Nokea
The nurse is administering furosemide to promote urinary excretion of excess fluids for a client with cirrhosis. When administering furosemide to this client, what should the nurse closely monitor?
- A. Sodium level
- B. Calcium level
- C. Magnesium level
- D. AST levels
Correct Answer: A
Rationale: Diuretics such as furosemide must be administered with caution because long-term use can cause sodium depletion. The other levels do not relate to the administration of furosemide.
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The nurse is caring for a client who has undergone surgery for a liver disorder and has started shivering. Which intervention would be appropriate?
- A. Provide the client with warm fluids.
- B. Cover the client with a light blanket.
- C. Ensure that the room temperature is below 70?°F.
- D. Place the client on a hypothermia blanket.
Correct Answer: B
Rationale: The nurse should cover the client with a light blanket to prevent shivering. This is because the client who has undergone surgery for liver disorder also faces the risk of hyperthermia related to infection, rejection, or both. Providing the client with warm fluids will not control shivering. The client is covered with a hypothermia blanket if the temperature rises to 105?°F. The room temperature need not be below 70?°F.
When performing a physical examination on a client with cirrhosis, a nurse notices that the client's abdomen is enlarged. Which intervention should the nurse consider?
- A. Report the condition to the physician immediately.
- B. Measure abdominal girth according to a set routine.
- C. Provide the client with nonprescription laxatives.
- D. Ask the client about food intake.
Correct Answer: B
Rationale: If the abdomen appears enlarged, the nurse measures it according to a set routine. Measuring the abdominal girth is the most accurate method of determining an increase or decrease in abdominal distention. It is not essential for the client to take laxatives unless prescribed. The client's food intake does not affect the size of the abdomen in case of cirrhosis. The nurse would report to the physician about abdominal enlargement along with other parameters of the assessment.
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?
- A. A liver biopsy
- B. A CT scan
- C. A prothrombin time
- D. Platelet count
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.
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?
- A. Vitamin K
- B. Octreotide
- C. Vasopressin
- D. Epinephrine
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.
A client with cirrhosis is complaining of severe pruritus related to the accumulation of bile salts. What can be prescribed for the client to relieve the itching?
- A. Cholestyaramine
- B. Kanamyycin
- C. Lactulose
- D. Cyclosporine
Correct Answer: A
Rationale: Cholestyramine may be prescribed to bind bile salts and relieve pruritus. Kanamycin is prescribed to reduce the bacterial count in the intestine. Lactulose is used to decrease the amount of ammonia level in the blood. Cyclosporine is used to prevent rejection of a transplanted organ.