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Med Surg 3 Exam 4
Exam 4
| Question | Answer |
|---|---|
| abnormal dilation of an artery resulting in a weakened wall (right below kidneys) | aneurysm |
| what does AAA stand for? | Abdominal Aortic Aneurysm |
| complications of AAA? | atherosclerosis (plaque in arteries), genetic, connective tissue disorder (Marfan Syndrome), traumatic injury, infection |
| As an artery dilates, what happens to the wall (think AAA)? | force on the wall is increased resulting in continued growth & potential rupture |
| What are manifestations of AAA? | without complications, patient can be asymptomatic |
| How do you diagnose an AAA? | radiograph, CT, TEE (esophageal)- echocardiogram, MRI; visualization & palpation is not reliable |
| blood pressure control for AAA? | 120/80 or lower is good *BETA BLOCKERS* |
| at what size of aneurysm does intervention (usually surgical) take place? | 5-5.5 cm |
| Open surgical repair of AAA: | used when aneurysm bursted; high risk (large incision); high mortality rate; graft is placed after being surgically open (acts as layers of the artery) |
| Endovascular aneurysm repair: | less invasive than open surgical repair (less chance of complications); used if patient is not a candidate for open surgery; done in cath lab using guidwire to place the endograft (similar to stents); patient usually stays inpatient for one night |
| what is similar to a balloon popping? | aortic rupture |
| does an aortic rupture have a high or low mortality rate? | high mortality |
| what are the manifestations of an aortic rupture? | rapid, severe pain in the chest, abdomen, or flank (consistent pain); syncope; HYPOtension; rapid shock & hemorrhage |
| what surgical intervention is done after an aortic rupture takes place? | open surgical repair |
| the separation of lining of the vessel allowing blood to enter (think of layers of a vessel wall): | aortic dissection |
| does an aortic dissection have a low or high mortality rate? | high mortality |
| what is different about an aortic dissection rather than an aortic rupture? | dissection typically extends forward from point of origin; acute onset of severe pain does not change but location may migrate* |
| manifestations of an aortic dissection: | ripping, stabbing, tearing, burning that radiates straight to the back; HYPERtension is more common than hypotension |
| what are interventions for an aortic dissection? | BP control, fluid management, anticoagulation |
| surgical or medical treatment of an aortic dissection is based on what? | based on type (A, B, etc.) |
| what are the 3 main management keys to treating an aortic rupture? | manage ABCs #1, pain control, tight BP control |
| what size gauge needle is given to a patient with an aortic rupture? | 20 or 18- gives fluids at a faster rate |
| what is a common beta blocker administered to a patient with an aortic rupture? | esmolol |
| what kinds of interventions are needed to do for a patient going into surgery for an aortic aneurysm rupture? | fluid management (start an IV), blood products needed (type & cross match), consent forms, intubate patient |
| what does a ripping, tearing pain in the patient's back signify? what is the immediate treatment? | aortic dissection; surgical intervention |
| critical assessment of possibility of aortic rupture: | decreased pulses, pale, cold, decreased circulation |
| increased pressure in the portal system; causes shunting of blood to lower pressure vessels & collateral vessels: | portal hypertension |
| what does portal hypertension impact? | esophagus, rectum, abdomen- worried about varices |
| what is a common cause of portal hypertension? | genetics |
| portal hypertension: fluid is pushed out contributing to what? | ascites (into peritoneal cavity) |
| manifestations of portal hypertension? | ascites, GI bleeding |
| portal hypertension treatment: channel is created in liver, like a stent- to help create better flow; temporary method; liver is extremely vascular | transjugular intrahepatic portosystemic shunt (TIPS) |
| Portal hypertension treatment: are all patients good candidates for a liver transplant? | no |
| what medications should be administered to a patient with portal hypertension? | diuretics to keep fluid off; beta blockers* to take pressure off |
| what invasive procedure is done to treat ascites/ explain? | paracentesis; informed consent is needed, doctor explains prior to procedure, procedure removes fluid in the body |
| paracentesis: only 2 L of fluid is removed from the patient's body at a time to avoid what? | hypovolemic shock |
| dilated, tortuous vessels (winedy): | esophageal varices |
| esophageal varices is most common in what body parts? | esophagus & stomach |
| esophageal varices is a complication of what? | portal hypertension |
| rupture of esophageal varices causes what? | life threatening hemorrhage |
