ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 47 Questions
Question 1 of 5
The nurse is admitting a client to their room at the hospital and observes that the client's skin and sclera are jaundiced. What does the nurse expect the client's total bilirubin levels to be?
Correct Answer: D
Rationale: Normally, total bilirubin concentration ranges from 0.2 to 1.3 mg/dL. If the serum bilirubin level exceeds 2.5 mg/dL, jaundice is visible, notably on the skin, oral mucous membranes, and, especially, sclera.
Question 2 of 5
A client is admitted to the hospital with acute hemorrhage from esophageal varices. What medication should the nurse anticipate administering that will reduce pressure in the portal venous system and control esophageal bleeding?
Correct Answer: B
Rationale: Acute hemorrhage from esophageal varices is life threatening. Resuscitative measures include administration of IV fluids and blood products. IV octreotide is started as soon as possible. Octreotide is preferred because of fewer side effects. Octreotide reduces pressure in the portal venous system and is preferred to the previously used agents, vasopressin or terlipressin. Vitamin K promotes blood coagulation in bleeding conditions, resulting from liver disease.
Question 3 of 5
A client is suspected of having cirrhosis of the liver. What diagnostic procedure will the nurse prepare the client for in order to obtain a confirmed diagnosis?
Correct Answer: A
Rationale: A liver biopsy, which reveals hepatic fibrosis, is the most conclusive diagnostic procedure. It can be performed in the radiology department with ultrasound or CT to identify appropriate placement of the trocar or biopsy needle. A prothrombin time and platelet count will assist with determining if the client is at increased risk for bleeding.
Question 4 of 5
The nurse is caring for a client with severe acute pancreatitis with a glucose level of 750 mg/dL. What does the nurse understand is the cause of this level of hyperglycemia?
Correct Answer: D
Rationale: Complications from severe acute pancreatitis are serious and sometimes fatal. Hyperglycemia results from an imbalance of glucagon, insulin, and somatostatin. Increase in circulating calcium does not result in an increase in glucose levels. The nurse cannot assume that the client has diabetes and is noncompliant.
Question 5 of 5
A client with cirrhosis has portal hypertension, which is causing esophageal varices. What is the goal of the interventions that the nurse will provide?
Correct Answer: C
Rationale: Methods of treating portal hypertension aim to reduce fluid accumulation and venous pressure. There is no cure for cirrhosis; treating the esophageal varices is only a small portion of the overall objective. Promoting optimal neurologic function will not reduce portal hypertension.