.DD has the diagnosis of biliary cirrhosis. you noticed some bruising on his arms and legs and
want to follow up on the following lab values consistent with his disease. You know to evaluate
which of the following?
B. platelets, PT/INR, HGB and Vitamin K plasma level.
“C” is the only answer with Vitamin K, so by process of elimination its that, plus the other labs are used to check for clotting issues too.
Patients with cirrhosis are susceptible to bleeding and easy bruising because there is a decrease in the production of bile in the liver, preventing the absorption of which vitamin? Answer Vitamin K.
Your patient will be receiving external beam radiation on an outpatient basis. In teaching your
patient about what to expect from the therapy, you should be sure to include the following?
B. You may experience altered taste sensation.
Rationale: External Beam radiation therapy will not make you radioactive. It does not cure anything in one session. External Beam radiation comes from a machine that aims radiation directly at your cancer. It Means it treats a specific part of your body. Side Effects include: Difficulty swallowing, skin changes, fatigue, nausea, hair loss, swelling, tenderness and inflammation. When having radiation therapy, you may have some changes in your skin in the area being treated. Your skin may turn red, peel or itch.
. A patient with hepatitis B is being discharged in 2 days. In the discharge teaching plan, the
nurse should include instructions to do which of the following?
B. Use a condom during sexual intercourse
Rationale: Hepatitis B virus may be transmitted by mucosal exposure to infected blood,
blood products, or other body fluids (e.g., semen, vaginal secretions, saliva). Hepatitis B is a
sexually transmitted disease that is acquired through unprotected sex with an infected
person. Condom use should be taught to patients to prevent transmission of hepatitis B.
. To prevent the spread of hepatitis A virus (HAV) infection the nurse is especially careful
when doing which of the following?
A. Emptying bedpans
A is the correct answer. HAV is transmitted primarily person-to-person by the fecal-oral
route. Food can be a method of transmission but needs to be fecally contaminated. Since
the transmission of hepatitis A is fecal-oral and not saliva or blood like hepatitis B, taking a
temperature and changing IV tubing would not spread hepatitis A.
. During the icteric phase of hepatitis, the nurse would expect the patient's laboratory
results to include which of the following?
A. Increased direct (conjugated) and indirect (unconjugated) serum bilirubin.
Icteric Phase: decrease in the flu-like symptoms but will have jaundice and dark urine
(buildup of bilirubin) yellowing of skin and white part of the eyeball, clay-colored stool
(bilirubin not going to stool to give it’s normal brown color) enlarged liver and pain in this
area.
Unconjugated hyperbilirubinemia is a condition defined as elevated serum or plasma
bilirubin (unconjugated) levels above the reference range of the laboratory. Unconjugated
hyperbilirubinemia usually results from dysregulation in the bilirubin metabolism that
includes increased production, impaired hepatic uptake, and decreased conjugation of
bilirubin.
Unconjugated bilirubin goes to the liver where it is conjugated by the liver then goes to the
gallbladder. If the liver is diseased, it’s able to conjugate some, but not all. This leaves
conjugated AND unconjugated bilirubin in the system. The Icteric phase just means the
Jaundice phase, so there is increased conjugated and increased unconjugated bilirubin in the
icteric phase. Pretty sure the answer is correct.
. The nurse assesses a patient with cirrhosis and finds 4 + pitting edema of the feet and legs
and massive ascites. The nurse recognizes that one factor contributing to edema and ascites in
patients with cirrhosis is which of the following?
gastrointestinal vessels.
d. Decreased renin-angiotensin response related to decreased renal blood flow.
C. Hyperaldosteronism caused by liver's ability to inactivate the hormone
What is the etiology of ascites?-portal htn (pressure causes leakage of fluid & protein) -
hypoalbuminemia (loss of oncotic pressure) -hyperaldosteronism -excessive ADH secretion
The nurse is caring for an adult client with acute pancreatitis. Which laboratory finding lead
the nurse to believe that this diagnosis is correct?
B. Lipase, 625 U/L (Normal 0-160)
Rationale: Unlike amylase, there is significant reabsorption of lipase in the renal tubules so
the serum concentrations remain elevated for 8–14 days.
Serum amylase and lipase levels are typically elevated in persons with acute pancreatitis.
However, these elevations may only indicate pancreastasis. In research studies, amylase or lipase levels at least 3 times above the reference range are generally considered diagnostic
of acute pancreatitis
. The nurse is providing discharge teaching for a client who has just undergone laparoscopic
cholecystectomy surgery. Which statement by the client indicates understanding of the
instructions?
B. “I will have a low-fat diet with small, frequent meals.”
After cholecystectomy, clients need a nutritious diet without a lot of excess fat; otherwise a
special diet is not recommended for most clients. Good fluid intake is healthy for all people
but is not related to the surgery. Drinking fluids between meals helps with dumping
syndrome, which is not seen with this operation. Restriction of sweets is not required.
