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NUR 414 FINAL EXAM QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES (VERIFIED ANSWER), EXAMS OF
NURSING
A nurse reviews a medical record of a client with ascites. What does the nurse identify that may
be causing the ascites?
A.
Portal hypotension
B.
Kidney malfunction
C.
Diminished plasma protein level
D.
Decreased production of potassium - ANSWER-C. Diminished plasma protein level
The liver manufactures albumin, the major plasma protein. A deficit of this protein lowers the
osmotic (oncotic) pressure in the intravascular space, leading to a fluid shift. An enlarged liver
compresses the portal system, causing increased, rather than decreased, pressure. The kidneys
are not the primary source of the pathologic condition. It is the liver's ability to man
A client is admitted to the hospital with ascites. The client reports drinking a quart of vodka
mixed in orange juice every day for the past three months. To assess the potential for
withdrawal symptoms, which question would be appropriate for the nurse to ask the client?
A.
"When was your last drink of vodka?"
B.
"Why do you mix the vodka with orange juice?"
C.
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"What prompts your drinking episodes?"
D.
"Do you also eat when you drink?" - ANSWER-A. "When was your last drink of vodka?"
The nurse must determine when the client had the last drink to gauge when the body may react
to lack of alcohol (withdrawal). Factors that prompt drinking are important, but do not affect
the body's response to withdrawal from the substance. Whether the client also eats when the
client drinks will not influence the body's response to withdrawal from the alcohol. Whether the
client mixes vodka with orange juice will not influence the body's withdrawal from the alcohol.
A client with a 20-year history of excessive alcohol use is admitted to the hospital with jaundice
and ascites. A priority nursing action during the first 48 hours after the client's admission is to:
A.
Determine the client's reasons for drinking.
B.
Monitor the client's vital signs
C.
Improve the client's nutritional status.
D.
Increase the client's fluid intake. - ANSWER-B. Monitor the client's vital signs
A client's vital signs, especially the pulse and temperature, will increase before the client
demonstrates any of the more severe symptoms of withdrawal from alcohol. Increasing intake is
contraindicated initially because it may cause cerebral edema. Improving nutritional status
becomes a priority after the problems of the withdrawal period have subsided. Determining the
client's reasons for drinking is not a priority until after the detoxification process.
The nurse is providing discharge instructions to a client who is recovering from an acute case of
viral hepatitis. Which statement by the client indicates a need for further education?
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A.
"I will avoid alcohol."
B.
"I will take acetaminophen for pain"
C.
"I will be sure to take naps throughout the day."
D.
"I will eat small frequent meals." - ANSWER-B. "I will take acetaminophen for pain."
Acetaminophen is damaging to the liver and is contraindicated in clients with hepatitis. Clients
should avoid alcohol, eat small frequent meals, and be sure to get plenty of rest.
The nurse is caring for a client who is scheduled to have a percutaneous liver biopsy. Which
findings warrant the postponement of the procedure? Select all that apply.
A.
Hemoglobin less than 9 g/dL
B.
Platelet count of 160,000/mm3
C.
Marked ascites
D.
Ecchymosis and purpura
E.
Hepatic cirrhosis - ANSWER-A. Hemoglobin less than 9 g/dL
C. Marked ascites
D. Ecchymosis and purpura
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To do a liver biopsy when a client has marked ascites increases the risk of leakage of ascitic fluid.
The liver biopsy should be postponed. A client with a hemoglobin of less than 9 g/dL should not
have a liver biopsy because the client cannot take the risk of the puncture of a hepatic blood
vessel. A diagnosis of hepatic cirrhosis is not a reason to postpone a liver biopsy, because it is
done to detect the presence of hepatic cirrhosis. Although a platelet count of 160,000/mm3 is
within the low range of the expected platelet count for an adult, a liver biopsy is not
contraindicated. A count of less than 50,000/mm3 is critical and requires postponement of the
test. Ecchymosis and purpura are signs of bruising and If the client has numerous bruises it may
indicate deficient thrombocytes or prolonged clotting; both are contraindications for a
percutaneous liver biopsy.
A child is diagnosed with hepatitis A. The client's parent expresses concern that the other
members of the family may get hepatitis because they all share the same bathroom. The nurse's
best reply is:
A.
"All family members, including your child, need to wash their hands after using the bathroom."
B.
"I suggest that you buy a commode exclusively for your child's use."
C. "You will need to clean the bathroom from top to bottom every time a family member uses
it."
D. "Your child may use the bathroom, but you need to use disposable toilet covers." - ANSWER-
A. "All family members, including your child, need to wash their hands after using the
bathroom."
Hepatitis A is spread via the fecal-oral route; transmission is prevented by proper handwashing.
Buying a commode exclusively for the child's use is unnecessary; cleansing the toilet and
washing the hands should control the transmission of microorganisms. It is not feasible to clean
"from top to bottom" each time the bathroom is used. The use of disposable toilet covers is
inadequate to prevent the spread of microorganisms if the bathroom used by the child also is
used by others. Handwashing by all family members must be part of the plan to prevent the
spread of hepatitis to other family members.
