Nursing II - Chapter 35
"Hold out your arms and hands." - ANS-The nurse is collecting data from a patient with liver
failure to detect hepatic encephalopathy. Which instruction does the nurse give to the patient to
collect the data?
"I need to get my extra weight off as quick as possible." - ANS-A patient is being treated for
acute cholecystitis. The patient is instructed on dietary measures to reduce the possibility of
recurrent episodes. Which patient comment indicates a need to reinforce teaching?
Abdominal distention, respiratory distress, and midepigastric pain - ANS-The nurse is collecting
data from a patient with acute pancreatitis. Which symptoms should
the nurse anticipate?
Amylase - ANS-The nurse is caring for a patient with chronic pancreatitis. While reviewing
laboratory data, the nurse would expect an elevation in which serum laboratory value?
Answer: _____0.25_________ mL - ANS-The nurse is to administer promethazine 12.5 mg
intramuscularly and has 50 mg/mL on hand. How many milliliters should be drawn up? Fill in the
blank.
Bile duct obstruction - ANS-The nurse is collecting data for a patient who develops jaundice and
dark-colored urine. The nurse recognizes that which of the following is most likely the cause of
these clinical manifestations?
Decrease in the amount of bile in the T-tube - ANS-The nurse is assisting with the care of a
patient following a liver transplant for cirrhosis. Which finding will the nurse report immediately to
the RN or HCP?
Gallstones and inflammations - ANS-The nurse is reinforcing patient teaching regarding the
causes of gallbladder disorders.
Which condition does the nurse present as being a common cause?
Get adequate rest.
Ingest nutritious foods.
Abstain from all alcohol. - ANS-A patient recovering from hepatitis is concerned about liver
damage from the infection. Which instructions does the nurse provide the patient to prevent
long-term liver damage? (Select all that apply.)
Headache
Flu-like symptoms
Nausea - ANS-The nurse is collecting data for a patient with suspected acute hepatitis A
infection. Which clinical manifestations would the nurse expect the patient to report? Select all
that apply.
Increase high-quality protein to promote healing.
Avoid dietary fats to prevent postoperative nausea or pain.
Call the HCP if fever, redness, or drainage indicates infection. - ANS-The nurse is preparing to
reinforce discharge teaching for a patient who underwent a
cholecystectomy. Which information does the nurse plan to cover? (Select all that apply.)
Jaundice - ANS-A patient presents at the HCP's office with epigastric pain. The patient's
temperature and pulse and respiration rates are all elevated. Which additional symptom will the
nurse associate as a possible sign of cholelithiasis?
Liver dysfunction - ANS-The nurse is obtaining information from a patient who is obese and has
diabetes mellitus (DM). Upon physical examination, the nurse notes generalized ecchymosis, an
enlarged and tender liver with palpation, and evidence of ascites with percussion. Which
possible disease condition does the nurse identify from the findings?
Liver failure - ANS-The nurse is gathering information about a new patient in an adult clinic. The
patient states, "I have severe arthritis, but I control the pain with two 650-mg acetaminophen
tablets four times a day." Which condition does the nurse associate with the patient's medication
regimen?
Long-term treatment with a dissolution drug - ANS-The nurse is providing care for an older adult
patient with a diagnosis of small noncalcified gallstones. The HCP prefers to avoid surgery on
the patient due to age and a medical history of cardiac disorders. Which medical treatment does
the nurse most likely expect the HCP to prescribe?
Low vitamin K - ANS-The nurse is planning care for a patient with cirrhosis. For which condition
would the nurse place the patient on bleeding precautions?
Maintain functional ability of the liver. - ANS-The nurse is providing care for a patient admitted
with acute liver failure related to an acetaminophen overdose. Which goal is associated with
care for the patient?
Maintain low physical activity. - ANS-The nurse is reinforcing teaching provided to a patient with
esophageal varices. Which suggestion is the least important?
Neurologic - ANS-The nurse is providing care for a patient admitted with serious acute
pancreatitis. The patient is in guarded condition and exhibits multiple manifestations of
pancreatitis complications. The nurse is aware that which body system is unlikely to lead to
patient death?
Patient expresses satisfaction with pain control. - ANS-The nurse is planning care for a newly
admitted patient with acute pancreatitis. Which patient outcome should receive the highest
priority in the plan of care?
Perform frequent hand washing and do not share personal items. - ANS-A patient reports that a
family member is diagnosed with hepatitis and asks the nurse the best way to prevent becoming
infected. Which is the best information for the nurse to provide?
Performance of a Whipple procedure - ANS-A patient just receives a diagnosis of pancreatic
cancer with metastasis to the liver, gallbladder, and stomach. The nurse is informed that the
patient has agreed to palliative care. Which intervention seems unexpected to the nurse?
Place in an upright or slightly leaning forward position. - ANS-The nurse is providing care for a
patient diagnosed with chronic pancreatitis. The patient's vital signs are blood pressure 130/78
mm Hg, respirations 28 breaths/min and labored with O2 saturation rate of 90%, pulse 102
beats/min, and pain level of 7 on a 0-to-10 scale. Which immediate nursing action is
appropriate?
Prostatic hypertrophy - ANS-A patient with biliary colic is prescribed an anticholinergic
medication to help treat the condition. For which medical diagnosis should the nurse question
the administration of this medication?
Provide analgesics for pain relief.
Encourage coughing and deep breathing.
Assist with splinting during coughing. - ANS-The nurse is caring for a patient who had an open
cholecystectomy 24 hours ago. Which actions should the nurse take to assist the patient to
maintain an effective breathing pattern? Select all that apply.
Roast chicken, rice, gelatin dessert - ANS-The nurse reinforces teaching for a patient after a
cholecystectomy who is on a low-fat diet. The nurse will know that the patient understands the
diet if which menu items are selected?
Sedatives are potentially toxic to the cirrhosis patient. - ANS-The nurse is caring for a patient
with cirrhosis. The nurse would cautiously use sedatives for the patient due to which of the
following?
T-tube drainage is 600 mL over the past 24-hour period. - ANS-The nurse is providing care for a
client following an open cholecystectomy involving the removal of large gallstones and
placement of a T-tube. Which third day postsurgical manifestation will cause the nurse to report
the finding?
To constrict vessel dilation to the esophageal varices - ANS-A patient with liver failure and
esophageal varices is prescribed to receive vasopressin. For which purpose does the nurse
recognize the need for this medication?
