sh is good for me, I’ll still get to eat a
lot of baked fi sh.”
[ ] 3. “I can have a hamburger and fries when I go out
with friends.”
[ ] 4. “I guess I’ll eat more roasted turkey for dinner.”
Because the client’s gallbladder was unable to concentrate
and excrete bile, it could not be visualized by cholecystography.
The physician orders an ultrasound of the gallbladder.
The nurse explains the scheduled procedure to the client.
124. Which comment indicates that the client has an
accurate understanding of the preparation necessary for the
procedure?
[ ] 1. “Preparation involves withholding food for
approximately 8 to 12 hours.”
[ ] 2. “I’ll need to drink a container of barium just before
the X-ray.”
[ ] 3. “I’ll be allowed to eat a large test meal the night
before the X-ray.”
[ ] 4. “Just before the test, they’ll insert a large needle
into one of my arm veins.”
Ultrasound of the client’s gallbladder reveals several
stones in the common bile duct. A laparoscopic cholecystectomy
is scheduled.
125. Which statements made by the nurse provide the
best explanations of this procedure? Select all that apply.
[ ] 1. The procedure will require moderate sedation.
[ ] 2. The surgery will require a long period of gastric
decompression.
[ ] 3. The abdomen will be infl ated with carbon dioxide
to provide a maximum view.
[ ] 4. There will be four small puncture sites.
[ ] 5. Most clients return home the evening after the
procedure.
[ ] 6. A T-tube is inserted to drain bile until the surgical
wound heals.
Another client comes to the clinic with signs and symptoms
related to gallbladder disease but is not a candidate for a
laparoscopic cholecystectomy. The surgeon schedules an
open cholecystectomy.
The client returns from surgery with a nasogastric tube,
a T-tube for bile drainage, and a Jackson-Pratt tube for
wound drainage in place.
126. Immediately after surgery, the nurse assesses the
drainage from the T-tube. Which assessment fi nding best
indicates that the drainage color is normal at this time?
[ ] 1. The drainage is dark red or pale pink.
[ ] 2. The drainage is clear or transparent.
[ ] 3. The drainage is bright red or orange.
[ ] 4. The drainage is greenish yellow or brown.
127. The nurse is required to take which actions when
emptying the drainage receptacle of the client’s JacksonPratt closed-wound drain? Select all that apply.
[ ] 1. Empty the drainage into a measuring container.
[ ] 2. Adjust the suction setting to low continuous suction.
[ ] 3. Squeeze the receptacle to expel air.
[ ] 4. Release the roller clamp.
[ ] 5. Cover the vent.
[ ] 6. Stabilize the drainage tube.
128. The nurse should anticipate implementing which
interventions to manage this client’s T-tube? Select all that
apply.
[ ] 1. Record the amount of drainage from the T-tube.
[ ] 2. Unclamp the T-tube at hourly intervals.
[ ] 3. Keep the T-tube drainage bag parallel with the
incision.
[ ] 4. Inspect the skin around the tube for irritation.
[ ] 5. Maintain the client in Fowler’s position.
[ ] 6. Notify the physician if the drainage changes color.
129. When the nurse assesses the T-tube in the early
postoperative period, which fi nding requires immediate
action?
[ ] 1. The drainage bag is hanging below the abdomen.
[ ] 2. The drainage tubing is currently clamped.
[ ] 3. The drainage tube is taped to the client’s right side.
[ ] 4. The drainage volume was 100 mL in the past 6 hours.
130. When the client begins to consume food again,
which routine for clamping and unclamping the T-tube
should the nurse plan to follow?
[ ] 1. Unclamp the tube during the day.
[ ] 2. Unclamp the tube during the night.
[ ] 3. Unclamp the tube for 2 hours after eating.
[ ] 4. Unclamp the tube for 2 hours before eating.
131. How would the nurse reestablish negative pressure
within the Jackson-Pratt tube when emptying the drainage
bulb reservoir?
