Question 1

CORRECT
For a client in hepatic coma, which outcome would be the most appropriate?
The client is oriented to time, place, and person.

B The client exhibits no ecchymotic areas.

C The client increases oral intake to 2,000 calories/day.
D The client exhibits increased serum albumin level.
Question 1 Explanation:

Hepatic coma is the most advanced stage of hepatic encephalopathy. As hepatic coma resolves, improvement in
the client’s level of consciousness occurs. The client should be able to express orientation to time, place, and
person. Ecchymotic areas are related to decreased synthesis of clotting factors. Although oral intake may be
related to level of consciousness, it is more closely related to anorexia. The serum albumin level reflects hepatic
synthetic ability, not level of consciousness.

Question 2
CORRECT
Jordin is a client with jaundice who is experiencing pruritus. Which nursing intervention would be included in
the care plan for the client?

A Administering vitamin K subcutaneously

B Applying pressure when giving I.M. injections
C Decreasing the client’s dietary protein intake
Keeping the client’s fingernails short and smooth

Question 2 Explanation:

The client with pruritus experiences itching, which may lead to skin breakdown and possibly infection from
scratching. Keeping his fingernails short and smooth helps prevent skin breakdown and infection from
scratching. Applying pressure when giving I.M. injections and administering vitamin K subcutaneously are
important if the client develops bleeding problems. Decreasing the client’s dietary intake is appropriate if the
client’s ammonia levels are increased.

Question 3
CORRECT
Marie, a 51-year-old woman, is diagnosed with cholecystitis. Which diet, when selected by the client, indicates
that the nurse’s teaching has been successful?

A 4-6 small meals of low-carbohydrate foods daily

B High-fat, high-carbohydrate meals
Low-fat, high-carbohydrate meals

D High-fat, low protein meals

Question 3 Explanation:

For the client with cholecystitis, fat intake should be reduced. The calories from fat should be substituted with
carbohydrates. Reducing carbohydrate intake would be contraindicated. Any diet high in fat may lead to
another attack of cholecystitis.

Question 4
CORRECT
The hospital administrator had undergone percutaneous transhepatic cholangiography. which assessment
finding indicates complication after the operation?
Fever and chills

B Hypertension
C Bradycardia
D Nausea and diarrhea
Question 4 Explanation:

Septicemia is a common complication after a percutaneous transhepatic cholangiography. Evidence of fever

and chills, possibly indicative of septicemia, is important. HYpotension, not hypertension, is associated with
septicemia. Tachycardia, not bradycardia, is most likely to occur. Nausea and diarrhea may occur but are not
classic signs of sepsis.

Question 5
CORRECT
When planning home care for a client with hepatitis A, which preventive measure should be emphasized to
protect the client’s family?

A Keeping the client in complete isolation

Using good sanitation with dishes and shared bathrooms
C Avoiding contact with blood-soiled clothing or dressing
D Forbidding the sharing of needles or syringes
Question 5 Explanation:

Hepatitis A is transmitted through the fecal oral route or from contaminated water or food. Measures to protect
the family include good handwashing, personal hygiene and sanitation, and use of standard precautions.
Complete isolation is not required. Avoiding contact with blood-soiled clothing or dressings or avoiding the
sharing of needles or syringes are precautions needed to prevent transmission of hepatitis B.

Question 6
WRONG
For Jayvin who is taking antacids, which instruction would be included in the teaching plan?

A “Take the antacids with 8 oz of water.”

“Avoid taking other medications within 2 hours of this one.”

C “Continue taking antacids even when pain subsides.”

“Weigh yourself daily when taking this medication.”

Question 6 Explanation:

Antacids neutralize gastric acid and decrease the absorption of other medications. The client should be
instructed to avoid taking other medications within 2 hours of the antacid. Water, which dilutes the antacid,
should not be taken with antacid. A histamine receptor antagonist should be taken even when pain subsides.
Daily weights are indicated if the client is taking a diuretic, not an antacid.

Question 7
WRONG
Which clinical manifestation would the nurse expect a client diagnosed with acute cholecystitis to exhibit?

