Nokea
The nurse is caring for the client diagnosed with ascites secondary to hepatic cirrhosis. Which information should the nurse report to the health-care provider?
- A. A decrease in the client's daily weight of one (1) pound.
- B. An increase in urine output after administration of a diuretic.
- C. An increase in abdominal girth of two (2) inches.
- D. A decrease in the serum direct bilirubin to 0.6 mg/dL.
Correct Answer: C
Rationale: An increase in abdominal girth (2 inches) suggests worsening ascites, requiring HCP notification. Weight loss, increased urine output, and normal bilirubin are expected or less urgent.
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The experienced nurse is instructing the new nurse. The experienced nurse explains that the definitive diagnosis of PUD involves which test?
- A. A urea breath test
- B. Upper GI endoscopy with biopsy
- C. Barium contrast studies
- D. The string test
Correct Answer: B
Rationale: A. A urea breath test only tests for the presence of Helicobacter pylori (H. pylori). B. The gastric mucosa can be visualized with an endoscope. A biopsy is possible to differentiate PUD from gastric cancer and to obtain tissue specimens to identify H. pylori. These are used to make a definitive diagnosis of PUD. C. Barium studies do not provide an opportunity for biopsy and H. pylori testing. D. A urea breath test and a string test only test for the presence of H . pylori.
The clinic nurse is returning client calls. Which client should the nurse call first?
- A. The 39-year-old client complaining of headache pain with a 3 on the pain scale.
- B. The 45-year-old client who needs a prescription refill for warfarin.
- C. The 54-year-old client diagnosed with diabetes type 1 who has been vomiting.
- D. The 60-year-old client who cannot afford to buy food and needs assistance.
Correct Answer: C
Rationale: Vomiting in a type 1 diabetic risks diabetic ketoacidosis, a medical emergency, requiring immediate attention. Headache, warfarin refill, and food insecurity are less urgent.
The client is admitted with end-stage liver failure and is prescribed the laxative lactulose (Chronulac). Which statement indicates the client needs more teaching concerning this medication?
- A. I should have two to three soft stools a day.
- B. I must check my ammonia level daily.
- C. If I have diarrhea, I will call my doctor.
- D. I should check my stool for any blood.
Correct Answer: B
Rationale: Clients do not routinely check ammonia levels at home; this is done clinically if needed. The other statements reflect correct understanding of lactulose use for hepatic encephalopathy.
The nurse is caring for the client diagnosed with cirrhosis. After completing discharge education, the nurse recognizes the need for further teaching when the client makes which statement?
- A. “My cirrhosis was caused from too much alcohol; I plan to stop drinking.”
- B. “I need to rest more; I plan on only going to work on a part-time basis.”
- C. “Propranolol has been ordered to decrease my blood pressure.”
- D. “Furosemide will help to reduce the amount of abdominal fluid.”
Correct Answer: C
Rationale: A. Alcohol intake is a major cause of cirrhosis and must be eliminated from the client’s diet. B. Rest may enable the liver to restore itself and should be encouraged. C. Although propranolol (Inderal) does decrease BP, it is not ordered for this purpose in treating cirrhosis. Prophylactic treatment with a nonselective beta blocker like propranolol has been shown to reduce the risk of bleeding from esophageal varices and to reduce bleeding-related deaths. D. Furosemide (Lasix) is used in combination with potassium-sparing diuretics to decrease ascites.
The client has had a liver biopsy. Which postprocedure intervention should the nurse implement?
- A. Instruct the client to void immediately.
- B. Keep the client NPO for eight (8) hours.
- C. Place the client on the right side.
- D. Monitor blood urea nitrogen (BUN) and creatinine level.
Correct Answer: C
Rationale: Placing the client on the right side applies pressure to the biopsy site, reducing bleeding risk. Voiding, NPO status, and BUN/creatinine are not specific to liver biopsy care.