[ ] 1. By compressing the bulb reservoir and closing the
drainage valve
[ ] 2. By opening the drainage valve, allowing the bulb
to fi ll with air
[ ] 3. By fi lling the bulb reservoir with sterile normal
saline solution
[ ] 4. By securing the bulb reservoir to the skin near the
wound
Nursing Care of Clients with Disorders
of the Liver
A 20-year-old college student goes to the university
health service after developing a sudden onset of fl ulike
symptoms.
132. When the health nurse monitors the client’s laboratory
test results, which elevated level would strongly suggest
a possible liver disorder?
[ ] 1. Serum potassium
[ ] 2. Serum creatinine
[ ] 3. Blood urea nitrogen (BUN)
[ ] 4. Alanine aminotransferase (ALT)
The physician determines that the college student has
hepatitis A.
133. When the client asks the nurse how the hepatitis A
was acquired, what is the best answer?
[ ] 1. Fecal-oral route
[ ] 2. Insect carriers
[ ] 3. Infected blood
[ ] 4. Wound drainage
An infection control nurse is consulted on measures for
reducing the potential transmission of the hepatitis A virus
to others.
134. On the basis of the routes of transmission for this
disease, which infection control measure is essential to
include in the client’s care plan?
[ ] 1. Wear gloves whenever entering the client’s room.
[ ] 2. Don a mask and gown when providing direct care.
[ ] 3. Maintain the client in a private room at all times.
[ ] 4. Perform vigorous hand washing after leaving the
room.
Several of the college student’s friends call the health
service because they are concerned about their own risks
for acquiring hepatitis A.
135. To prevent the spread of hepatitis A, the nurse
correctly advises that close contacts receive which
medication?
[ ] 1. An antibiotic
[ ] 2. Serum immunoglobulin
[ ] 3. Hepatitis vaccine
[ ] 4. An anti-infl ammatory drug
A 23-year-old develops jaundice and goes to the public
health department. Testing reveals that the cause of the
client’s jaundice is hepatitis B. The nurse gathers information
regarding the client’s social history.
136. What information from the client’s history indicates
a predisposition for acquiring hepatitis B? Select all that
apply.
[ ] 1. The client moved from Europe.
[ ] 2. The client is a sexually active homosexual.
[ ] 3. The client abuses alcohol.
[ ] 4. The client works in a restaurant.
[ ] 5. The client has had a blood transfusion.
[ ] 6. The client was punctured with an unused needle.
137. Which measure is most appropriate if a nurse who
has not received a series of vaccinations for hepatitis B
experiences a needle-stick injury while caring for this
client?
[ ] 1. Obtain immediate immunization with hepatitis B
vaccine.
[ ] 2. Receive hepatitis B immunoglobulin within 1 week.
[ ] 3. Take penicillin (Pentam) for a minimum of 10 days.
[ ] 4. Scrub the puncture site with diluted household
bleach.
138. The nurse informs the client that because of the
disease, it is essential to avoid which activity for life?
[ ] 1. Sexual activity
[ ] 2. Donating blood
[ ] 3. Drinking alcohol
[ ] 4. Traveling to foreign countries
A 60-year-old client seeks medical attention with symptoms
of vomiting blood and passing bloody stools. The
tentative diagnosis is cirrhosis of the liver.
139. Which information in the client’s health history
most likely relates to the development of cirrhosis? Select
all that apply.
[ ] 1. The client drinks a fi fth of whiskey daily.
[ ] 2. The client smokes two packs of cigarettes per day.
[ ] 3. The client has a history of pancreatitis.
[ ] 4. The client has been taking antihypertensive medications
for the past 15 years.
[ ] 5. The client eats poorly as a consequence of being
homeless for 5 years.
[ ] 6. The client has been exposed to asbestos.
140. If the client’s cirrhosis is advanced, what will the
nurse expect to fi nd during the initial health assessment?
Select all that apply.
[ ] 1. Laboratory results revealing an elevated serum
cholesterol level
[ ] 2. The presence of spiderlike blood vessels on
the skin
[ ] 3. An unusually large and edematous abdomen
[ ] 4. An abnormally high blood glucose level
[ ] 5. Skin that is jaundiced
[ ] 6. Vein engorgement around the umbilicus
141. Which assessment fi nding indicates that the client is
bleeding from somewhere in the upper GI tract?