. A shunting procedure is considered for a patient with cirrhosis following an episode of
bleeding esophageal varices. A correct statement related to this procedure includes which of the
following?
C. These procedures increase the risk of hepatic encephalopathy.
The risk for hepatic encephalopathy increases after shunt procedures because blood
bypasses the portal system and ammonia is diverted past the liver and into the systemic
circulation.
. The nurse has spent several days reviewing measures to cope with chronic pancreatitis with
Mr. P., a patient with alcohol related pancreatitis. Which statement is most indicative that Mr. P.
understands his teaching plan?
D. I need to cut out the glass of wine I have with dinner.
Rationale: If you have chronic pancreatitis you must stop drinking alcohol completely.
Your pancreas will be unable to work properly and any alcohol can make the condition
worse, causing more damage to your pancreas. Damage from chronic pancreatitis can be
irreversible.
. The nurse identifies the collaborative problem of potential complication: electrolyte
imbalance for a patient with severe acute pancreatitis. Assessment findings that alert the nurse to
electrolyte imbalances associated with acute pancreatitis include which of the following?
A patient is admitted to the hospital with a sudden onset of severe right upper quadrant pain
that radiates to the right shoulder. She has a history of fat intolerance and heartburn. The nurse
recognizes that the patient most likely has a biliary tract obstruction when the patient reports
experiencing which of the following?
. A client is admitted to the hospital with anorexia, and ascites. Serum AST, SGPT, LDH, and
total bilirubin are significantly elevated. Based on the client's lab results, the nurse performing an
admission assessment will expect to find?
D. Jaundice.
Rationale: Elevated LFT’s indicate liver dysfunction affecting conjugation of bilirubin
(pigment). Unconjugated bilirubin cannot be excreted via the kidney or the GI tract and stays in
the bloodstream and causes yellowing of the skin - jaundice
As the RN caring for GT in the ICU, you will expect to find which set of abnormal
laboratory parameters consistent with the diagnosis of “acute pancreatitis”?
. A patient's tumor is stage T2, N0, M0. This staging indicates which of the following about
the patient's status?
a. There is an advanced tumor with indication of metastasis but no indication of lymph node
involvement
b. The patient has a measurable tumor with no metastasis or involvement of nodes.
c. There is an advanced tumor with metastasis
d. There is an advanced tumor with indication of involvement of lymph nodes but no
indication of metastasis
b. The patient has a measurable tumor with no metastasis or involvement of nodes.
Rationale: T refers to tumor size, N refers to nodules and M refers to metastases. If the number
after N and M is 0, it indicates that the tumor has not spread into neighboring regional nodes
distant metastases have not been found.
The nurse is admitting a severely leucopenic patient who is receiving radiation therapy.
Which is the most appropriate room for this patient?
A. A private room with protective isolation
Rationale: Leukopenic patients are immuno-cpompromised and prone to infection. Effective
infection control include admitting patient in a private room with protective isolation.
Following a hypophysectomy for a pituitary tumor, the nurse suspects that the patient has
developed diabetes insipidus upon finding which of the following?
D. A urine specific gravity of 1.001.
Rationale: Urine specific gravity less than 1.005 is indicative of DI
. When reviewing the chart for a patient with cervical cancer, the nurse notes that the cancer is
staged as T2 N2, M2. The nurse will teach the patient which of the following?
D. The tumor has spread.
Rationale: T refers to tumor size, N refers to nodules and M refers to metastases. If the number
after M is greater than 0, it indicates that distant metastases have been found and the tumor has
spread.
What teaching is essential for the client who has received an injection of iodine-131, an
unsealed radioisotope?
A. “Do not share a toilet with anyone else for 3 days.”
A patient with a large stomach tumor that is attached to the liver is scheduled to have a
debulking procedure. The nurse explains that the expected outcome of the surgery is which of the
following?
C. Reduction of the tumor size.
Rationale: A debulking surgery reduces the size of the tumor and makes radiation and
chemotherapy more effective. Debulking surgeries do not control tumor growth. The tumor is
debulked because it is attached to the liver, a vital organ (not to relieve pressure on the stomach).
Debulking does not sever the sensory nerves, although pain may be lessened by the reduction in
pressure on the abdominal organs
The client with obstructive jaundice asks the nurse why his skin is so itchy. Which is the
nurse's best response?
skin.”
C. “The itching is caused by the accumulation of bile salts in the skin.”
Rationale: In obstructive jaundice, the normal flow of bile into the duodenum is blocked,
allowing excess bile salts to accumulate on the skin. This leads to itching, or pruritus.