A Jaundice, dark urine, and steatorrhea

Acute right lower quadrant (RLQ) pain, diarrhea, and
B dehydration
Ecchymosis petechiae, and coffee-ground emesis
Nausea, vomiting, and anorexia

Question 7 Explanation:
Acute cholecystitis is an acute inflammation of the gallbladder commonly manifested by the following:
anorexia, nausea, and vomiting; biliary colic; tenderness and rigidity the right upper quadrant (RUQ) elicited on
palpation (e.g., Murphy’s sign); fever; fat intolerance; and signs and symptoms of jaundice. Ecchymosis,
petechiae, and coffee-ground emesis are clinical manifestations of esophageal bleeding. The coffee-ground
appearance indicates old bleeding. Jaundice, dark urine, and steatorrhea are clinical manifestations of the icteric
phase of hepatitis.

Question 8
WRONG
Pierre who is diagnosed with acute pancreatitis is under the care of Nurse Bryan. Which intervention should the
nurse include in the care plan for the client?
Administration of vasopressin and insertion of a balloon
tamponade

B Preparation for a paracentesis and administration of diuretics

Maintenance of nothing-by-mouth status and insertion of
nasogastric (NG) tube with low intermittent suction
Dietary plan of a low-fat diet and increased fluid intake to
D 2,000 ml/day

Question 8 Explanation:

With acute pancreatitis, the client is kept on nothing-by-mouth status to inhibit pancreatic stimulation and
secretion of pancreatic enzymes. NG intubation with low intermittent suction is used to relieve nausea and
vomiting, decrease painful abdominal distention, and remove hydrochloric acid. Vasopressin would be
appropriate for a client diagnosed with bleeding esophageal varices. Paracentesis and diuretics would be
appropriate for a client diagnosed with portal hypertension and ascites. A low-fat diet and increased fluid intake
would further aggravate the pancreatitis.

Question 9
CORRECT
When teaching a client about pancreatic function, the nurse understands that pancreatic lipase performs which
function?

A Transports fatty acids into the brush border

Breaks down fat into fatty acids and glycerol

C Triggers cholecystokinin to contract the gallbladder

D Breaks down protein into dipeptides and amino acids
Question 9 Explanation:
Lipase hydrolyses or breaks down fat into fatty acids and glycerol. Lipase is not involved with the transport of
fatty acids into the brush border. Fat itself triggers cholecystokinin release. Protein breakdown into dipeptides
and amino acids is the function of trypsin, not lipase.

Question 10
WRONG
A 52-year-old man was referred to the clinic due to increased abdominal girth. He is diagnosed with ascites by
the presence of a fluid thrill and shifting dullness on percussion. After administering diuretic therapy, which
nursing action would be most effective in ensuring safe care?

A Measuring serum potassium for hyperkalemia

Assessing the client for hypervolemia

C Measuring the client’s weight weekly

Documenting precise intake and output

Question 10 Explanation:

For the client with ascites receiving diuretic therapy, careful intake and output measurement is essential for safe
diuretic therapy. Diuretics lead to fluid losses, which if not monitored closely and documented, could place the
client at risk for serious fluid and electrolyte imbalances. Hypokalemia, not hyperkalemia, commonly occurs
with diuretic therapy. Because urine output increases, a client should be assessed for hypovolemia, not
hypervolemia. Weights are also an accurate indicator of fluid balance. However, for this client, weights should
be obtained daily, not weekly.

Question 11
CORRECT
Which assessment finding indicates that lactulose is effective in decreasing the ammonia level in the client with
hepatic encephalopathy?
Passage of two or three soft stools daily

B Evidence of watery diarrhea

C Daily deterioration in the client’s handwriting
D Appearance of frothy, foul-smelling stools
Question 11 Explanation:

Lactulose reduces serum ammonia levels by inducing catharsis, subsequently decreasing colonic pH and
inhibiting fecal flora from producing ammonia from urea. Ammonia is removed with the stool. Two or three
soft stools daily indicate effectiveness of the drug. Watery diarrhea indicates overdose. Daily deterioration in
the client’s handwriting indicates an increase in the ammonia level and worsening of hepatic encephalopathy.
Frothy, foul-smelling stools indicate steatorrhea, caused by impaired fat digestion.

