ATI LPN
Test Bank for Medical Surgical Nursing: Concepts for Interprofessional Collaborative Care 10th Edition
Chapter 58 : Care of Patients with Liver Problems Questions
Question 1 of 5
A nurse cares for a client who is hemorrhaging from bleeding esophageal varices and has an esophagogastric tube. Which action should the nurse take first?
Correct Answer: D
Rationale: Maintaining airway patency is the primary nursing intervention for this client. The nurse suctions oral secretions to prevent aspiration. The client should be sedated, and balloon pressure should be maintained between 15 and 25 mm Hg. Irrigation with saline may be performed, but these actions are not a higher priority than airway patency.
Question 2 of 5
A nurse assesses a client who is prescribed an infusion of vasopressin (Pitressin) for bleeding esophageal varices. Which clinical manifestation should the nurse recognize as a potential complication?
Correct Answer: D
Rationale: Mid-sternal chest pain is indicative of acute angina or myocardial infarction, which can be precipitated by vasopressin. Nausea, vomiting, dizziness, syncope, fever, and chills are not typical side effects of vasopressin.
Question 3 of 5
A nurse cares for a client with hepatic portal-systemic encephalopathy (PSE). The client is thin and cachectic in appearance. Which statement best explains the rationale for a low-protein diet?
Correct Answer: B
Rationale: A low-protein diet is ordered when serum ammonia levels increase and/or the client shows signs of PSE. A low-protein diet helps reduce excessive breakdown of protein into ammonia by intestinal bacteria. Encephalopathy is caused by excess ammonia. A low-protein diet has no impact on restoring liver function. Increasing dietary protein will cause complications of liver failure and should not be suggested. Increased intravascular protein may help prevent ascites, but clients with liver failure are not able to effectively synthesize dietary protein.
Question 4 of 5
A nurse cares for a client who is prescribed lactulose (Heptalac). The client states, 'I do not want to take this medication because it causes diarrhea.' How should the nurse respond?
Correct Answer: A
Rationale: The purpose of administering lactulose to this client is to help ammonia leave the circulatory system through the colon. Lactulose draws water into the bowel with its high osmotic gradient, thereby producing a laxative effect and subsequently evacuating ammonia from the bowel. The client must understand that this is an expected therapeutic effect for him or her to remain compliant. The nurse should not suggest administering anything that would decrease the excretion of ammonia or holding the medication. There is no need to send a stool specimen to the laboratory because diarrhea is the therapeutic response to this medication.
Question 5 of 5
After teaching a client who has been diagnosed with hepatitis A, the nurse assesses the client's understanding. Which statement by the client indicates a correct understanding of the teaching?
Correct Answer: B
Rationale: The route of acquisition of hepatitis A infection is through close personal contact or ingestion of contaminated water or shellfish. Hepatitis A is not transmitted through medications. Hepatitis B can be spread through blood transfusions. Epstein-Barr virus causes a secondary infection, not a co-infection with hepatitis A.