NR 464 - Exam 1 (Saunders) - Liver,
Pancreas, Gallbladder
The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that
there is documentation of the presence of asterixis. How should the nurse assess for its
presence?
1. Dorsiflex the client's foot.
2. Measure the abdominal girth.
3. Ask the client to extend the arms.
4. Instruct the client to lean forward. - ✔️✔️3. Ask the client to extend the arms.
The nurse is reviewing the laboratory results for a client with cirrhosis and notes that the
ammonia level is 85 mcg/dL (51 mcmol/L). Which dietary selection does the nurse
suggest to the client?
1. Roast pork
2. Cheese omelet
3. Pasta with sauce
4. Tuna fish sandwich - ✔️✔️3. Pasta with sauce
The nurse is caring for a client with acute pancreatitis and is monitoring the client for
paralytic ileus. Which piece of assessment data should alert the nurse to this
occurrence?
1. Inability to pass flatus
2. Loss of anal sphincter control
3. Severe, constant pain with rapid onset
4. Firm, nontender mass palpable at the lower right costal margin - ✔️✔️1. Inability to
pass flatus
A sexually active young adult client has developed viral hepatitis. Which client
statement indicates the need for further teaching?
,1. "I should avoid drinking alcohol."
2. "I can go back to work right away."
3. "My partner should get the vaccine."
4. "A condom should be used for sexual intercourse." - ✔️✔️2. "I can go back to work
right away."
A client is diagnosed with viral hepatitis, complaining of "no appetite" and "losing my
taste for food." What instruction should the nurse give the client to provide adequate
nutrition?
1. Select foods high in fat.
2. Increase intake of fluids, including juices.
3. Eat a good supper when anorexia is not as severe.
4. Eat less often, preferably only 3 large meals daily. - ✔️✔️2. Increase intake of fluids,
including juices.
Although no special diet is required to treat viral hepatitis, it is generally recommended
that clients consume a low-fat diet, as fat may be tolerated poorly because of decreased
bile production. Small, frequent meals are preferable and may even prevent nausea.
Frequently, appetite is better in the morning, so it is easier to eat a good breakfast. An
adequate fluid intake of 2500 to 3000 mL/day that includes nutritional juices is also
important.
A client has developed hepatitis A after eating contaminated oysters. The nurse
assesses the client for which expected assessment finding?
1. Malaise
2. Dark stools
3. Weight gain
4. Left upper quadrant discomfort - ✔️✔️1. Malaise
A client has undergone esophagogastroduodenoscopy (EGD). The nurse should place
highest priority on which item as part of the client's care plan?
1. Monitoring the temperature
, 2. Monitoring complaints of heartburn
3. Giving warm gargles for a sore throat
4. Assessing for the return of the gag reflex - ✔️✔️4. Assessing for the return of the
gag reflex
**Except with esophageal varices
The health care provider has determined that a client has contracted hepatitis A based
on flulike symptoms and jaundice. Which statement made by the client supports this
medical diagnosis?
1. "I have had unprotected sex with multiple partners."
2. "I ate shellfish about 2 weeks ago at a local restaurant."
3. "I was an intravenous drug abuser in the past and shared needles."
4. "I had a blood transfusion 30 years ago after major abdominal surgery." - ✔️✔️2. "I
ate shellfish about 2 weeks ago at a local restaurant."
**Oral-fecal route
The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes
that the T-tube has drained 750 mL of green-brown drainage since the surgery. Which
nursing intervention is most appropriate?
1. Clamp the T-tube.
2. Irrigate the T-tube.
3. Document the findings.
4. Notify the health care provider. - ✔️✔️3. Document the findings.
Following cholecystectomy, drainage from the T-tube is initially bloody and then turns a
greenish-brown color. The drainage is measured as output. The amount of expected
drainage will range from 500 to 1000 mL/day. The nurse would document the output.
A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is
being assessed by the nurse. Which assessment findings would be consistent with
acute pancreatitis? Select all that apply.