| what is the first thing to manage in a patient who has esophageal varices? | protect airway!! (ABCs) |
| management of esophageal varices: | protect airway, volume resuscitate, control bleeding!! |
| manifestations of esophageal varices: | hematemesis (vomiting blood), melena (tarry, black stools), progresses to shock (r/t massive volume change) |
| what is key to treating esophageal varices? | bleeding control** |
| what medications are given to treat esophageal varices? | vasopressin (to constrict blood flow to those areas), octreotide |
| esophageal varices treatment: balloon inflates in esophagus & stomach | multilumen NG |
| in a multilumen NG (to treat esophageal varices), what balloon should be deflated first? | esophageal balloon |
| esophageal varices treatment: balloon tamponade- inflate balloon, putting pressure along walls | sengstaken-blakemore tube |
| esophageal varices treatment: twist rubber band to stop bleeding | variceal ligation or banding |
| esophageal varices treatment: look for bleeding in the stomach, inject something to harden vessels & stop bleeding in esophagus (difficult to perform d/t inability to visualize) | endoscopic sclerosis |
| what is uncommon as a primary cancer? | liver cancer |
| what is a common cause of liver cancer? | hepatitis |
| liver cancer is often masked by what? | cirrhosis or chronic hepatitis (hep C) |
| manifestations: weakness, anorexia, weight loss, fatigue, malaise, abdominal pain, palpable mass, signs of liver failure (jaundice- labs: ALT, AST) | liver cancer |
| treatment: surgical resection, radiation, chemotherapy (difficult to treat- radiation/chemo used to keep patient comfortable) | liver cancer |
| liver transplant pre-op: | education (precautions, s/sx of rejection), risk for rejection, life long therapy, immunosuppression |
| what is monitored post-op liver transplant? | infection (increased WBCs, fever, chills, increased HR), rejection, bleeding (patients don't have adequate clotting factors to begin with), pneumonia |
| complications of liver transplant: | VAP (ventilator assisted pneumonia), rejection, infection, bleeding |
| uncommon cancer, high mortality rate: | esophageal cancer |
| risk factors of esophageal cancer: | excess alcohol use, smoking, chemical, chronic reflux |
| manifestations: progressive dysphagia, weight loss, anemia, regurgitations, anorexia, chest pain, chronic cough (inflammatory response) | esophageal cancer |
| treatments: combo of chemo & radiation to prolong life; resection (take out bad, put new one in)-esophagectomy; palliative care | esophageal cancer |
| trypsin & enzymes within the pancreas are prematurely activated; intrapancreatic inflammation, extrapancreatic/systemic injury occurs: | pancreatitis |
| diagnosis of pancreatitis (must have 2/3): | abdominal pain (acute onset), serum amylase and/or lipase more than 3 times the upper limit of normal, characteristics of acute pancreatitis on CT scan |
| normal amylase level: | 30-170 |
| normal lipase level: | 14-280 |
| what is the gold standard when diagnosing pancreatitis? | CT scan |
| pancreatitis diagnosis: invasive test to visualize structure of pancreas; inject contrast dye, take images; benefits: visualize if obstruction is present & can also intervene at that point | Endoscopic retrograde cholangiopancreatography (ERCP) |
| labs: WBC elevated, hematocrit elevated, elevated amylase/lipase, BUN/creatinine, hypocalcemia | pancreatitis |
| not as dangerous test as ERCP- not invasive; but can not intervene | MRCP |
| pancreatitis- integumentary: | cullen sign, grade turners sign |
| pancreatitis sign: umbilicus is blue r/t loss of blood supply --> bruising | cullen sign |
| pancreatitis sign: discoloration goes to flank | grade turners sign |
| pancreatitis- hematologic complications: | DIC related to SIRS- microclots |
| what lab should be watched with pancreatitis? | glucose levels |
| complications: pancreatic necrosis, pancreatic abscess (takes weeks to develop), pseudocyst, abdominal compartment syndrome | pancreatitis local complications |
| complications: SIRS/MODS, respiratory insufficiency & failure, hypovolemic shock, renal failure, decreased LOC, DIC, hyeprglycemia | pancreatitis systemic complications |
| #1 priority management for pancreatitis? | stabilize hemodynamic status (airway, breathing, circulation) |
| 6 medical management for pancreatitis: | stabilize hemodynamic status, control pain, minimize pancreatic stimulation (PPIs, TPN, NPO, NG tube), provide psychosocial support, correct underlying problem, prevent or treat complications |
| most lethal types of cancer; rare | pancreatic cancer |
| pancreatic cancer risk factors: | smoking, chronic pancreatitis, DM, cirrhosis, obesity, genetic |
| anorexia, nausea, weight loss, dull pain (in gut or lower back) *few symptoms until very advanced* | pancreatic cancer |
