NCLEX Practice Questions: Liver, Biliary and Pancreatic Disorders
Terms in this set (20)
1. For a client in hepatic coma, which outcome would be the most appropriate?
A. The client is oriented to time, place, and person.
B. The client exhibits no ecchymotic areas.
C. The client increases oral intake to 2,000 calories/day.
D. The client exhibits increased serum albumin level.
1. Answer: A. The client is oriented to time, place, and person.
Hepatic coma is the most advanced stage of hepatic encephalopathy. As hepatic coma resolves, improvement in the client's level of consciousness occurs. The client should be able to express orientation to time, place, and person. Ecchymotic areas are related to decreased synthesis of clotting factors. Although oral intake may be related to level of consciousness, it is more closely related to anorexia. The serum albumin level reflects hepatic synthetic ability, not level of consciousness.
2. Jordin is a client with jaundice who is experiencing pruritus. Which nursing intervention would be included in the care plan for the client?
A. Administering vitamin K subcutaneously
B. Applying pressure when giving I.M. injections
C. Decreasing the client's dietary protein intake
D. Keeping the client's fingernails short and smooth
2. Answer: D. Keeping the client's fingernails short and smooth
The client with pruritus experiences itching, which may lead to skin breakdown and possibly infection from scratching. Keeping his fingernails short and smooth helps prevent skin breakdown and infection from scratching. Applying pressure when giving I.M. injections and administering vitamin K subcutaneously are important if the client develops bleeding problems. Decreasing the client's dietary intake is appropriate if the client's ammonia levels are increased.
3. Marie, a 51-year-old woman, is diagnosed with cholecystitis. Which diet, when selected by the client, indicates that the nurse's teaching has been successful?
A. 4-6 small meals of low-carbohydrate foods daily
B. High-fat, high-carbohydrate meals
C. Low-fat, high-carbohydrate meals
D. High-fat, low protein meals
3. Answer: C. Low-fat, high-carbohydrate meals
For the client with cholecystitis, fat intake should be reduced. The calories from fat should be substituted with carbohydrates. Reducing carbohydrate intake would be contraindicated. Any diet high in fat may lead to another attack of cholecystitis.
4. The hospital administrator had undergone percutaneous transhepatic cholangiography. which assessment finding indicates complication after the operation?
A. Fever and chills
D. Nausea and diarrhea
4. Answer: A. Fever and chills
Septicemia is a common complication after a percutaneous transhepatic cholangiography. Evidence of fever and chills, possibly indicative of septicemia, is important. Hypotension, not hypertension, is associated with septicemia. Tachycardia, not bradycardia, is most likely to occur. Nausea and diarrhea may occur but are not classic signs of sepsis.
5. When planning home care for a client with hepatitis A, which preventive measure should be emphasized to protect the client's family?
A. Keeping the client in complete isolation
B. Using good sanitation with dishes and shared bathrooms
C. Avoiding contact with blood-soiled clothing or dressing
D. Forbidding the sharing of needles or syringes
5. Answer: B. Using good sanitation with dishes and shared bathrooms
Hepatitis A is transmitted through the fecal oral route or from contaminated water or food. Measures to protect the family include good handwashing, personal hygiene and sanitation, and use of standard precautions. Complete isolation is not required. Avoiding contact with blood-soiled clothing or dressings or avoiding the sharing of needles or syringes are precautions needed to prevent transmission of hepatitis B.
6. For Jayvin who is taking antacids, which instruction would be included in the teaching plan?
A. "Take the antacids with 8 oz of water."
B. "Avoid taking other medications within 2 hours of this one."
C. "Continue taking antacids even when pain subsides."
D. "Weigh yourself daily when taking this medication."
6. Answer: B. "Avoid taking other medications within 2 hours of this one."
Antacids neutralize gastric acid and decrease the absorption of other medications. The client should be instructed to avoid taking other medications within 2 hours of the antacid. Water, which dilutes the antacid, should not be taken with antacid. A histamine receptor antagonist should be taken even when pain subsides. Daily weights are indicated if the client is taking a diuretic, not an antacid.
7. Which clinical manifestation would the nurse expect a client diagnosed with acute cholecystitis to exhibit?
A. Jaundice, dark urine, and steatorrhea
B. Acute right lower quadrant (RLQ) pain, diarrhea, and dehydration
C. Ecchymosis petechiae, and coffee-ground emesis
D. Nausea, vomiting, and anorexia
7. Answer: D. Nausea, vomiting, and anorexia
Acute cholecystitis is an acute inflammation of the gallbladder commonly manifested by the following: anorexia, nausea, and vomiting; biliary colic; tenderness and rigidity the right upper quadrant (RUQ) elicited on palpation (e.g., Murphy's sign); fever; fat intolerance; and signs and symptoms of jaundice. Ecchymosis, petechiae, and coffee-ground emesis are clinical manifestations of esophageal bleeding. The coffee-ground appearance indicates old bleeding. Jaundice, dark urine, and steatorrhea are clinical manifestations of the icteric phase of hepatitis.