[ ] 1. The client has midepigastric pain.
[ ] 2. The client states, “I feel nauseated.”
[ ] 3. The client’s stools are black and sticky.
[ ] 4. The client’s abdomen is distended and boardlike.
The physician considers performing a liver biopsy to confi
rm a diagnosis of cirrhosis.
142. If the liver biopsy is performed, the nurse must
monitor the client immediately after the procedure for
which potential complication?
[ ] 1. Hemorrhage
[ ] 2. Infection
[ ] 3. Blood clots
[ ] 4. Collapsed lung
143. After a liver biopsy, which nursing order is most
appropriate to add to the client’s care plan?
[ ] 1. Ambulate the client twice each shift.
[ ] 2. Keep the client in high Fowler’s position.
[ ] 3. Position the client on the right side.
[ ] 4. Elevate the client’s legs on two pillows.
The physician orders magnetic resonance imaging (MRI)
instead of the liver biopsy to confi rm the diagnosis.
144. Before the magnetic resonance imaging (MRI)
study is performed, which nursing action is essential?
[ ] 1. Administering a pretest sedative
[ ] 2. Removing the client’s dental bridge
[ ] 3. Asking if the client is allergic to opiates
[ ] 4. Inserting a Foley retention catheter
The care plan indicates that the nurse should monitor the
client with cirrhosis each day for signs and symptoms of
ascites.
145. To implement this nursing order, which nursing
action is most appropriate?
[ ] 1. Reviewing the client’s serum bilirubin levels
[ ] 2. Monitoring the client for vomiting and diarrhea
[ ] 3. Pressing on the client’s abdomen testing for
rebound tenderness
[ ] 4. Measuring the client’s abdominal circumference
Magnetic resonance imaging (MRI) confi rms the diagnosis
of hepatic cirrhosis and reveals a large amount of fl uid in
the peritoneal cavity. A paracentesis is planned.
146. Which nursing action is most appropriate before
assisting with the paracentesis?
[ ] 1. Asking the client to void
[ ] 2. Withholding food and water
[ ] 3. Clipping hair from the client’s abdomen
[ ] 4. Placing the crash cart outside the client’s room
147. After the paracentesis has been performed, which
nursing responsibility is essential?
[ ] 1. Increasing the client’s oral fl uid intake
[ ] 2. Recording the volume of withdrawn fl uid
[ ] 3. Administering a prescribed analgesic
[ ] 4. Encouraging the client to deep-breathe
The client’s I.V. line has infi ltrated and has to be removed
and restarted in a new site. The licensed practical nurse
(LPN) collaborates with the registered nurse (RN) about
assisting with these procedures.
148. Which nursing action is most appropriately delegated
to the LPN?
[ ] 1. Clean the new insertion site with an antiseptic.
[ ] 2. Flush the I.V. line with no more than 1 mL at any
given time.
[ ] 3. Obtain a vial of vitamin K to keep at the bedside.
[ ] 4. Apply pressure to the old insertion site after I.V.
removal.
149. Which laboratory result, if elevated, is most indicative
that the client may develop hepatic encephalopathy?
[ ] 1. Serum creatinine
[ ] 2. Serum bilirubin
[ ] 3. Blood ammonia
[ ] 4. Blood urea nitrogen
150. Which assessment fi nding best indicates that the
cirrhotic client’s condition is worsening?
[ ] 1. The client is diffi cult to arouse.
[ ] 2. The client’s urine output is 100 mL/hour.
[ ] 3. The client develops pancreatitis.
[ ] 4. The client’s breath smells fruity.
The seriousness of the client’s condition is explained to the
client’s spouse. The spouse is prepared for the possibility
of the client’s death.
151. When the client’s spouse begins crying while recalling
various signifi cant events they shared together, which
nursing action is most therapeutic at this time?
[ ] 1. Offer to call a close family member.
[ ] 2. Listen to the spouse’s expressions of thoughts.
[ ] 3. Suggest calling a clergyman from their church.
[ ] 4. Ask about the spouse’s future plans.
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. If you become nauseated, breathe deeply into
a paper bag.
■ 3. Keep adhesive dressings in place for 6 weeks.
