Question 23
A client with pneumonia has arterial blood gases of pH 7.33 (7.35-7.45), PaO2 94 (80-100), PaCO2 49 (35-45), HCO3 25 (22-26). Which intervention should the nurse implement?
- Assist the client to cough and deep breath (Correct Answer)
- Administer oxygen via nasal cannula
- Assist the client to breath into a paper bag
- Administer sodium bicarbonate
Question 24
The nurse evaluates the admission assessment data for a 59-year-old client with end-stage liver disease. Which findings are significant?
- Weight gain (Significant)
- Black, tarry stools (Significant)
- LOC (Significant)
- Abdominal distension (Significant)
- Respiratory rate (Significant)
- Dyspnea (Significant)
- Temperature (Significant)
- Orthopnea (Significant)
Question 25
Classify the following assessment findings from the admission records as most consistent with Ascites, Bleeding Esophageal Varices, or Hepatic Encephalopathy.
- Muscle twitching: Hepatic Encephalopathy
- Abdominal distension with bulging flanks: Ascites
- Orthpnea and dyspnea: Ascites
- Black, tarry stools: Bleeding Esophageal Varices
- Rapid weight gain: Ascites
- Agitation, confusion, impaired thinking: Hepatic Encephalopathy
- Hyperreflexia: Hepatic Encephalopathy
- Tachycardia and hypotension: Bleeding Esophageal Varices Medical-Surg Questions
Question 26
Five days post-op liver transplantation surgery, assessment finds the client is drowsy, has increasing jaundice, and a temperature of 101.9F. Which clinical determination is most accurate?
- The client is experiencing an expected recovery
- The client is experiencing acute graft rejection
- The client is experiencing systemic infection
- The client is experiencing hepatic encephalopathy
Question 27
Identify the findings that support the determination of acute graft rejection.
- Increasing jaundice (Correct Answer)
- Fever (Temp 101.9F) (Correct Answer)
- Elevated ALT (46 units/L) (Correct Answer)
- Tacrolimus Level 4 ng/mL
- RR 22
Question 28
Which findings five days after treatment for rejection indicate a therapeutic response?
- Client has pale yellow skin and white sclera (Correct Answer)
- Client alert and oriented x 3 with moderate pain (Correct Answer)
- ALT 30 units/L; AST 31 units/L (Correct Answer)
- Temperature 100.2F
- Tacrolimus Level 2 ng/mL
Question 42
The nurse is caring for a client after bariatric surgery. Which assessment finding would indicate that the client is experiencing an anastomotic leak?
- Client complains of inability to pass gas and cramping
- Client complains of headache and ringing in the ears
- Client complains of tingling and burning in both hands
- Client complains of abdominal pain and racing heart rate
Question 43
The nurse is caring for a client with bleeding esophageal varices with new orders for the somatostatin receptor agonist octreotide acetate. When the client asks how the medication works, which statement by the nurse is appropriate?
- “Octreotide acetate decreases pressure within the varices.”
- “Octreotide acetate helps reduce gastric discomfort.”
- “Octreotide acetate increases production of gastrin and serotonin.”
- “Octreotide acetate will help you to stay calm and relax more.”
Question 44
The nurse is caring for a client with long term ascites who is scheduled for placement of a transjugular intrahepatic portosystemic shunt (TIPS). Which statement by the client indicates a need for further instruction?
- “I don’t want to have another surgery to remove the stent.”
- “The shunt will be placed through my jugular vein.”
- “I will need to schedule regular ultrasounds for a year.”
- “The procedure is minimally invasive, so risks are decreased.”
Question 45
The nurse is reviewing assessment data and lab values for a client admitted with a small bowel obstruction. Which findings correlate with the client’s diagnosis? (Select all that apply)
- Serum potassium of 2.8 mEq/L (3.5-5)
- Abdominal pain in upper quadrants
- Metabolic alkalosis
- Low pitched bowel sounds
- Serum sodium of 121 (136-145)
- Loss of 12 lb without dieting
Question 46
The nurse is caring for a client prescribed the beta blocker Propranolol for esophageal varices and the client asks, “What does the medication do to treat my condition?” Which response by the nurse is appropriate?
- “This medication prevents bleeding by lowering blood pressure.”
- “This medication is used to slow your heart rate.”
- “This medication is injected to dry up the bleeding varices.”
- “This medication is given to increase urine output.”
Question 47
The nurse is providing education on diet planning for a client diagnosed with diverticulosis. The nurse knows the teaching is effective when the client selects which meal for dinner? Medical-Surg Questions
- Spicy roasted chicken with corn and a cup of coffee with cream
- Baked fish with steamed carrots, wheat dinner roll, and glass of unsweetened tea
- Spaghetti with meat sauce, sliced cucumbers, and hot tea with lemon
- Chicken Caesar salad with sliced almonds, cup of bean soup, and glass of low-fat milk
Question 48
The nurse is coming on shift and receives report on the clients listed below. Which client should the nurse see first?
- Client with diverticulitis complaining of left lower quadrant pain with temperature reading of 100.2F
- Client with colon obstruction who has been passing ribbon-like stools for the past 4 hours
- Client who is 12 hours postoperative colon resection who is complaining of nausea
- Client with small bowel obstruction who has an NG tube to low suction, with potassium level of 2.3.
Question 49
A nurse is caring for a client with hepatic portal-systemic encephalopathy (PSE) who is thin and frail, and the family expresses concerns that the client is receiving little dietary protein. Which response by the nurse is appropriate?
- “Low dietary protein is needed to prevent fluid from leaking into the abdomen.”
- “Increasing dietary protein will help the client gain weight and muscle mass.”
- “A low-protein diet will help the liver rest and will restore liver function.”
- “Less protein in the diet will help reduce confusion associated with liver failure.”
Question 50
The nurse is caring for a client with a bowel obstruction who has a newly placed nasogastric (NG) tube. Which nursing intervention is the priority for this client in relation to care of the NG tube?
- Turn the suction down to a lower setting while ascultating bowel sounds
- Secure the tube to the client’s chin to avoid skin breakdown on the nose
- Flush the tube with water every 2 hours to maintain patency of the tube
- Assess for proper placement of the tube, tube patency and output every 4 hours