8. Pierre who is diagnosed with acute pancreatitis is under the care of Nurse Bryan. Which intervention should the nurse include in the care plan for the client?
A. Administration of vasopressin and insertion of a balloon tamponade
B. Preparation for a paracentesis and administration of diuretics
C. Maintenance of nothing-by-mouth status and insertion of nasogastric (NG) tube with low intermittent suction
D. Dietary plan of a low-fat diet and increased fluid intake to 2,000 ml/day
8. Answer: C. Maintenance of nothing-by-mouth status and insertion of nasogastric (NG) tube with low intermittent suction
With acute pancreatitis, the client is kept on nothing-by-mouth status to inhibit pancreatic stimulation and secretion of pancreatic enzymes. NG intubation with low intermittent suction is used to relieve nausea and vomiting, decrease painful abdominal distention, and remove hydrochloric acid. Vasopressin would be appropriate for a client diagnosed with bleeding esophageal varices. Paracentesis and diuretics would be appropriate for a client diagnosed with portal hypertension and ascites. A low-fat diet and increased fluid intake would further aggravate the pancreatitis.
9. When teaching a client about pancreatic function, the nurse understands that pancreatic lipase performs which function?
A. Transports fatty acids into the brush border
B. Breaks down fat into fatty acids and glycerol
C. Triggers cholecystokinin to contract the gallbladder
D. Breaks down protein into dipeptides and amino acids
9. Answer: B. Breaks down fat into fatty acids and glycerol
Lipase hydrolyses or breaks down fat into fatty acids and glycerol. Lipase is not involved with the transport of fatty acids into the brush border. Fat itself triggers cholecystokinin release. Protein breakdown into dipeptides and amino acids is the function of trypsin, not lipase.
10. A 52-year-old man was referred to the clinic due to increased abdominal girth. He is diagnosed with ascites by the presence of a fluid thrill and shifting dullness on percussion. After administering diuretic therapy, which nursing action would be most effective in ensuring safe care?
A. Measuring serum potassium for hyperkalemia
B. Assessing the client for hypervolemia
C. Measuring the client's weight weekly
D. Documenting precise intake and output
10. Answer: D. Documenting precise intake and output
For the client with ascites receiving diuretic therapy, careful intake and output measurement is essential for safe diuretic therapy. Diuretics lead to fluid losses, which if not monitored closely and documented, could place the client at risk for serious fluid and electrolyte imbalances. Hypokalemia, not hyperkalemia, commonly occurs with diuretic therapy. Because urine output increases, a client should be assessed for hypovolemia, not hypervolemia. Weights are also an accurate indicator of fluid balance. However, for this client, weights should be obtained daily, not weekly.
11. Which assessment finding indicates that lactulose is effective in decreasing the ammonia level in the client with hepatic encephalopathy?
A. Passage of two or three soft stools daily
B. Evidence of watery diarrhea
C. Daily deterioration in the client's handwriting
D. Appearance of frothy, foul-smelling stools
11. Answer: A. Passage of two or three soft stools daily
Lactulose reduces serum ammonia levels by inducing catharsis, subsequently decreasing colonic pH and inhibiting fecal flora from producing ammonia from urea. Ammonia is removed with the stool. Two or three soft stools daily indicate effectiveness of the drug. Watery diarrhea indicates overdose. Daily deterioration in the client's handwriting indicates an increase in the ammonia level and worsening of hepatic encephalopathy. Frothy, foul-smelling stools indicate steatorrhea, caused by impaired fat digestion.
12. Nurse Farrah is providing care for Kristoff who has jaundice. Which statement indicates that the nurse understands the rationale for instituting skin care measures for the client?
A. "Jaundice is associated with pressure ulcer formation."
B. "Jaundice impairs urea production, which produces pruritus."
C. "Jaundice produces pruritus due to impaired bile acid excretion."
D. "Jaundice leads to decreased tissue perfusion and subsequent breakdown."
12. Answer: C. "Jaundice produces pruritus due to impaired bile acid excretion."
Jaundice is a symptom characterized by increased bilirubin concentration in the blood. Bile acid excretion is impaired, increasing the bile acids in the skin and causing pruritus. Jaundice is not associated with pressure ulcer formation. However, edema and hypoalbuminemia are. Jaundice itself does not impair urea production or lead to decreased tissue perfusion.
