1-102 of 102
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A nurse is caring for a client with a blocked bile duct from a tumor. What manifestation
of obstructive jaundice should the nurse anticipate?
A. Watery, blood-streaked diarrhea
B. Orange and foamy urine
C. Increased abdominal girth
D. Decreased cognition
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B. Orange and foamy urine
A client is admitted to the ED with an apparent overdose of IV heroin. After stabilizing
the client's cardiopulmonary status, the nurse should prepare to perform what
intervention?
A. Administer a bolus of lactated Ringer.
,B. Administer naloxone hydrochloride (Narcan).
C. Insert an indwelling urinary catheter.
D. Perform a focused neurologic assessment.
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B) Administer naloxone hydrochloride (Narcan).
A nurse is caring for a client with cirrhosis secondary to heavy alcohol use. The nurse's
most recent assessment reveals subtle changes in the client's cognition and behavior.
What is the nurse's most appropriate response?
A. Ensure that the client's sodium intake does not exceed recommended levels.
B. Report this finding to the primary provider due to the possibility of hepatic
encephalopathy.
C. Inform the primary provider that the client should be assessed for alcoholic
hepatitis.
D. Implement interventions aimed at ensuring a calm and therapeutic care
environment.
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B. Report this finding to the primary provider due to the possibility of
hepatic encephalopathy.
A client 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?
A. Continuous monitoring for portal hypertension
B. Administration of immunosuppressive drugs during the first weeks after
transplantation
C. Real-time monitoring of vascular changes in the hepatic system
D. Delivery of a continuous chemotherapeutic dose
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D. Delivery of a continuous chemotherapeutic dose
A client with liver disease has developed ascites; the nurse is collaborating with the
client to develop a nutritional plan. The nurse should prioritize which of the following
in the client's plan?
A. Increased potassium intake
B. Fluid restriction to 2 L per day
C. Reduction in sodium intake
D. High-protein, low-fat diet
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C. Reduction in sodium intake
A client admitted to the ED with severe diarrhea and vomiting is subsequently
diagnosed with food poisoning. The nurse caring for this client assesses for signs and
symptoms of fluid and electrolyte imbalances. For what signs and symptoms would
this nurse assess? Select all that apply.
A. Dysrhythmias
B. Hypothermia
C. Hypotension
D. Hyperglycemia
E. Delirium
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, A) Dysrhythmias
C) Hypotension
E) Delirium
A nurse has entered the room of a client with cirrhosis and found the client on the
floor. The client reports falling when transferring to the commode. The client's vital
signs are within reference ranges and the nurse observes no apparent injuries. What is
the nurse's most appropriate action?
A. Remove the client's commode and supply a bedpan.
B. Complete an incident report and submit it to the unit supervisor.
C. Have the client assessed by the primary provider due to the risk of internal
bleeding.
D. Perform a focused abdominal assessment in order to rule out injury.
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C. Have the client assessed by the primary provider due to the risk of
internal bleeding.
A client who attempted suicide is being treated in the ED. The client is accompanied
by the client's mother, father, and brother. When planning the nursing care of this
family, the nurse should perform which of the following actions?
A. Refer the family to a psychiatrist in order to provide them with support.
B. Explore the causes of the client's suicide attempt with the family.
C. Encourage the family to participate in the bedside care of the client.
D. Ensure that the family receives appropriate crisis intervention services.
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D) Ensure that the family receives appropriate crisis intervention services.