NUR 414 FINAL EXAM QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES (VERIFIED ANSWER), EXAMS OF
NURSING
A nurse reviews a medical record of a client with ascites. What does the nurse identify that may
be causing the ascites?
A.
Portal hypotension
B.
Kidney malfunction
C.
Diminished plasma protein level
D.
Decreased production of potassium - ANSWER-C. Diminished plasma protein level
The liver manufactures albumin, the major plasma protein. A deficit of this protein lowers the
osmotic (oncotic) pressure in the intravascular space, leading to a fluid shift. An enlarged liver
compresses the portal system, causing increased, rather than decreased, pressure. The kidneys
are not the primary source of the pathologic condition. It is the liver's ability to man
A client is admitted to the hospital with ascites. The client reports drinking a quart of vodka
mixed in orange juice every day for the past three months. To assess the potential for
withdrawal symptoms, which question would be appropriate for the nurse to ask the client?
A.
"When was your last drink of vodka?"
B.
"Why do you mix the vodka with orange juice?"
C.
,2|Page
"What prompts your drinking episodes?"
D.
"Do you also eat when you drink?" - ANSWER-A. "When was your last drink of vodka?"
The nurse must determine when the client had the last drink to gauge when the body may react
to lack of alcohol (withdrawal). Factors that prompt drinking are important, but do not affect
the body's response to withdrawal from the substance. Whether the client also eats when the
client drinks will not influence the body's response to withdrawal from the alcohol. Whether the
client mixes vodka with orange juice will not influence the body's withdrawal from the alcohol.
A client with a 20-year history of excessive alcohol use is admitted to the hospital with jaundice
and ascites. A priority nursing action during the first 48 hours after the client's admission is to:
A.
Determine the client's reasons for drinking.
B.
Monitor the client's vital signs
C.
Improve the client's nutritional status.
D.
Increase the client's fluid intake. - ANSWER-B. Monitor the client's vital signs
A client's vital signs, especially the pulse and temperature, will increase before the client
demonstrates any of the more severe symptoms of withdrawal from alcohol. Increasing intake is
contraindicated initially because it may cause cerebral edema. Improving nutritional status
becomes a priority after the problems of the withdrawal period have subsided. Determining the
client's reasons for drinking is not a priority until after the detoxification process.
The nurse is providing discharge instructions to a client who is recovering from an acute case of
viral hepatitis. Which statement by the client indicates a need for further education?
,3|Page
A.
"I will avoid alcohol."
B.
"I will take acetaminophen for pain"
C.
"I will be sure to take naps throughout the day."
D.
"I will eat small frequent meals." - ANSWER-B. "I will take acetaminophen for pain."
Acetaminophen is damaging to the liver and is contraindicated in clients with hepatitis. Clients
should avoid alcohol, eat small frequent meals, and be sure to get plenty of rest.
The nurse is caring for a client who is scheduled to have a percutaneous liver biopsy. Which
findings warrant the postponement of the procedure? Select all that apply.
A.
Hemoglobin less than 9 g/dL
B.
Platelet count of 160,000/mm3
C.
Marked ascites
D.
Ecchymosis and purpura
E.
Hepatic cirrhosis - ANSWER-A. Hemoglobin less than 9 g/dL
C. Marked ascites
D. Ecchymosis and purpura
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To do a liver biopsy when a client has marked ascites increases the risk of leakage of ascitic fluid.
The liver biopsy should be postponed. A client with a hemoglobin of less than 9 g/dL should not
have a liver biopsy because the client cannot take the risk of the puncture of a hepatic blood
vessel. A diagnosis of hepatic cirrhosis is not a reason to postpone a liver biopsy, because it is
done to detect the presence of hepatic cirrhosis. Although a platelet count of 160,000/mm3 is
within the low range of the expected platelet count for an adult, a liver biopsy is not
contraindicated. A count of less than 50,000/mm3 is critical and requires postponement of the
test. Ecchymosis and purpura are signs of bruising and If the client has numerous bruises it may
indicate deficient thrombocytes or prolonged clotting; both are contraindications for a
percutaneous liver biopsy.
A child is diagnosed with hepatitis A. The client's parent expresses concern that the other
members of the family may get hepatitis because they all share the same bathroom. The nurse's
best reply is:
A.
"All family members, including your child, need to wash their hands after using the bathroom."
B.
"I suggest that you buy a commode exclusively for your child's use."
C. "You will need to clean the bathroom from top to bottom every time a family member uses
it."
D. "Your child may use the bathroom, but you need to use disposable toilet covers." - ANSWER-
A. "All family members, including your child, need to wash their hands after using the
bathroom."
Hepatitis A is spread via the fecal-oral route; transmission is prevented by proper handwashing.
Buying a commode exclusively for the child's use is unnecessary; cleansing the toilet and
washing the hands should control the transmission of microorganisms. It is not feasible to clean
"from top to bottom" each time the bathroom is used. The use of disposable toilet covers is
inadequate to prevent the spread of microorganisms if the bathroom used by the child also is
used by others. Handwashing by all family members must be part of the plan to prevent the
spread of hepatitis to other family members.