■ 4. Report bile-colored drainage from any
incision.
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 orders?
■ 1. I.V. fl uid therapy of normal saline solution
to be infused at 100 mL/hour until further
orders.
■ 2. Administer morphine sulfate 10 mg I.M.
every 4 hours as needed for severe abdominal
pain.
■ 3. Nothing by mouth (NPO) until further orders.
■ 4. Insert a nasogastric tube and connect to low
intermittent suction.
3. A client is admitted to the hospital with a
diagnosis of cholecystitis from cholelithiasis. The
client has severe abdominal pain, nausea, and has
vomited several times. Based on these data, which
nursing diagnosis would have the highest priority
for intervention at this time?
■ 1. Anxiety related to severe abdominal discomfort.
■ 2. Defi cient fl uid volume related to vomiting.
■ 3. Pain related to gallbladder infl ammation.
■ 4. Imbalanced nutrition: Less than body requirements
related to vomiting.
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.
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?
■ 1. Providing the client with information about
what to expect postoperatively.
■ 2. Telling the client it is normal to be afraid.
■ 3. Reassuring the client by telling her that surgery
is a common procedure.
■ 4. Stressing the importance of following the
physician’s instructions after surgery.
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:
■ 1. Irrigate the tube with 20 mL of normal saline
every 4 hours.
■ 2. Unclamp the T-tube and empty the contents
every day.
■ 3. Assess the color and amount of drainage
every shift.
■ 4. Monitor the multiple incision sites for bile
drainage.
7. At 8 a.m., 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:
Output Record
Date T-tube
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.
8. The nurse measures the amount of bile drainage
from a T-tube and records it by which one of the
following methods?
■ 1. Adding it to the client’s urine output.
■ 2. Charting it separately on the output record.
■ 3. Adding it to the amount of wound drainage.
■ 4. Subtracting it from the total intake for each
day.
9. 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?
■ 1. Cheese omelet.
■ 2. Peanut butter.
■ 3. Ham salad sandwich.
■ 4. Roast beef.
10. 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:
■ 1. Hydromorphone (Dilaudid) I.V.
■ 2. Diltiazem (Cardizem) PO.
■ 3. Meperidine (Demerol) I.M.
■ 4. Promethazine (Phenergan).
11. The nurse prepares to administer promethazine
(Phenergan) 35 mg I.M. as ordered p.r.n. for
a client with cholecystitis complaining of nausea.
The ampule label reads that the medication is available
in 25 mg/mL. How many milliliters should the
nurse administer?
______________________ mL.
12. A client undergoes a laparoscopic cholecystectomy.
Which of the following dietary instructions
should the nurse give the client immediately after
surgery?
■ 1. “You cannot eat or drink anything for 24
hours.”
■ 2. “You may resume your normal diet the day
after your surgery.”
■ 3. “Drink liquids today and eat lightly for a few
days.”
■ 4. “You can progress from a liquid to a bland
diet as tolerated.”
13. Which of the following discharge instructions
would be appropriate for a client who has had
a laparoscopic cholecystectomy?
■ 1. Avoid showering for 48 hours after surgery.
■ 2. Return to work within 1 week.
■ 3. Leave dressings in place until you see the
surgeon at the postoperative visit.
■ 4. Use acetaminophen (Tylenol) to control any
fever.
14. 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.
■ 1. “I can resume my normal diet when I want.”
■ 2. “I need to avoid driving for about 4 weeks.”
■ 3. “I may experience some pain in my right
shoulder.”
■ 4. “I should spend 2 to 3 days in bed before
resuming activity.”
■ 5. “I can wash the puncture site with mild soap
and water.”
The Client with Viral Hepatitis
29. The nurse is assessing a client with chronic
hepatitis B who is receiving Lamivudine (Epivir).
What information is most important to communicate
to the physician?
■ 1. The client’s daily record indicates a 3 kg
weight gain over 2 days.
■ 2. The client is complaining of nausea.
■ 3. The client has a temperature of 99° F orally.
■ 4. The client has fatigue.
30. The nurse is assessing a client with hepatitis
and notices that the AST and ALT lab values have
increased. Which of the following statements by the
client requires further instruction by the nurse?