Question 12
CORRECT
Nurse Farrah is providing care for Kristoff who has jaundice. Which statement indicates that the nurse
understands the rationale for instituting skin care measures for the client?

A “Jaundice is associated with pressure ulcer formation.”

B “Jaundice impairs urea production, which produces pruritus.”
“Jaundice produces pruritus due to impaired bile acid
excretion.”
“Jaundice leads to decreased tissue perfusion and subsequent
D breakdown.”

Question 12 Explanation:

Jaundice is a symptom characterized by increased bilirubin concentration in the blood. Bile acid excretion is
impaired, increasing the bile acids in the skin and causing pruritus. Jaundice is not associated with pressure
ulcer formation. However, edema and hypoalbuminemia are. Jaundice itself does not impair urea production or
lead to decreased tissue perfusion.

Question 13
CORRECT
Which rationale supports explaining the placement of an esophageal tamponade tube in a client who is
hemorrhaging?

A Allowing the client to help insert the tube

B Beginning teaching for home care
C Maintaining the client’s level of anxiety and alertness
Obtaining cooperation and reducing fear

Question 13 Explanation:

An esophageal tamponade tube would be inserted in critical situations. Typically, the client is fearful and
highly anxious. The nurse therefore explains about the placement to help obtain the client’s cooperation and
reduce his fear. This type of tube is used only short term and is not indicated for home use. The tube is large
and uncomfortable. The client would not be helping to insert the tube. A client’s anxiety should be decreased,
not maintained, and depending on the degree of hemorrhage, the client may not be alert.

Question 14
CORRECT
For Rico who has chronic pancreatitis, which nursing intervention would be most helpful?

A Allowing liberalized fluid intake

Counseling to stop alcohol consumption

C Encouraging daily exercise

D Modifying dietary protein
Question 14 Explanation:

Chronic pancreatitis typically results from repeated episodes of acute pancreatitis. More than half of chronic
pancreatitis cases are associated with alcoholism. Counseling to stop alcohol consumption would be the most
helpful for the client. Dietary protein modification is not necessary for chronic pancreatitis. Daily exercise and
liberalizing fluid intake would be helpful but not the most beneficial intervention.

Question 15
WRONG
Mr. Hasakusa is in end-stage liver failure. Which interventions should the nurse implement when addressing
hepatic encephalopathy? (Select all that apply.)
Assessing the client’s neurologic status every 2 hours
Monitoring the client’s hemoglobin and hematocrit levels
Evaluating the client’s serum ammonia level
Monitoring the client’s handwriting daily
Preparing to insert an esophageal tamponade tube

F Making sure the client’s fingernails are short

Question 15 Explanation:

Hepatic encephalopathy results from an increased ammonia level due to the liver’s inability to covert ammonia
to urea, which leads to neurologic dysfunction and possible brain damage. The nurse should monitor the
client’s neurologic status, serum ammonia level, and handwriting. Monitoring the client’s hemoglobin and
hematocrit levels and insertion of an esophageal tamponade tube address esophageal bleeding. Keeping
fingernails short address jaundice.
Question 16
CORRECT
For a client with hepatic cirrhosis who has altered clotting mechanisms, which intervention would be most
important?

A Allowing complete independence of mobility

Applying pressure to injection sites

C Administering antibiotics as prescribed

D Increasing nutritional intake
Question 16 Explanation:

The client with cirrhosis who has altered clotting is at high risk for hemorrhage. Prolonged application of
pressure to injection or bleeding sites is important. Complete independence may increase the client’s potential
for injury, because an unsupervised client may injure himself and bleed excessively. Antibiotics and good
nutrition are important to promote liver regeneration. However, they are not most important for a client at high
risk for hemorrhage.

Question 17
CORRECT
A client with advanced cirrhosis has been diagnosed with hepatic encephalopathy. The nurse expects to assess
for:

A Malaise
B Stomatitis
Hand tremors

D Weight loss
Question 17 Explanation:

Hepatic encephalopathy results from the accumulation of neurotoxins in the blood, therefore the nurse wants to
assess for signs of neurological involvement. Flapping of the hands (asterixis), changes in mentation, agitation,
and confusion are common. These clients typically have ascites and edema so experience weight gain. Malaise
and stomatitis are not related to neurological involvement.