| pancreatic cancer treatments: | whipple- massive surgery; radiation; chemotherapy |
| important to remember for patients treatment with pancreas issues? | NPO!!! |
| when did kidney transplantation become first focus? | 1910s |
| when did immunosuppressant's develop? | 1950s |
| transplanting tissue from one body part to another (skin tissue from one part of the body to another) | autograft |
| heterograft: | valves |
| transplant from the same species (lung transplants) | allograft |
| living donor organs: | kidney, liver |
| deceased donor organs: | heart, lungs, etc. (have up to 24 hours to donate after brain dead) |
| brain death causes what? | other organs to fail over time |
| it's important to preserve organs through what? | oxygenation & perfusion needs |
| we should maintain donor within normal hemodynamic parameters through what? | CBP, maintaining fluid status (perfusion) |
| what should be done if a donor patient is diagnosed with diabetes insipidus? | replace ADH, salt poor fluids, closely monitor fluid status & electrolytes |
| thyroid protocol is used with what drip? | levothyroxine drip |
| as nurses care for a donor patient, maintain stability & follow orders from the what? | OPO- organ perfusion organization? |
| who should discuss donation w/ patient family members? | those who work for OPO |
| donor testing components: | blood testing, tissue typing, health history |
| it's very important to match tissue types for organ donors by using what? | human leukocyte antigens (HLA) |
| 100% organ match is only possible with what type of people? | twins |
| posttransplantation complication: blood clot within vascular of graft; extremely rare, won't get blood supply | vascular thrombosis |
| posttransplantation complication: site where graft is sutured- suture becomes loose? Can cause bleeding at site- can occur weeks after surgery- patient has to go back to surgery | anastomosis leakage |
| graft rejection: hyperacute | minutes to hours after patient receives graft |
| graft rejection: acute | days to months following transplant |
| graft rejection: chronic | lasts for several years until organ becomes dysfunctional; usually pick up over time; not as much that can be done |
| what is the leading cause of death in transplant patients? | infection!!! |
| CMV: | common cold; life threatening in transplant patients; low grade fever, pain, tired |
| viral infections; non hodgkins lymphoma is most common; happens at twice the rate of normal patients | malignancy |
| immunosuppressant therapy: suppresses cytotoxic T cells & B cells, considered most effective line of drugs we have | calcineurin inhibitors |
| types of calcineurin inhibitors: | cyclosporine, TACROLIMUS, sirolimus |
| concerns of calcineurin inhibitors: | infection, renal toxicity, lymphoma |
| a major side effect of tacrolimus: | hyperglycemia |
| most common transplant organ? | kidney |
| types of rejection: | graft vs host |
| immunosuppressant therapy: immunosuppressive, adjunct therapy & used in acute rejection | glucocorticoids |
| types of glucocorticoids: | prednisone, methylprednisolone |
| concerns of glucocorticoids: | bone disorders, diabetes, cataracts |
| immunosuppressant therapy: destroys target cells, organ rejection prophylaxis | cytotoxic agents |
| types of cytotoxic agents: | azathioprine, mycophenolate mofetil |
| concerns of cytotoxic agents: | neutropenia, infection, N/V, diarrhea |
| immunosuppressant therapy: newer; can be used for prophylaxis or during rejection | antibodies |
| types of antibodies: | basiliximab, lymphocyte immune gobulin |
| concerns of antibodies: | anaphylaxis, infection |
| nursing considerations for immunosuppressant therapy: | life long medications (may change over time); adherence is very important |
| hematopoietic stem cell transplantation is also called what? | bone marrow transplantation |
| hematopoietic stem cell transplantation is used for patients with what? | hematologic malignancy (leukemia, lymphoma) or bone marrow failure |
| high dose chemotherapy is given for patients in hematopoietic stem cell transplantation for what? | to wipe out immune system *huge risk for infection* |
| hematopoietic stem cell transplantation can be harvest from bone marrow or what? | peripheral blood (filtered out --> put back in) |
| how long does it take before hematopoietic stem cell tranplantation graft fully takes place? what is important to remember for this? | can take 5 weeks; patient must remain in protective environments during this time (strict isolation) |
| trauma centers: Methodist Hospital, Eskenazi Health, Riley Hospital for Children, St. Vincent Indianapolis | level 1 trauma center |
| trauma centers: terre haute Regional Hospital | level 2 trauma center |
| trauma centers: Union Hospital, Good Samaritan- Vincennes | level 3 trauma center |
| specific to kinetic injury which includes blunt trauma & penetrating trauma: | traumatic injury |