■ 1. “I require increased periods of rest.”
■ 2. “I follow a low-fat, high carbohydrate diet.”
■ 3. “I eat dry toast to relieve my nausea.”
■ 4. “I take acetaminophen (Tylenol) for arthritis
pain.”
31. College freshman are participating in a study
abroad program. When teaching them about hepatitis
B, the nurse should instruct the students on:
■ 1. Water sanitation.
■ 2. Single dormitory rooms.
■ 3. Vaccination for hepatitis D.
■ 4. Safe sexual practices.
32. Which of the following is normal for a client
during the icteric phase of viral hepatitis?
■ 1. Tarry stools.
■ 2. Yellowed sclera.
■ 3. Shortness of breath.
■ 4. Light, frothy urine.
33. The nurse is planning a home visit for a client
with hepatitis. In order to prevent transmission
the nurse should focus teaching on:
■ 1. Proper food handling.
■ 2. Insulin syringe disposal.
■ 3. Alpha-interferon.
■ 4. Use of condoms
34. 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?
■ 1. “Your fatigue should be gone by now. We will
evaluate you for a secondary infection.”
■ 2. “Your fatigue is an adverse effect of your drug
therapy. It will disappear when your treatment
regimen is complete.”
■ 3. “It is important for you to increase your
activity level. That will help decrease your
fatigue.”
■ 4. “It is normal for you to feel fatigued. The
fatigue should go away in the next 2 to 4
months.”
35. The nurse is developing a plan of care for the
client with viral hepatitis. The nurse should instruct
the client to:
■ 1. Obtain adequate bed rest.
■ 2. Increase fl uid intake.
■ 3. Take antibiotic therapy as ordered.
■ 4. Drink 8 oz of an electrolyte solution every
day.
36. When planning care for a client with viral
hepatitis, the nurse should review labororatory
reports for which of the following abnormal laboratory
values?
■ 1. Prolonged prothrombin time.
■ 2. Decreased blood glucose level.
■ 3. Elevated serum potassium level.
■ 4. Decreased serum calcium level.
37. The nurse should teach the client with viral
hepatitis to:
■ 1. Limit caloric intake and reduce weight.
■ 2. Increase carbohydrates and protein in the
diet.
■ 3. Avoid contact with others and live separately.
■ 4. Intensify routine exercise and increase
strength.
38. 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?
■ 1. Spray the house to eliminate infected insects.
■ 2. Tell family members to try to stay away from
the client.
■ 3. Tell family members to wash their hands frequently.
■ 4. Disinfect all clothing and eating utensils.
39. The nurse assesses that the client with hepatitis
is experiencing fatigue, weakness, and a general
feeling of malaise. The client tires rapidly during
morning care. Based on this information, which of
the following would be an appropriate nursing diagnosis?
■ 1. Impaired physical mobility related to malaise.
■ 2. Self-care defi cit related to fatigue.
■ 3. Ineffective coping related to long-term illness.
■ 4. Activity intolerance related to fatigue.
40. What would be the nurse’s best response to
the client’s expressed feelings of isolation as a result
of having hepatitis?
■ 1. “Don’t worry. It’s normal to feel that way.”
■ 2. “Your friends are probably afraid of contracting
hepatitis from you.”
■ 3. “I’m sure you’re imagining that!”
■ 4. “Tell me more about your feelings of isolation.”
41. 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?
■ 1. Retinopathy.
■ 2. Constipation.
■ 3. Flulike symptoms.
■ 4. Hypoglycemia.
42. 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?
■ 1. Hepatitis B is relatively uncommon among
college students.
■ 2. Frequent ingestion of alcohol can predispose
an individual to development of hepatitis B.
■ 3. Good personal hygiene habits are most effective
at preventing the spread of hepatitis B.
■ 4. The use of a condom is advised for sexual
intercourse.
43. Which of the following expected outcomes
would be appropriate for a client with viral hepatitis?
The client will:
■ 1. Demonstrate a decrease in fl uid retention
related to ascites.
■ 2. Verbalize the importance of reporting bleeding
gums or bloody stools.
■ 3. Limit use of alcohol to two to three drinks per
week.