Question 18
CORRECT
A client diagnosed with chronic cirrhosis who has ascites and pitting peripheral edema also has hepatic
encephalopathy. Which of the following nursing interventions are appropriate to prevent skin breakdown?
(Select all that apply.)

A Range of motion every 4 hours

Turn and reposition every 2 hours

C Abdominal and foot massages every 2 hours

Alternating air pressure mattress

E Sit in chair for 30 minutes each shift

Question 18 Explanation:

Edematous tissue must receive meticulous care to prevent tissue breakdown. Range of motion exercises
preserve joint function but do not prevent skin breakdown. Abdominal or foot massage will not prevent skin
breakdown but must be cleansed carefully to prevent breaks in skin integrity. The feet should be kept at the
level of heart or higher so Fowler’s position should be employed. An air pressure mattress, careful
repositioning can prevent skin breakdown.

Question 19
WRONG
Which of the following will the nurse include in the care plan for a client hospitalized with viral hepatitis?

A Increase fluid intake to 3000 ml per day

Adequate bed rest

C Bland diet
Administer antibiotics as ordered

Question 19 Explanation:

Treatment of hepatitis consists of bed rest during the acute phase to reduce metabolic demands on the liver,
thus increasing blood supply and cell regeneration. Forcing fluids, antibiotics, and bland diets are not part of
the treatment plan for viral hepatitis.

Question 20
WRONG
Spironolactone (Aldactone) is prescribed for a client with chronic cirrhosis and ascites. The nurse should
monitor the client for which of the following medication-related side effects?
Jaundice
Hyperkalemia
C Tachycardia
D Constipation
Question 20 Explanation:

This is a potassium-sparing diuretic so clients should be monitored closely for hyperkalemia. Diarrhea,
dizziness, and headaches are other more common side effects. Tachycardia, jaundice, and constipation are not
expected side effects of spironolactone (Aldactone).

1. Which condition is NOT a known cause of cirrhosis?

 A. Obesity
 B. Alcohol consumption
 C. Blockage of the bile duct

 D. Hepatitis C

 E. All are known causes of cirrhosis

The answer is E. All of these conditions can cause cirrhosis.

2. The liver receives it blood supply from two sources. One of these sources is called the
_________________, which is a vessel network that delivers blood _____________ in nutrients but
________ in oxygen.

 A. hepatic artery, low, high

 B. hepatic portal vein, high, low

 C. hepatic lobule, high, low

 D. hepatic vein, low, high
The answer is B. Majority of the blood flow to the liver comes from the hepatic portal vein. This vessel
network delivers blood HIGH in nutrients (lipids, proteins, carbs etc.) from organs that aid in the digestion of
food, but the blood is POOR in oxygen. The organs connected to the hepatic portal vein are: small/large
intestine, pancreas, spleen, stomach. Rich oxygenated blood comes from the hepatic artery to the liver.

3. A patient with late-stage cirrhosis develops portal hypertension. Which of the following options below
are complications that can develop from this condition? Select all that apply:

 A. Increase albumin levels

  B. Ascites

 C. Splenomegaly

 D. Fluid volume deficient

 E. Esophageal varices

The answer are B, C, and E. Portal Hypertension is where the portal vein becomes narrow due to scar tissue in
the liver, which is restricting the flow of blood to the liver. Therefore, pressure becomes increased in the
portal vein and affects the organs connected via the vein to the liver. The patient may experience ascites,
enlarged spleen "splenomegaly", and esophageal varices etc.

