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 obtains a clients health history at a community health clinic. Which statement alerts the nurse to a possible health threat to the client?
Correct Answer: B
Rationale: Acetaminophen (Tylenol) can cause liver damage if taken in large amounts. Clients should be taught not to exceed 4000 mg/day of acetaminophen. The nurse should teach the client about this limitation and should explain other drug options with the client to manage his or her arthritis pain. Two glasses of wine each week, a cousin with liver cancer, and the hepatitis vaccine do not place the client at risk for a liver disorder, and therefore do not require any health teaching.
Question 2 of 5
A nurse cares for a client who has cirrhosis of the liver. Which action should the nurse take to decrease the presence of ascites?
Correct Answer: B
Rationale: A low-sodium diet is one means of controlling abdominal fluid collection. Monitoring intake and output does not control fluid accumulation, nor does weighing the client. These interventions merely assess or monitor the situation. Increasing fluid intake would not be helpful.
Question 3 of 5
A nurse assesses a client who is recovering from a paracentesis 1 hour ago. Which assessment finding requires action by the nurse?
Correct Answer: A
Rationale: Rapid removal of ascitic fluid causes decreased abdominal pressure, which can contribute to hypovolemia. This can be manifested by a decrease in urine output to below 30 mL/hr. A slight increase in systolic blood pressure is insignificant. A decrease in respiratory rate indicates that breathing has been made easier by the procedure. The nurse would expect the clients weight to drop as fluid is removed. Six kilograms is less than 3 pounds and is expected.
Question 4 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 5 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.