■ 4. Restrict activity to within the home to prevent
The Client with Cirrhosis
44. A client with cirrhosis is receiving Lactulose
(Cephulac). During the assessment the nurse notes
increased confusion and asterixis. The nurse should:
■ 1. Assess for GI bleeding.
■ 2. Hold the Lactulose (Cephulac).
■ 3. Increase protein in the diet.
■ 4. Monitor serum bilirubin levels.
45. The nurse is assessing a client with cirrhosis
who has developed hepatic encephalopathy. The
nurse should notify the physician of a decrease in
which lab serum that is a potential precipitating factor
for hepatic encephalopathy?
■ 1. Aldosterone.
■ 2. Creatinine.
■ 3. Potassium.
■ 4. Protein.
46. A client has advanced cirrhosis of the liver.
The client’s spouse asks the nurse why his abdomen
is swollen, making it very diffi cult for him to
fasten his pants. How should the nurse respond to
provide the most accurate explanation of the disease
process?
■ 1. “He must have been eating too many foods
with salt in them. Salt pulls water with it.”
■ 2. “The swelling in his ankles must have moved
up closer to his heart so the fl uid circulates
better.”
■ 3. “He must have forgotten to take his daily
water pill.”
■ 4. “Blood is not able to fl ow readily through the
liver now, and the liver cannot make protein
to keep fl uid inside the blood vessels.”
47. 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.
■ 1. Preventing constipation.
■ 2. Administering lactulose (Cephulac).
■ 3. Monitoring coordination while walking.
■ 4. Checking the pupil reaction.
■ 5. Providing food and fl uids high in carbohydrate.
■ 6. Encouraging physical activity.
48. 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.
49. 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?
■ 1. Constipation.
■ 2. Hyperkalemia.
■ 3. Irregular pulse.
■ 4. Dysuria.
50. What diet should be implemented for a client
who is in the early stages of cirrhosis?
■ 1. High-calorie, high-carbohydrate.
■ 2. High-protein, low-fat.
■ 3. Low-fat, low-protein.
■ 4. High-carbohydrate, low-sodium.
51. A client with jaundice has pruritis and states
that he has areas of irritation from scratching. What
measures can the nurse discuss to prevent skin
breakdown? Select all that apply.
■ 1. Avoid lotions containing calamine.
■ 2. Take baking soda baths.
■ 3. Keep nails short and clean.
■ 4. Rub with knuckles instead of nails.
■ 5. Massage skin with alcohol.
■ 6. Increase sodium intake in diet.
52. 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?
■ 1. Supplement the diet with daily multivitamins.
■ 2. Limit daily alcohol intake.
■ 3. Take a sleeping pill at bedtime.
■ 4. Limit contact with other people whenever
possible.
53. The nurse is reviewing the chart information
for a client with increased ascites. The data include:
temperature 37.2° C; heart rate 118; shallow respirations
26; blood pressure 128/76; and SpO2 89% on
room air. Which action should receive priority by
the nurse?
■ 1. Assess heart sounds.
■ 2. Obtain an order for blood cultures.
■ 3. Prepare for a paracentesis.
■ 4. Raise the head of the bed.
54. Which of the following positions would be
appropriate for a client with severe ascites?
■
■
■
■
1. Fowler’s.
2. Side-lying.
3. Reverse Trendelenburg.
4. Sims.
55. The client with cirrhosis receives 100 mL
of 25% serum albumin I.V. Which fi nding would
best indicate that the albumin is having its desired
effect?
■ 1. Increased urine output.
■ 2. Increased serum albumin level.
■ 3. Decreased anorexia.
■ 4. Increased ease of breathing.
56. The nurse is planning care for a client being
admitted with bleeding esophageal varices. Vital
signs are: Pulse 100; respiratory rate 22; and blood
pressure 100/58. The nurse should prepare the client
for which of the following? Select all that apply.
■ 1. Administration of intravenous Octreotide
(Sandostatin).
■ 2. Endoscopy.
■ 3. Administration of a blood product.
■ 4. Minnesota tube insertion.
■ 5. Transjugular intrahepatic portosystemic shunt
(TIPS) procedure.