Your patient has been diagnosed with a metastatic brain tumor. You suspect that he
exhibiting SIADH when he exhibits which of the following?
A. Urine specific gravity 1.045
Rationale: A urine specific gravity higher that 1.030 is indicative of SIADH
patient with metastatic cancer of the colon experiences severe vomiting following each
administration of chemotherapy. Which is an important nursing intervention for this patient?
B. Administer prescribed antiemetics 1 hour before the treatments.
Rationale: Treatment with antiemetics before chemotherapy may help to prevent anticipatory
nausea. Although nausea may lead to poor nutrition, there is no indication that the patient needs
instruction about nutrition. The patient should eat small, frequent meals. Offering food and
beverages during chemotherapy is likely to cause nausea.
. When caring for a patient with cirrhosis the nurse notices flapping tremors of the wrist and
fingers. How should the nurse chart this finding?
D. Asterixis noted
Rationale: Cirrhosis can cause flapping of the hands (asterixis), changes in mentation, agitation,
and confusion
. Which information noted by the nurse reviewing the laboratory results of a patient who is
receiving chemotherapy is most important to report to the healthcare provider?
A. WBC count of 800/μl
Rationale: Neutropenia places the patient at risk for severe infection and is an indication that the
chemotherapy dose may need to be lower or that white blood cell (WBC) growth factors such as
filgrastim (Neupogen) are needed. The other laboratory data do not indicate any immediate lifethreatening adverse effects of the chemotherapy
The nurse is caring for a client with chronic pancreatitis. Which statement by the client
indicates that additional teaching is needed?
C. “At least now I am immune to this condition and I can't get it twice.”
. The nurse has identified the nursing diagnosis of imbalanced nutrition: less than body requirements related to altered taste sensation in a patient with lung cancer who has had a 10% loss in weight. Which is an appropriate nursing intervention that addresses the etiology of this problem?
C. Avoid presenting foods for which the patient has a strong dislike.
Rationale: The patient will eat more if disliked foods are avoided and foods that patient likes are
included instead. Additional spice is not usually an effective way to enhance taste. Adding baby
meats to foods will increase calorie and protein levels, but does not address the issue of taste.
Patients will not improve intake by eating foods that are beneficial but have unpleasant taste.
. What statement indicates that the client understands teaching about neutropenia and bone
marrow suppression?
D. It will be better for me to do my holiday shopping online this year.
Rationale: Bone marrow suppression may lead to low neutropenic levels and are prone to sepsis.
Shopping online is a way to control and prevent infection
Your patient with tumor lysis syndrome (TLS) has been admitted to your unit and is under
your care. You know that the plan for him should include which of the following?
D. Uric acid level testing, hydration, and cardiac monitoring
Rationale: Increases uric acid that affects the kidneys, treat with fluids and mannitol
The nurse is caring for a patient with a history of alcoholism. Which of the following
findings would indicate that the patient has possibly developed chronic pancreatitis?
C. Steatorrhea (fatty stools)
Rationale: Manifestations of chronic pancreatitis include vomiting, nausea, weight loss,
flatulence, constipation, and steatorrhea that result from a decrease in pancreatic enzyme
secretion.
The client who has just had a mastectomy is crying. When the nurse asks about her crying,
the client responds, “I know I shouldn’t cry because this surgery may well save my life.” What is
the nurse’s best response?
B. It’s important to express these feelings you have. It’s alright to tell me about it
Rationale: Cancer surgery can involve the loss of a body part or a decrease in function.
Mourning or grieving for a body image alteration is a healthy response in adapting or adjusting
to a new image.
A client is receiving brachytherapy with a sealed radiation source for cervical cancer. Which
nurse will be assigned to provide personal care to this client?
D. An oncology certified nurse with three years’ experience
Rationale: The client is emitting radioactivity and poses a radiation hazard to others at this time.
An experienced oncology nurse will provide the best care.
. The client’s radiation implant has become dislodged overnight, and the nurse finds it in the
client’s bed. What will the nurse do first?
A. Get tongs and the lead pig
Rationale: The implant does emit radiation and should be placed into the secure, lead-lined
container in the client’s room. The nurse does not directly touch this implant but uses longhandled tongs for this purpose. The nurse does not need to assess the client’s skin, nor should he
or she attempt to replace the source. Moving the client is not necessary, although in keeping with
facility policy, the radiation safety officer may need to be notified.
. The client receiving intravenous chemotherapy asks the nurse the reason for wearing a mask,
gloves, and gown when he or she is giving the drugs to the client. What is the nurse’s best
response?
D. The clothing protects me from accidentally absorbing these drugs
Rationale: Most chemotherapy drugs are absorbed through the skin and mucous membranes. As
a result, health care workers who prepare or give these drugs, especially nurses and pharmacists,
are at risk for absorbing them. Even at low doses, chronic exposure to chemotherapy drugs can
affect health.