| tissue deformation without interruption of skin integrity (car accident-internal bleeding in abdomen) | blunt trauma |
| injury sustained by the transmission of energy to body tissues from a moving object that interrupts skin & tissue integrity (stabbing, impaled by an object) | penetrating trauma |
| risk factors for traumas: | age (older-falls, younger- car accidents), gender, alcohol/drug use, geography (proximity to trauma centers, rural areas- work incidents) |
| blunt trauma: tearing force; spinal injury, aortic tear, spenic injury, renal injury, liver (no break in skin- internally): | shearing |
| blunt trauma: being propelled forward & stopped suddenly; think of MVA; can result in shearing forces | acceleration/deceleration |
| blunt trauma: pressed or squeezed together; heart & lungs, spinal column, bowel, liver (hit by car & pushed into building; something falls on someone) | compression |
| penetrating trauma: typically localized damage; think of thoracic & abdominal cavities close proximity (major organs in those areas); think of stabbing; do not remove an impaled object, protect! (can lead to hemorrhage) | low to medium energy missiles |
| penetrating trauma: cavitation (creating larger opening?) Trajectory; gun shot wound | high energy missiles |
| penetrating trauma: penetrating object; like a secondary explosion within a patient; can break off & cause more damage | secondary missiles |
| response to traumatic injury: cardiac output increases, blood volume is increased, more able to withstand blood loss, fetus is really well protected early on | pregnancy |
| ABCDE: airway, breathing, circulation, disability, exposure/evacuation | Primary survey |
| first thing in primary survey? | cervical spine immobilization! |
| airway management for traumatic injuries (3): | jaw-thrust maneuver, intubation, surgical airway |
| 2 or more ribs brake --> patient can't support structure --> pushing in on the lungs (can't expand) *stabilize (mechanical ventilation)* | flail chest |
| opening to chest cavity (tension)- allows air to enter pleural space but not escape; lung becomes collapsed; puts pressure on heart; causes trachea to deviate from that side to unaffected side; affects cardiac output | tension pneumothorax |
| lung collapses, not the same pressure building up in thoracic cavity; trachea remains at midline; tape sterile dressing on 3 sides, allowing patient to inhale/exhale through one side not taped down | open pneumothorax |
| sac fills w/ blood, overcome ability of heart to pump; insert needle (not nursing task) to remove fluid | cardiac tamponade |
| FGHI: full set of vitals (focused assessments), give comfort measures, history & head-to-toe assessment, inspect posterior surfaces | secondary survey |
| if patient becomes hemodynamically unstable, they should return to what? | primary survey |
| what's important to remember when doing an abdominal assessment? | observe before palpating |
| what shot should be given in a blunt or penetrating trauma? | tetanus (no matter when their last shot was) |
| if viscera is protruding, cover w/ what kind of dressing? | sterile, moist saline dressing |
| why are pelvic fractures life threatening? | major arteries running through that area of the body |
| types of burns: flames, hot objects | thermal (fire, oven) |
| types of burns: acid, alkali, organic substances (exposed to chemical at work); cause eschar tissue to form | chemical |
| types of burns: electrical current (around house, minor burns); electrical burns at work (more severe) | electrical |
| types of burns: radiant injury (cancer patients, throat/esophageal cancer), frostbite | radiation & extreme cold |
| why are diabetics more susceptible to burns? | altered sensation |
| burns: epidermis & superficial layer | superficial partial thickness |
| burns: epidermis & deep layer of dermis (hair follicles) | deep partial thickness |
| burns: epidermis, dermis, subcutaneous layers of skin & tissue | full thickness |
| burns: extends to muscle, tendons, or bone | deep full thickness |
| burn classification charts: | lund & browder chart; RULE OF NINES |
| severity/extent of burn: | depth |
| lund & browder chart is based on what? | age (harder to memorize); great to use on peds floor; most commonly seen in burn centers |
| rule of nines is used to see what? | what percentage of body area is covered by burns; not broken down by age (not as accurate) |
| what is the #1 goal in burn resuscitation? | fluid resuscitation |
| burns: maintain urine output at what? | 0.5 mL/KG/HR |
| burns: you should get as much fluid in the patient as possible by doing what? | 2 large bore IV's |
| burn fluids should start with what? | lactated ringers or isotonic crystalloids for those w/ less than 40% injury |
| electrical burns may need cardiac monitoring for what? | dysrhythmias |