■ 6. Immediate endotracheal intubation.
57. A client with a Sengstaken-Blakemore tube
has a sudden drop in SpO2 and increase in respiratory
rate to 40 breaths/minute. The nurse should do
which of the following in order from fi rst to last?
2. Remove the tube.
3. Defl ate the tube by cutting with bedside
scissors.
4. Apply oxygen via face mask.
1. Affi rm airway obstruction by the tube.
58. The physician orders oral neomycin (Mycifradin)
as well as a neomycin enema for a client
with cirrhosis. The expected outcome of this therapy
is to:
■ 1. Reduce abdominal pressure.
■ 2. Prevent straining during defecation.
■ 3. Block ammonia formation.
■ 4. Reduce bleeding within the intestine.
59. 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?
■ 1. Decreased mental status.
■ 2. Elevated blood pressure.
■ 3. Decreased urine output.
■ 4. Labored respirations.
60. A client’s serum ammonia level is elevated,
and the physician orders 30 mL of lactulose (Cephulac).
Which of the following is an adverse effect of
this drug?
■ 1. Increased urine output.
■ 2. Improved level of consciousness.
■ 3. Increased bowel movements.
■ 4. Nausea and vomiting.
61. The nurse has an order to administer 2 oz of
lactulose (Cephulac) to a client who has cirrhosis.
How many milliliters of lactulose should the nurse
administer?
_______________________ mL.
62. A client is to be discharged with a prescription
for lactulose (Cephulac). The nurse teaches the
client and the client’s spouse how to administer
this medication. Which of the following statements
would indicate that the client has understood the
information?
■ 1. “I’ll take it with Maalox.”
■ 2. “I’ll mix it with apple juice.”
■ 3. “I’ll take it with a laxative.”
■ 4. “I’ll mix the crushed tablets in some gelatin.”
63. 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?
■ 1. “I should eat a high-protein, high-carbohydrate
diet to provide energy.”
■ 2. “It is safer for me to take acetaminophen
(Tylenol) for pain instead of aspirin.”
■ 3. “I should avoid constipation to decrease
chances of bleeding.”
■ 4. “If I get enough rest and follow my diet, it is
possible for my cirrhosis to be cured.”
64. The nurse is preparing a client for a paracentesis.
The nurse should:
■ 1. Have the client void immediately before the
procedure.
■ 2. Place the client in a side-lying position.
■ 3. Initiate an I.V. line to administer sedatives.
■ 4. Place the client on nothing-by-mouth (NPO)
status 6 hours before the procedure.
65. Which of the following interventions should
the nurse anticipate incorporating into the client’s
plan of care when hepatic encephalopathy initially
develops?
■ 1. Inserting a nasogastric (NG) tube.
■ 2. Restricting fl uids to 1,000 mL/day.
■ 3. Administering I.V. salt-poor albumin.
■ 4. Implementing a low-protein diet.
66. A client with ascites and peripheral edema
is at risk for impaired skin integrity. To prevent skin
breakdown, the nurse should:
■ 1. Institute range-of-motion (ROM) exercise
every 4 hours.
■ 2. Massage the abdomen once a shift.
■ 3. Use an alternating air pressure mattress.
■ 4. Elevate the lower extremities.
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.
68. 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?
2. The client with acute pancreatitis who is
requesting pain medication.
3. 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 his discharge instructions.
1. The client with cirrhosis who became confused
and disoriented during the night.
69. The nurse should institute which of the
following measures to prevent transmission of the
hepatitis C virus to health care personnel?
■ 1. Administering hepatitis C vaccine to all
health care personnel.
■ 2. Decreasing contact with blood and bloodcontaminated
fl uids.
■ 3. Wearing gloves when emptying the bedpan.
■ 4. Wearing a gown and mask when providing
direct care.
70. The nurse is taking care of a client who has
an I.V. infusion pump. The pump alarm rings. What
should the nurse do in order from fi rst to last?
2. Determine if the infusion pump is plugged
into an electrical outlet.
3. Assess the client’s access site for infi ltration or
infl ammation.
4. Assess the tubing for hindrances to fl ow of
solution.