front 1 1. A nurse is caring for a patient with liver failure and is
performing an assessment in the knowledge of the patient’s increased
risk of bleeding. The nurse recognizes that this risk is related to
the patient’s inability to synthesize prothrombin in the liver. What
factor most likely contributes to this loss of function? | back 1 Ans: D |
front 2 2. A nurse is performing an admission assessment of a patient with a
diagnosis of cirrhosis. What technique should the nurse use to palpate
the patient’s liver? | back 2 Ans: C |
front 3 3. A patient with portal hypertension has been admitted to the
medical floor. The nurse should prioritize which of the following
assessments related to the manifestations of this health
problem? | back 3 Ans: C |
front 4 4. A nurse educator is teaching a group of recent nursing graduates
about their occupational risks for contracting hepatitis B. What
preventative measures should the educator promote? Select all that
apply. | back 4 Ans: A, B |
front 5 5. A nurse is caring for a patient with cancer of the liver whose
condition has required the insertion of a percutaneous biliary
drainage system. The nurse’s most recent assessment reveals the
presence of dark green fluid in the collection container. What is the
nurse’s best response to this assessment finding? | back 5 Ans: A |
front 6 6. A patient who has undergone liver transplantation is ready to be
discharged home. Which outcome of health education should the nurse
prioritize? | back 6 Ans: C |
front 7 7. A triage nurse in the emergency department is assessing a patient
who presented with complaints of general malaise. Assessment reveals
the presence of jaundice and increased abdominal girth. What
assessment question best addresses the possible etiology of this
patient’s presentation? | back 7 Ans: A |
front 8 8. A nurse is participating in the emergency care of a patient who
has just developed variceal bleeding. What intervention should the
nurse anticipate? | back 8 Ans: D |
front 9 9. A nurse is caring for a patient with hepatic encephalopathy. While
making the initial shift assessment, the nurse notes that the patient
has a flapping tremor of the hands. The nurse should document the
presence of what sign of liver disease? | back 9 Ans: A |
front 10 10. A local public health nurse is informed that a cook in a local
restaurant has been diagnosed with hepatitis A. What should the nurse
advise individuals to obtain who ate at this restaurant and have never
received the hepatitis A vaccine? | back 10 Ans: D |
front 11 11. A participant in a health fair has asked the nurse about the role
of drugs in liver disease. What health promotion teaching has the most
potential to prevent drug-induced hepatitis? | back 11 Ans: B |
front 12 12. Diagnostic testing has revealed that a patient’s hepatocellular
carcinoma (HCC) is limited to one lobe. The nurse should anticipate
that this patient’s plan of care will focus on what
intervention? | back 12 Ans: C |
front 13 13. A patient has been diagnosed with advanced stage breast cancer
and will soon begin aggressive treatment. What assessment findings
would most strongly suggest that the patient may have developed liver
metastases? | back 13 Ans: B |
front 14 14. A patient is being discharged after a liver transplant and the
nurse is performing discharge education. When planning this patient’s
continuing care, the nurse should prioritize which of the following
risk diagnoses? | back 14 Ans: A |
front 15 15. A patient with a liver mass is undergoing a percutaneous liver
biopsy. What action should the nurse perform when assisting with this
procedure? | back 15 Ans: A |
front 16 16. A nurse is caring for a patient with hepatic encephalopathy. The
nurse’s assessment reveals that the patient exhibits episodes of
confusion, is difficult to arouse from sleep and has rigid
extremities. Based on these clinical findings, the nurse should
document what stage of hepatic encephalopathy? | back 16 Ans: C |
front 17 17. A patient has developed hepatic encephalopathy secondary to
cirrhosis and is receiving care on the medical unit. The patient’s
current medication regimen includes lactulose (Cephulac) four times
daily. What desired outcome should the nurse relate to this
pharmacologic intervention? | back 17 Ans: A |
front 18 18. A nurse is performing an admission assessment for an 81-year-old
patient who generally enjoys good health. When considering normal,
age-related changes to hepatic function, the nurse should anticipate
what finding? | back 18 Ans: D |
front 19 19. A nurse is caring for a patient with a blocked bile duct from a
tumor. What manifestation of obstructive jaundice should the nurse
anticipate? | back 19 Ans: B |
front 20 20. During a health education session, a participant has asked about
the hepatitis E virus. What prevention measure should the nurse
recommend for preventing infection with this virus? | back 20 Ans: A |
front 21 21. A patient’s physician has ordered a “liver panel” in response to
the patient’s development of jaundice. When reviewing the results of
this laboratory testing, the nurse should expect to review what blood
tests? Select all that apply. | back 21 Ans: A, C, D |
front 22 22. A patient with liver disease has developed jaundice; the nurse is
collaborating with the patient to develop a nutritional plan. The
nurse should prioritize which of the following in the patient’s
plan? | back 22 Ans: C |
front 23 23. A nurse is amending a patient’s plan of care in light of the fact
that the patient has recently developed ascites. What should the nurse
include in this patient’s care plan? | back 23 Ans: D |
front 24 24. A nurse is caring for a patient who has been admitted for the
treatment of advanced cirrhosis. What assessment should the nurse
prioritize in this patient’s plan of care? | back 24 Ans: B |
front 25 25. A patient with a diagnosis of cirrhosis has developed variceal
bleeding and will imminently undergo variceal banding. What
psychosocial nursing diagnosis should the nurse most likely prioritize
during this phase of the patient’s treatment? | back 25 Ans: C |
front 26 26. A patient with a diagnosis of esophageal varices has undergone
endoscopy to gauge the progression of this complication of liver
disease. Following the completion of this diagnostic test, what
nursing intervention should the nurse perform? | back 26 Ans: B |
front 27 27. A patient with esophageal varices is being cared for in the ICU.
