GNRS 558: ACTUAL TEST BANK FINAL EXAM 3 LATEST
ACTUAL QUESTIONS AND CORRECT DETAILED ANSWERS
WITH RATIOANLES (VERIFIED ANSWERS) |ALREADY
GRADED A+
A patient is being treated for bleeding esophageal varices with balloon
tamponade. Which nursing action will be included in the plan of care?
a. Instruct the patient to cough every hour.
b. Monitor the patient for shortness of breath.
c. Verify the position of the balloon every 4 hours.
d. Deflate the gastric balloon if the patient reports nausea.
ANS: B The most common complication of balloon tamponade is
aspiration pneumonia. In addition, if the gastric balloon ruptures, the
esophageal balloon may slip upward and occlude the airway. Coughing
increases the pressure on the varices and increases the risk for bleeding.
Balloon position is verified after insertion and does not require further
verification. Balloons may be deflated briefly every 8 to 12 hours to avoid
tissue necrosis, but if only the gastric balloon is deflated, the esophageal
balloon may occlude the airway. Balloons are not deflated for nausea.
,Which result is most important for the nurse to monitor to detect possible
complications in a patient with severe cirrhosis who has bleeding
esophageal varices?
a. Bilirubin levels
b. Ammonia levels
c. Potassium levels
d. Prothrombin time
ANS: B The protein in the blood in the gastrointestinal tract will be
absorbed and may result in an increase in the ammonia level because the
liver cannot metabolize protein very well. The prothrombin time, bilirubin,
and potassium levels should also be monitored, but they will not be
affected by the bleeding episode.
A patient with cirrhosis has ascites and 4+ edema of the feet and legs. Which
nursing action will be included in the plan of care?
a. Restrict daily dietary protein intake.
b. Reposition the patient every 4 hours.
c. Perform passive range of motion twice daily.
d. Place the patient on a pressure-relief mattress.
ANS: D The pressure-relieving mattress will decrease the risk for skin
breakdown for this patient. Adequate dietary protein intake is necessary in
patients with ascites to improve oncotic pressure. Repositioning the
patient every 4 hours will not be adequate to maintain skin integrity.
Passive range of motion will not take the pressure off areas such as the
sacrum that are vulnerable to breakdown.
,Which finding indicates to the nurse that a patient's transjugular
intrahepatic portosystemic shunt (TIPS) placed 3 months ago has been
effective?
a. Increased serum albumin level
b. Decreased indirect bilirubin level
c. Improved alertness and orientation
d. Fewer episodes of bleeding varices
ANS: D TIPS is used to lower pressure in the portal venous system and
decrease the risk of bleeding from esophageal varices. Indirect bilirubin
level and serum albumin levels are not affected by shunting procedures.
TIPS will increase the risk for hepatic encephalopathy.
How would the nurse prepare a patient with ascites for paracentesis?
a. Place the patient on NPO status.
b. Assist the patient to lie flat in bed.
c. Ask the patient to empty the bladder.
d. Position the patient on the right side.
ANS: C The patient should empty the bladder to decrease the risk of
bladder perforation during the procedure. The patient would be
positioned in Fowler's position and would not be able to lie flat without
compromising breathing. Because no sedation is required for
paracentesis, the patient does not need to be NPO.
, Which finding is most important for the nurse to communicate to the health
care provider about a patient who received a liver transplant 1 week ago?
a. Dry palpebral and oral mucosa
b. Crackles at bilateral lung bases
c. Temperature 100.8F (38.2C)
d. No bowel movement for 4 days
ANS: C The risk of infection is high in the first few months after liver
transplant, and fever is frequently the only sign of infection. The other
patient data indicate the need for further assessment or nursing actions
and might be communicated to the health care provider, but they do not
indicate a need for urgent action.
Which laboratory test result will the nurse monitor to evaluate the effects
of therapy for a patient who has acute pancreatitis?
a. Lipase
b. Calcium
c. Bilirubin
d. Potassium
ANS: A Lipase is elevated in acute pancreatitis. Although changes in the
other values may occur, they would not be useful in evaluating whether the
prescribed therapies have been effective.