1. Diarrhea
Pancreas, Gallbladder
The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that
there is documentation of the presence of asterixis. How should the nurse assess for its
presence?
1. Dorsiflex the client's foot.
2. Measure the abdominal girth.
3. Ask the client to extend the arms.
4. Instruct the client to lean forward. - ✔️✔️3. Ask the client to extend the arms.
The nurse is reviewing the laboratory results for a client with cirrhosis and notes that the
ammonia level is 85 mcg/dL (51 mcmol/L). Which dietary selection does the nurse
suggest to the client?
1. Roast pork
2. Cheese omelet
3. Pasta with sauce
4. Tuna fish sandwich - ✔️✔️3. Pasta with sauce
The nurse is caring for a client with acute pancreatitis and is monitoring the client for
paralytic ileus. Which piece of assessment data should alert the nurse to this
occurrence?
1. Inability to pass flatus
2. Loss of anal sphincter control
3. Severe, constant pain with rapid onset
4. Firm, nontender mass palpable at the lower right costal margin - ✔️✔️1. Inability to
pass flatus
A sexually active young adult client has developed viral hepatitis. Which client
statement indicates the need for further teaching?
,1. "I should avoid drinking alcohol."
2. "I can go back to work right away."
3. "My partner should get the vaccine."
4. "A condom should be used for sexual intercourse." - ✔️✔️2. "I can go back to work
right away."
A client is diagnosed with viral hepatitis, complaining of "no appetite" and "losing my
taste for food." What instruction should the nurse give the client to provide adequate
nutrition?
1. Select foods high in fat.
2. Increase intake of fluids, including juices.
3. Eat a good supper when anorexia is not as severe.
4. Eat less often, preferably only 3 large meals daily. - ✔️✔️2. Increase intake of fluids,
including juices.
Although no special diet is required to treat viral hepatitis, it is generally recommended
that clients consume a low-fat diet, as fat may be tolerated poorly because of decreased
bile production. Small, frequent meals are preferable and may even prevent nausea.
Frequently, appetite is better in the morning, so it is easier to eat a good breakfast. An
adequate fluid intake of 2500 to 3000 mL/day that includes nutritional juices is also
important.
A client has developed hepatitis A after eating contaminated oysters. The nurse
assesses the client for which expected assessment finding?
1. Malaise
2. Dark stools
3. Weight gain
4. Left upper quadrant discomfort - ✔️✔️1. Malaise
A client has undergone esophagogastroduodenoscopy (EGD). The nurse should place
highest priority on which item as part of the client's care plan?
1. Monitoring the temperature
, 2. Monitoring complaints of heartburn
3. Giving warm gargles for a sore throat
4. Assessing for the return of the gag reflex - ✔️✔️4. Assessing for the return of the
gag reflex
**Except with esophageal varices
The health care provider has determined that a client has contracted hepatitis A based
on flulike symptoms and jaundice. Which statement made by the client supports this
medical diagnosis?
1. "I have had unprotected sex with multiple partners."
2. "I ate shellfish about 2 weeks ago at a local restaurant."
3. "I was an intravenous drug abuser in the past and shared needles."
4. "I had a blood transfusion 30 years ago after major abdominal surgery." - ✔️✔️2. "I
ate shellfish about 2 weeks ago at a local restaurant."
**Oral-fecal route
The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes
that the T-tube has drained 750 mL of green-brown drainage since the surgery. Which
nursing intervention is most appropriate?
1. Clamp the T-tube.
2. Irrigate the T-tube.
3. Document the findings.
4. Notify the health care provider. - ✔️✔️3. Document the findings.
Following cholecystectomy, drainage from the T-tube is initially bloody and then turns a
greenish-brown color. The drainage is measured as output. The amount of expected
drainage will range from 500 to 1000 mL/day. The nurse would document the output.
A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is
being assessed by the nurse. Which assessment findings would be consistent with
acute pancreatitis? Select all that apply.
1. Diarrhea