| if more than 10% of body area is covered w/ more of a depth of burn, patient should be transferred to where? | burn center |
| 4 mL LR x TBSA % burned x patient weight (kg): | parkland formula |
| what's important to remember w/ the parkland formula? | give half of the amount in the first 8 hours and the second half of the amount over the next 16 hours |
| for fluid resuscitation in burn victims, what are we trying to balance? | fluid perfusion w/ edema |
| when should you assess peripheral vascular in burn patients? | initially and then every hour through resuscitative phase |
| stiff, tough, dead skin, cannot expand in relation to edema | eschar |
| results from excess fluid, may go from escharotomy (incision in eschar to take pressure off peripheral system) to faciotomy | compartment syndrome |
| decreased pulmonary perfusion results from what? | decreased oxygen diffusion |
| concern regarding impending obstruction; burns, singed hair, facial erythema, tachypnea, hoarse voice, brassy cough, stridor: | upper airway injury |
| how should an upper airway injury be treated? | 100% oxygen via snug fitting nonrebreather (determine if intubation is needed) |
| usually gaseous & chemical products, think respiratory failure & ARDS!!! Ulceration of mucous membranes, edema, excessive secretions, atelectasis (parts of lungs collapse) | lower airway injury |
| saturates hemoglobin resulting in hypoxemia (pulse ox cant tell difference between carbon monoxide & oxygen) headache, trouble remembering, acting off, difficulty breathing: | carbon monoxide poisoning |
| how should carbon monoxide poisoning be treated? | high concentrations of oxygen |
| neurologic resuscitative phase is more common with what types of injuries? | electrical & lightning injuries |
| burns- resuscitative phase: anxiety, delirium, PTSD, depression | psychologic |
| burns- metabolic can persist for up to how many months in those over 40% impacted? | 24 months |
| burns- metabolic: hypometabolism | first 24-36 hours |
| burns- metabolic: persistent high glucose, due in part to heat loss (causes things to go up like HR, pulse, etc.) | hypermetabolism |
| burns- resuscitative phase: renal | creatinine may not reflect true renal function early; acute renal failure is common; thinking about shock |
| burns- giving too much fluid (especially in the first few hours) can lead to what? | hemodilution |
| what is used to help guide fluid resuscitation? | urine output |
| burns- remove clothing, jewelry, belts, etc.; brush off dry chemical & use continuous water lavage; decontaminate; elevate burned extremities (helps w/ edema), give tetanus prophylaxis | initial care |
| burns- when does the rehabilitative phase begin? | 2-3 days post injury (begin as early as possible) |
| burns- rehabilitative phase: | prevent & control infection; preserve tissue; promote wound closure |
| when transferring a burn victim, what should you cover them with? | clean, dry sheet |
| what kind of dressings should not be given to burn victims? | wet to dry dressings |
| absolute or relatively deficiency in insulin: | DKA |
| blood sugar > 250-500? | uncontrolled hyperglycemia |
| DKA is more common in what patients? | type 1 diabetes |
| what is the #1 reason to throw someone into DKA? | infection |
| DKA: ketones increase resulting in decreased pH (below 7.20); makes respiratory system try to rid body of acid through carbon dioxide & water (Kussmaul breathing); bicarb tries to compensate but becomes overwhelmed & levels drop | metabolic acidosis |
| DKA: elevated glucose increased intravascular osmotic pressure, draws extravascular fluids into intravascular compartment; body responds by trying to rid glucose & urine; RAAS & ADH work to compensate but eventually will decompensate which leads to death | osmotic diuresis |
| DKA- ketones produced by free fatty acids that the body uses for energy | ketosis |
| DKA #1 priority? | hydration |
| DKA labs? | glucose, ketones, ABGs, electrolytes, CBC |
| results from insulin deficiency & insulin resistance; slower onset than DKA & less common, higher mortality rate, immune compromised | hyperglycemic hyperosmolar state (HHS) |
| HHS is typically in what people? | elderly w/ type 2 diabetes |
| extreme hyperglycemia, usually higher than in DKA, usually over 600 | hyperglycemic hyperosmolar state (HHS) |
| HHS- osmotic diuresis: | typically worse than DKA, severe dehydration & hypotension, loss of electrolytes |
| neurologic alterations in HHS: | stupor, coma, seizures (may progress over days) |
| management of DKA & HHS: | restore fluid volume (NS); correct electrolyte imbalances (potassium); clear ketones & reduce acidosis; normalize glucose gradually; monitor status; prevent complications (hypoglycemia, hypokalemia); identify cause |
| insulin therapy- regular insulin; minimum of hourly glucose checks | continuous low-dose intravenous insulin infusion |
