ASSESSMENT

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ASSESSMENT

This Assessment Is Powered By ACHIEVERS NCLEX-RN CONSULT [0240356615]. HEPATITIS AND LIVER CIRRHOSIS ASSESSMENT. QUESTIONS SOURCE: UWORLD, KAPLAN, HESI, AND ARCHER. PassMark: 20/25. BEST WISHES!.

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1. The nurse prepares to admit a client with worsening cirrhosis who is on the waiting list for a liver transplant. Based on the client's electronic health record, the nurse anticipates which assessment findings? Select all that apply. Click on the exhibit button for additional information. [Refer to exhibits 1 and exhibit 2]
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1 point

Exhibit 1

Exhibit 2

1.Ascites

2.Bruising

3.Constipation

4.Itching

5.Lethargy

Required

2. A student nurse is preparing to administer the hepatitis B vaccine to a newborn. Which statement by the student nurse requires the preceptor to provide further teaching?
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1 point

1."A ⅝-inch, 25-gauge needle is appropriate for intramuscular injection in newborns."

2."I will clean the injection site with an antiseptic swab before administration."

3."I will draw the medication into a 1-mL syringe."

4."The medication should be administered into the deltoid muscle

Q3. Which nursing interventions would the nurse implement when caring for a client newly diagnosed with acute, viral hepatitis B?

Select all that apply.

1 point

1. Offer small, frequent meals to prevent nausea

2. Promote rest periods between periods of activity

3. Provide a diet high in fat and low in carbohydrates

4. Teach the client not to share razors or toothbrushes with others

5. Teach the client to abstain from drinking alcohol

Required

Q4. The nurse is caring for a client with end-stage liver failure from hepatitis C who is being seen in the clinic for worsening ascites. The client is treated in the infusion center with intravenous (IV) albumin, IV furosemide, and oral spironolactone. The following day the nurse checks the client's labs. Which of the following lab findings is most important for the nurse to communicate to the health care provider?
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1 point

1. Albumin 2.5 g/dL (25 g/L)

2. INR 1.4

3. Potassium 3.0 mEq/L (3.0 mmol/L)

4. Sodium 131 mEq/L (131 mmol/L)

Q5. The nurse administers lactulose to a client diagnosed with cirrhosis and hepatic encephalopathy. Which nursing action is inappropriate when administering this medication?
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1 point

1. Assess mental status and orientation

2. Give on an empty stomach for rapid effect

3. Hold if 3 soft stools occur in a day

4. Mix with fruit juice to improve flavor

Q6. A female client with liver cirrhosis and chronic anemia is hospitalized for a deep venous thrombosis. The client is receiving a heparin infusion and suddenly develops epistaxis. Which laboratory value would indicate that the heparin infusion needs to be turned off?

1 point

1.Hematocrit of 30% (0.30)

2.Partial thromboplastin time of 110 seconds

3.Platelet count of 80,000/mm3 (80 x 109/L)

4.Prothrombin time of 11 seconds

Q7. Which of these are correct nursing actions related to client positioning? Select all that apply.

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1 point

1.Position client in high Fowler's for a paracentesis related to end-stage cirrhosis

2.Position client on left side after liver biopsy

3.Position client on side with head, back, and knees flexed after lumbar puncture

4.Position client Trendelenburg on left side if air embolism is suspected

5.Position client with arm raised above head for chest tube placement

Required

Q8. The nurse is caring for a client with cirrhosis. Assessment findings include ascites, peripheral edema, shortness of breath, fatigue, and generalized discomfort. Which interventions would be appropriate for the nurse to implement to promote the client's comfort?

Select all that apply.
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1 point

1. Encourage adequate sodium intake

2. Place client in semi-Fowler position

3. Place client in Trendelenburg position

4. Provide alternating air pressure mattress

5. Use music to provide a distraction

Required

Q9. The nurse admits a client with cirrhosis who has an upper gastrointestinal bleed from suspected gastroesophageal varices. Which new prescription should the nurse question?
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1 point

1. Administer pantoprazole IV piggyback every 12 hours

2. Initiate continuous octreotide IV infusion

3. Insert and maintain a nasogastric tube

4. Maintain NPO status except for PO medications

Q10. The nurse is evaluating a client with liver cirrhosis who received IV albumin after a paracentesis to drain ascites. Which assessment finding indicates that the albumin has been effective? *

1 point

1. Abdominal circumference reduced from admission recording

2. Flapping tremor no longer visible with arm extension

3. Shortness of breath no longer experienced in supine position

4. Vital signs remain within the client's normal parameters

Q11. The nurse provides discharge instructions to a client with cirrhosis who has portal hypertension, ascites, and esophageal varices. Which statement by the client indicates that the teaching was effective?
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1 point

1. "I may have one alcoholic drink a day, but no more."

2. "I may take aspirin instead of acetaminophen for fever or pain."

3. "I should avoid straining while having a bowel movement."

4. "I should eat a protein- and sodium-restricted diet."