13. Which rationale supports explaining the placement of an esophageal tamponade tube in a client who is hemorrhaging?
A. Allowing the client to help insert the tube
B. Beginning teaching for home care
C. Maintaining the client's level of anxiety and alertness
D. Obtaining cooperation and reducing fear
13. Answer: D. Obtaining cooperation and reducing fear
An esophageal tamponade tube would be inserted in critical situations. Typically, the client is fearful and highly anxious. The nurse therefore explains about the placement to help obtain the client's cooperation and reduce his fear. This type of tube is used only short term and is not indicated for home use. The tube is large and uncomfortable. The client would not be helping to insert the tube. A client's anxiety should be decreased, not maintained, and depending on the degree of hemorrhage, the client may not be alert.
14. For Rico who has chronic pancreatitis, which nursing intervention would be most helpful?
A. Allowing liberalized fluid intake
B. Counseling to stop alcohol consumption
C. Encouraging daily exercise
D. Modifying dietary protein
14. Answer: B. Counseling to stop alcohol consumption
Chronic pancreatitis typically results from repeated episodes of acute pancreatitis. More than half of chronic pancreatitis cases are associated with alcoholism. Counseling to stop alcohol consumption would be the most helpful for the client. Dietary protein modification is not necessary for chronic pancreatitis. Daily exercise and liberalizing fluid intake would be helpful but not the most beneficial intervention.
15. Mr. Hasakusa is in end-stage liver failure. Which interventions should the nurse implement when addressing hepatic encephalopathy? (Select all that apply.)
A. Assessing the client's neurologic status every 2 hours
B. Monitoring the client's hemoglobin and hematocrit levels
C. Evaluating the client's serum ammonia level
D. Monitoring the client's handwriting daily
E. Preparing to insert an esophageal tamponade tube
F. Making sure the client's fingernails are short
15. Answer: A, C, D
Hepatic encephalopathy results from an increased ammonia level due to the liver's inability to covert ammonia to urea, which leads to neurologic dysfunction and possible brain damage. The nurse should monitor the client's neurologic status, serum ammonia level, and handwriting. Monitoring the client's hemoglobin and hematocrit levels and insertion of an esophageal tamponade tube address esophageal bleeding. Keeping fingernails short address jaundice.
16. For a client with hepatic cirrhosis who has altered clotting mechanisms, which intervention would be most important?
A. Allowing complete independence of mobility
B. Applying pressure to injection sites
C. Administering antibiotics as prescribed
D. Increasing nutritional intake
16. Answer: B. Applying pressure to injection sites
The client with cirrhosis who has altered clotting is at high risk for hemorrhage. Prolonged application of pressure to injection or bleeding sites is important. Complete independence may increase the client's potential for injury, because an unsupervised client may injure himself and bleed excessively. Antibiotics and good nutrition are important to promote liver regeneration. However, they are not most important for a client at high risk for hemorrhage.
17. A client with advanced cirrhosis has been diagnosed with hepatic encephalopathy. The nurse expects to assess for:
C. Hand tremors
D. Weight loss
17. Answer: C. Hand tremors
Hepatic encephalopathy results from the accumulation of neurotoxins in the blood, therefore the nurse wants to assess for signs of neurological involvement. Flapping of the hands (asterixis), changes in mentation, agitation, and confusion are common. These clients typically have ascites and edema so experience weight gain. Malaise and stomatitis are not related to neurological involvement.
18. A client diagnosed with chronic cirrhosis who has ascites and pitting peripheral edema also has hepatic encephalopathy. Which of the following nursing interventions are appropriate to prevent skin breakdown? (Select all that apply.)
A. Range of motion every 4 hours
B. Turn and reposition every 2 hours
C. Abdominal and foot massages every 2 hours
D. Alternating air pressure mattress
E. Sit in chair for 30 minutes each shift
18. Answer: B, D
Edematous tissue must receive meticulous care to prevent tissue breakdown. Range of motion exercises preserve joint function but do not prevent skin breakdown. Abdominal or foot massage will not prevent skin breakdown but must be cleansed carefully to prevent breaks in skin integrity. The feet should be kept at the level of heart or higher so Fowler's position should be employed. An air pressure mattress, careful repositioning can prevent skin breakdown.
19. Which of the following will the nurse include in the care plan for a client hospitalized with viral hepatitis?
A. Increase fluid intake to 3000 ml per day
B. Adequate bed rest
C. Bland diet
D. Administer antibiotics as ordered
19. Answer: B. Adequate bed rest
Treatment of hepatitis consists of bed rest during the acute phase to reduce metabolic demands on the liver, thus increasing blood supply and cell regeneration. Forcing fluids, antibiotics, and bland diets are not part of the treatment plan for viral hepatitis.
20. Spironolactone (Aldactone) is prescribed for a client with chronic cirrhosis and ascites. The nurse should monitor the client for which of the following medication-related side effects?
20. Answer: B. Hyperkalemia
This is a potassium-sparing diuretic so clients should be monitored closely for hyperkalemia. Diarrhea, dizziness, and headaches are other more common side effects. Tachycardia, jaundice, and constipation are not expected side effects of spironolactone (Aldactone).
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