. Which intervention is important for the nurse to implement to prevent complications from
tumor lysis syndrome during chemotherapy?
C. Ensures that the client has a fluid intake of 3000 to 5000 mL/day
Rationale: The most important treatment modality in the prevention of TLS is hyperhydration
with IV fluids beginning prior to chemotherapy in high-risk patients (Coiffier et al., 2008).
Fluid administration increases renal tubular flow and promotes the elimination of urates and
phosphates
. The nurse teaches the client with superior vena cava syndrome that improvement is
characterized by which clinical manifestation?
A. The client’s hands are less swollen
Rationale: With superior vena cava syndrome, blood flow through the vena cava is compromised
as a result of tumor growth. Blood backs up into the periphery, and the client experiences upper
body swelling, including the hands and feet.
. After receiving their reports, which patient will the nurse assess first
B. The client with neutropenia who has just been admitted with a possible infection
Rationale: neutropenic patients are priority due to the risk for rapid progression to severe
infections and sepsis
he nurse is caring for a client with acute pancreatitis. Which nursing intervention will best
reduce discomfort for the client?
A. Maintaining NPO status for the client with IV fluids
Rationale: The client should be kept NPO to reduce GI activity and reduce pancreatic enzyme
production. IV fluids should be used to prevent dehydration. The client may need a nasogastric
(NG) tube. Pain medications should be given around the clock and more frequently than every 4
to 6 hours. A fetal position with legs drawn up to the chest will promote comfort.
The nurse correlates decreased hepatic synthesis of which substance in the client who
develops ascites and 3+ pitting peripheral edema?
B. Albumin
Rationale: ascites results from increased pressure in the venous system caused by low levels of
serum albumin (which contributes to decreased colloid osmotic pressure
For the client with cirrhosis, which nursing intervention would be most effective in
attempting to control fluid accumulation in the abdominal cavity?
B. Providing a low-sodium diet
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.
client with an esophagogastric tube suddenly experiences acute respiratory distress. Which
is the nurse’s first action?
A. Cutting the balloon ports and removing the tube
Rationale: When respiratory compromise is noted in a client with an esophagogastric tube, the
nurse should immediately cut both ports with a pair of scissors that is kept at the bedside and
remove the tube. The nurse would not call the health care provider until the client was out of
immediate danger. Once the tube has been removed, the nurse can reposition the client and apply
oxygen
. Which finding in the client receiving an infusion of vasopressin to beat bleeding esophageal
varices indicates to the nurse a serious adverse effect of the drug?
B. Midsternal chest pain
Rationale: In large doses, vasopressin may produce increased blood pressure, coronary
insufficiency, myocardial ischemia or infarction, and dysrhythmia
The nurse correlates which rationale for a protein-restricted diet in the client with hepatic
encephalopathy?
C. A low-protein diet will help the amount of ammonia in the blood
Rationale: Encephalopathy is caused by accumulation of toxins in the liver, one of which is
ammonia. Ammonia is produced when proteins are broken down by the body. In a patient with
cirrhosis the liver is not able to clear this toxin from the body; thus, it is important to restrict
protein intake.
9. The nurse recognizes which client as being at greatest risk of developing hepatitis A?
D. An older woman who has eaten raw shellfish
Rationale: Hepatitis A is transmitted via fecal/oral route. Modes: daycare, restaurants (shellfish).
The route of acquisition of hepatitis A infection is through close personal contact or ingestion of
contaminated water or shellfish.
. Which statement by the client with alcohol-induced cirrhosis indicates the need for further
teaching?
D. I need to avoid all protein in my diet
Rationale: Based on the degree of liver involvement and decreased function, protein intake may
have to be decreased. However, some protein is necessary for the synthesis of albumin and
normal healing. The other statements indicate accurate understanding of self-care measures for
this client.
The nurse is concerned that a 45yr old female pt with cholelithiasis will develop acute pancreatitis, why is the nurse concerned? SATA
E. This pt has gall stones
D. Because the pt is a female
Do you really need to draw a Ca level to be concerned? Should really be drawing a systemic lipase.Also, don’t need to draw a triglyceride level.
Pt is admitted to rule out acute pancreatitis which of the following lab tests will provide the most accurate information to support this?
A. Lipase
lipase is more validating than amylase—provides a longer period for trending
when assessing a pts pain level the nurse concludes that a pt is experiencing acute pancreatitis with what assessment? SATA
B. Pain is less when the pt leans forward
c. Pain is sharp like a knife occurs w/o warning
Pt with acute pancreatitis is experiencing pain, the nurse would like to help the pt with a position change, which 2 positions would help this pt?