| insulin therapy- mild to moderate cases, rapid-acting, administer every 1-2 hours | subcutaneous insulin in DKA |
| insulin therapy- non critical patients, usually those who oral agents will not work during hospitalization | sliding-scale insulin administration |
| insulin therapy- no universal acceptance titration algorithm; desired blood glucose controversial | intensive insulin therapy |
| once glucose has started to decrease, switch from NS to what? | D5 with 1/2 NS |
| what to watch for in DKA/HHS: | potassium, sodium, phosphate |
| what should be corrected before insulin is given? | potassium |
| only insulin you give IV? | regular insulin |
| if infection is the cause of DKA, what should be given? | ATB |
| A client is admitted with newly diagnosed aortic valve stenosis. The nurse closely monitors this client for development of which cardiac dysrhythmia that may cause immediate decompensation? | Atrial fibrillation |
| A client has been diagnosed with infective endocarditis. Which teaching information should the nurse provide to this client? (Select all that apply.) | “It is very important that you take your antibiotics on time and according to the directions provided.” “You will have several blood tests done to determine which antibiotic is necessary.” |
| A client has been diagnosed with heart failure. How should the nurse explain this disorder to the client? | “The two bottom pumping chambers of your heart are not working correctly.” |
| : A nurse is preparing to administer the client’s daily dose of carvedilol (Coreg). What findings would indicate need to collaborate with the prescriber before administration? (Select all that apply.) | 1. Heart rate of 48 beats/min 3. Second degree AV block 5. Shortness of breath at rest |
| A client’s blood pressure has measured 139/85 mmHg and 136/88 mmHg at the last two monthly appointments. What should the nurse tell the client about these blood pressure measurements? | “Your blood pressure measurements fall in the prehypertension range.” |
| Which food choices would the nurse interpret as indicating that the client understands dietary instruction for the management of hypertension? (Select all that apply.) | 1. Low-fat milk at lunch 3. Potassium-bearing fruits such as bananas for breakfast |
| A client has been diagnosed with hypertensive emergency. Which interventions would the emergency department nurse anticipate delivering? (Select all that apply.) | 1. Admitting the client to the hospital 2. Titrating IV medications to control the blood pressure |
| A client is admitted to the emergency department in a hypertensive crisis. Which finding would indicate to the nurse that this is actually a hypertensive emergency? | 4. Client complains of chest pain. |
| A client with history of an abdominal aortic aneurysm (AAA) has been admitted for treatment of pneumonia. Which assessment finding would require the nurse to contact the client’s primary healthcare provider immediately? (Select all that apply.) | 1. The client becomes suddenly hypotensive. 4. The client reports hip pain. 5. There is new absence of pedal pulses in the left foot. |
| A nurse is providing discharge instruction to a client whose abdominal aortic aneurysm (AAA) will be treated medically. Which topics should the nurse include in this instruction? | 1. Importance of smoking cessation |
| A client presents in the emergency department and reports taking an intentional overdose of acetaminophen 3 days earlier. The client says, “I thought it would kill me, but I just got sick.” What assessment finding would corroborate this client’s report? | 3. The client’s ALT and AST enzymes are elevated. |
| A client w a history of heart failure reports to the clinic complaining of tenderness at the right costal margin along w increasing SOB. The nurse would ask assessment questions to determine if which common process is occurring? | 3. The client’s liver is engorged |
| A client is prescribed N-acetylcysteine (NAC) as treatment of an acetaminophen overdose. Which nursing interventions are essential? (Select all that apply.) | 2. Be certain to give each dose on time. 3. Warn the client that the taste and smell are not pleasant. 5. Start the medication as soon as possible after the prescription is written. |
| A client’s total bilirubin is elevated. Which other lab result would the nurse expect if this client has liver failure? | 3. Increased alkaline phosphatase (ALP) |
| A client has been diagnosed with grade II hepatic encephalopathy. The nurse should expect which assessment? | 4. Intermittent asterixis |
| A client is receiving lactulose (Cephulac). Which findings would the nurse evaluate as indicating this medication is having the desired effects? (Select all that apply.) | 1. The client’s serum ammonia level is dropping. 2. The client is having two to four soft stools daily. |
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