ACTUAL QUESTIONS AND CORRECT DETAILED ANSWERS
WITH RATIOANLES (VERIFIED ANSWERS) |ALREADY
GRADED A+
A patient is being treated for bleeding esophageal varices with balloon
tamponade. Which nursing action will be included in the plan of care?
a. Instruct the patient to cough every hour.
b. Monitor the patient for shortness of breath.
c. Verify the position of the balloon every 4 hours.
d. Deflate the gastric balloon if the patient reports nausea.
ANS: B The most common complication of balloon tamponade is
aspiration pneumonia. In addition, if the gastric balloon ruptures, the
esophageal balloon may slip upward and occlude the airway. Coughing
increases the pressure on the varices and increases the risk for bleeding.
Balloon position is verified after insertion and does not require further
verification. Balloons may be deflated briefly every 8 to 12 hours to avoid
tissue necrosis, but if only the gastric balloon is deflated, the esophageal
balloon may occlude the airway. Balloons are not deflated for nausea.
,Which result is most important for the nurse to monitor to detect possible
complications in a patient with severe cirrhosis who has bleeding
esophageal varices?
a. Bilirubin levels
b. Ammonia levels
c. Potassium levels
d. Prothrombin time
ANS: B The protein in the blood in the gastrointestinal tract will be
absorbed and may result in an increase in the ammonia level because the
liver cannot metabolize protein very well. The prothrombin time, bilirubin,
and potassium levels should also be monitored, but they will not be
affected by the bleeding episode.
A patient with cirrhosis has ascites and 4+ edema of the feet and legs. Which
nursing action will be included in the plan of care?
a. Restrict daily dietary protein intake.
b. Reposition the patient every 4 hours.
c. Perform passive range of motion twice daily.
d. Place the patient on a pressure-relief mattress.
ANS: D The pressure-relieving mattress will decrease the risk for skin
breakdown for this patient. Adequate dietary protein intake is necessary in
patients with ascites to improve oncotic pressure. Repositioning the
patient every 4 hours will not be adequate to maintain skin integrity.
Passive range of motion will not take the pressure off areas such as the
sacrum that are vulnerable to breakdown.
,Which finding indicates to the nurse that a patient's transjugular
intrahepatic portosystemic shunt (TIPS) placed 3 months ago has been
effective?
a. Increased serum albumin level
b. Decreased indirect bilirubin level
c. Improved alertness and orientation
d. Fewer episodes of bleeding varices
ANS: D TIPS is used to lower pressure in the portal venous system and
decrease the risk of bleeding from esophageal varices. Indirect bilirubin
level and serum albumin levels are not affected by shunting procedures.
TIPS will increase the risk for hepatic encephalopathy.
How would the nurse prepare a patient with ascites for paracentesis?
a. Place the patient on NPO status.
b. Assist the patient to lie flat in bed.
c. Ask the patient to empty the bladder.
d. Position the patient on the right side.
ANS: C The patient should empty the bladder to decrease the risk of
bladder perforation during the procedure. The patient would be
positioned in Fowler's position and would not be able to lie flat without
compromising breathing. Because no sedation is required for
paracentesis, the patient does not need to be NPO.
, Which finding is most important for the nurse to communicate to the health
care provider about a patient who received a liver transplant 1 week ago?
a. Dry palpebral and oral mucosa
b. Crackles at bilateral lung bases
c. Temperature 100.8F (38.2C)
d. No bowel movement for 4 days
ANS: C The risk of infection is high in the first few months after liver
transplant, and fever is frequently the only sign of infection. The other
patient data indicate the need for further assessment or nursing actions
and might be communicated to the health care provider, but they do not
indicate a need for urgent action.
Which laboratory test result will the nurse monitor to evaluate the effects
of therapy for a patient who has acute pancreatitis?
a. Lipase
b. Calcium
c. Bilirubin
d. Potassium
ANS: A Lipase is elevated in acute pancreatitis. Although changes in the
other values may occur, they would not be useful in evaluating whether the
prescribed therapies have been effective.