Q12. A client diagnosed with cirrhosis is experiencing pruritus. Which strategies are appropriate for the nurse to teach the client to promote comfort and skin integrity?

Select all that apply.
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1 point

1. Apply cool, moist washcloths to the affected areas

2. Keep the fingernails trimmed short to minimize skin scratching

3. Take a hot bath or shower to alleviate itching sensations

4. Use skin protectant or moisturizing cream over unbroken skin

5. Wear cotton gloves or long-sleeved clothing to avoid scratching

Required

Q13. The unlicensed assistive personnel (UAP) assists a client with cirrhosis who underwent paracentesis 4 hours ago. The UAP reports to the nurse that the client was lightheaded and unsteady while ambulating to the chair. Which action should the nurse implement first?
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1 point

1. Ask the UAP to take a set of vital signs

2. Assess the symptoms reported by the UAP

3. Hold the prescribed diuretic medications

4. Instruct the UAP to assist the client to bed

Q14. A nurse is taking care of a male client who has just been diagnosed with hepatitis C. Which statement about this condition is accurate? *

1 point

a. The potential for chronic liver disease is unlikely

b. Symptoms set in abruptly

c. The incubation period for hepatitis C is usually 2-26 weeks

d. Vaccinations are available for hepatitis C

Q15. The nurse is admitting a patient diagnosed with hepatitis B. The nurse would be able to put the patient in the same room with which of the following patients?

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1 point

A. A patient with heart failure receiving diuretics

B. A patient with bacterial meningitis receiving antibiotics

C. A patient with prostate cancer receiving brachytherapy

D. A patient with varicella prescribed antivirals

Q16. The community health nurse is evaluating an individual’s risks of developing Hepatitis A. The nurse knows which age group is at the highest risk of acquiring Hepatitis A?
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1 point

A. Newborns

B. The elderly, ages 60 to 90

C. Teenagers older than age 15

D. Children older than 1 year but younger than 15 years

Q17. The nurse is caring for a patient receiving lactulose. Which of the following finding would indicate a therapeutic response?
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1 point

A. Increased liver enzymes

B. Increased level of consciousness

C. Decreased urinary calcium

D. Increased gastric pH

Q18. The home care nurse provides care to a client with alcoholic cirrhosis. Which caregiver statement requires intervention by the nurse? (Select all that apply.)
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1 point

1. "I will give the low dose aspirin with breakfast."

2. "Elastic-waist pants are more comfortable for my client."

3. "I'm trying to prepare more salads and leafy green vegetables."

4. "We often have to wake the client to eat meals."

5. "Sometimes the client doesn't get to the commode in time."

6. "The client's appetite is not good, so I'm glad to see a weight gain."

Required

Q19. Which of the following body substances can transmit hepatitis C (select all that apply)?
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1 point

A. Sweat

B. Urine

C. Stool

D. Blood

E. Semen

Required

20. A nurse is caring for a client with cirrhosis of the liver and a GI bleed who was admitted to the emergency department. The client has indicated he is a Jehovah’s Witness. The nurse understands that the client would not accept which of the following (select all that apply)?

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1 point

A. Lactated ringer’s solution

B. Platelets

C. Dextran

D. Erythropoietin

E. Whole blood

Required

Q21. A client with liver cirrhosis has been advised to follow a high-protein diet. The nurse evaluates the effectiveness of the diet if the total protein level is which of the following values? *

1 point

A. 6.9 g/dL.

B. 4.9 g/dL.

C. 2.9 g/dL.

D. 0.9 g/dL.

Q22. A nurse is assessing a client who is in the advanced stage of chronic liver disease. The nurse should identify which of the following findings as an indication the client has developed hepatic encephalopathy? (Select all that apply.)
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1 point

A. Anorexia

B. Change in orientation

C. Asterixis

D. Ascites

E. Fetor hepaticus

Required

Q23. A client is being admitted with a diagnosis of cirrhosis of the liver. What assessment findings should the nurse anticipate in this client?

SATA

1 point

1. Firm, nodular liver

2. Ascites

3. Increased serum albumin levels

4. Increased ALT and AST levels

5. Lowered ammonia levels

6. Bleeding from the GI tract

Required

Q24. The nurse is caring for clients diagnosed with liver cirrhosis. Which client does the nurse need to see first?

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1 point

• A. A client with ascites who has a poor appetite

• B. A client with a pain level of 8 with suspected liver cancer

• C. A client with jaundice, +3 pitting edema, and elevated LFTs

• D. A client with tarry stool and lightheadedness

Q25. A client diagnosed with cirrhosis of the liver reports, “I cannot catch my breath.” Which finding does the nurse report to the health care provider? (Select all that apply.)

1 point

1.Palpable swelling on bilateral ankles.

2.Blood pressure of 165/90 mm Hg.

3.Auscultation of crackles in the lung fields.

4.Bulging jugular vein.

5.A weight gain of 2 kg (4.4 lb) in 24 hours.

6.Blood urea nitrogen (BUN) level is 7 mg/dL (2.5 mmol/L).

Required

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