The varices have begun to bleed and the patient is at risk for
hypovolemia. The patient has Ringer’s lactate at 150 cc/hr infusing.
What else might the nurse expect to have ordered to maintain volume
for this patient? | back 27 Ans: D |
front 28 28. A patient with a history of injection drug use has been diagnosed
with hepatitis C. When collaborating with the care team to plan this
patient’s treatment, the nurse should anticipate what
intervention? | back 28 Ans: B |
front 29 29. A group of nurses have attended an inservice on the prevention of
occupationally acquired diseases that affect healthcare providers.
What action has the greatest potential to reduce a nurse’s risk of
acquiring hepatitis C in the workplace? | back 29 Ans: A |
front 30 30. A patient has been admitted to the critical care unit with a
diagnosis of toxic hepatitis. When planning the patient’s care, the
nurse should be aware of what potential clinical course of this health
problem? Place the following events in the correct sequence. | back 30 Ans: B |
front 31 31. A previously healthy adult’s sudden and precipitous decline in
health has been attributed to fulminant hepatic failure, and the
patient has been admitted to the intensive care unit. The nurse should
be aware that the treatment of choice for this patient is
what? | back 31 Ans: C |
front 32 32. A nurse is caring for a patient with cirrhosis secondary to heavy
alcohol use. The nurse’s most recent assessment reveals subtle changes
in the patient’s cognition and behavior. What is the nurse’s most
appropriate response? | back 32 Ans: B |
front 33 33. A patient with end-stage liver disease has developed
hypervolemia. What nursing interventions would be most appropriate
when addressing the patient’s fluid volume excess? Select all that
apply. | back 33 Ans: A, C, E |
front 34 34. A patient with liver cancer is being discharged home with a
biliary drainage system in place. The nurse should teach the patient’s
family how to safely perform which of the following actions? | back 34 Ans: D |
front 35 35. A patient with cirrhosis has experienced a progressive decline in
his health; and liver transplantation is being considered by the
interdisciplinary team. How will the patient’s prioritization for
receiving a donor liver be determined? | back 35 Ans: B |
front 36 36. A nurse has entered the room of a patient with cirrhosis and
found the patient on the floor. The patient states that she fell when
transferring to the commode. The patient’s vital signs are within
reference ranges and the nurse observes no apparent injuries. What is
the nurse’s most appropriate action? | back 36 Ans: C |
front 37 37. A patient with liver cancer is being discharged home with a
hepatic artery catheter in place. The nurse should be aware that this
catheter will facilitate which of the following? | back 37 Ans: D |
front 38 38. A nurse on a solid organ transplant unit is planning the care of
a patient who will soon be admitted upon immediate recovery following
liver transplantation. What aspect of nursing care is the nurse’s
priority? | back 38 Ans: A |
front 39 39. A 55-year-old female patient with hepatocellular carcinoma (HCC)
is undergoing radiofrequency ablation. The nurse should recognize what
goal of this treatment? | back 39 Ans: A |
front 40 40. A nurse is caring for a patient with severe hemolytic jaundice.
Laboratory tests show free bilirubin to be 24 mg/dL. For what
complication is this patient at risk? | back 40 Ans: C |