4. Your patient with cirrhosis has severe splenomegaly. As the nurse you will make it priority to monitor the
patient for signs and symptoms of? Select all that apply:

 A. Thrombocytopenia

 B. Vision changes

 C. Increased PT/INR

 D. Leukopenia

The answers are A, C, and D. A patient with an enlarged spleen (splenomegaly) due to cirrhosis can experience
thrombocytopenia (low platelet count), increased PT/INR (means it takes the patient a long time to stop
bleeding), and leukopenia (low white blood cells). The spleen stores platelets and WBCs. An enlarged spleen
can develop due to portal hypertension, which causes the platelets and WBCs to become stuck inside the
spleen due to the increased pressure in the hepatic vein (hence lowering the count and the body’s access to
these important cells for survival).

5. A patient is admitted with hepatic encephalopathy secondary to cirrhosis. Which meal option selection
below should be avoided with this patient?

 A. Beef tips and broccoli rabe

 B. Pasta noodles and bread

 C. Cucumber sandwich with a side of grapes
 D. Fresh salad with chopped water chestnuts
The answer is A. Patients who are experiencing hepatic encephalopathy are having issues with toxin build up
in the body, specifically ammonia. Remember that ammonia is the byproduct of protein breakdown, and
normally the liver can take the ammonia from the protein breakdown and turn it into urea (but if the cirrhosis
is severe enough this can’t happen). Therefore, the patient should consume foods LOW in protein until the
encephalopathy subsides. Option A is very high in protein while the others are low in protein. Remember
meats, legumes, eggs, broccoli rabe, certain grains etc. are high in protein.

6. During your morning assessment of a patient with cirrhosis, you note the patient is disoriented to person
and place. In addition while assessing the upper extremities, the patient's hands demonstrate a flapping
motion. What lab result would explain these abnormal assessment findings?

 A. Decreased magnesium level

 B. Increased calcium level

 C. Increased ammonia level

 D. Increased creatinine level
The answer is C. Based on the assessment findings and the fact the patient has cirrhosis, the patient is
experiencing hepatic encephalopathy. This is due to the buildup of toxins in the blood, specifically ammonia.
The flapping motion of the hands is called "asterixis". Therefore, an increased ammonia level would confirm
these abnormal assessment findings.

7. You are receiving shift report on a patient with cirrhosis. The nurse tells you the patient’s bilirubin levels
are very high. Based on this, what assessment findings may you expect to find during your head-to-toe
assessment? Select all that apply:

 A. Frothy light-colored urine

 B. Dark brown urine

 C. Yellowing of the sclera

 D. Dark brown stool

 E. Jaundice of the skin

 F. Bluish mucous membranes

The answers are B, C, and E. High bilirubin levels are because the hepatocytes are no longer able to properly
conjugate the bilirubin because they are damaged. This causes bilirubin to leak into the blood and urine
(rather than entering the bile and being excreted in the stool). Therefore, the bilirubin stays in the blood and
will enter the urine. This will cause the patient to experience yellowing of the skin, sclera of the eyes, and
mucous membranes (“jaundice”) and have dark brown urine. The stools would be CLAY-COLORED not dark
brown (remember bilirubin normally gives stool it brown color but it will be absent).

8. A 45 year old male has cirrhosis. The patient reports concern about the development of enlarged breast
tissue. You explain to the patient that this is happening because?
  A. The liver cells are removing too much estrogen from the body which causes the testicles to produce
excessive amounts of estrogen, and this leads to gynecomastia.
 B. The liver is producing too much estrogen due to the damage to the liver cells, which causes the level
to increase in the body, and this leads to gynecomastia.
 C. The liver cells are failing to recycle estrogen into testosterone, which leads to gynecomastia.
 D. The liver cells are failing to remove the hormone estrogen properly from the body, which causes

the level to increase in the body, and this leads to gynecomastia.

The answer is D.

9. You're providing an in-service to new nurse graduates about esophageal varices in patients with cirrhosis.
You ask the graduates to list activities that should be avoided by a patient with this condition. Which
activities listed are correct: Select all that apply

 A. Excessive coughing

 B. Sleeping on the back

 C. Drinking juice

 D. Alcohol consumption

 E. Straining during a bowel movement

 F. Vomiting

The answers are A, D, E, and F. Esophageal varices are dilated vessels that are connected from the throat to
the stomach. They can become enlarged due to portal hypertension in cirrhosis and can rupture (this is a
medical emergency). The patient should avoid activities that could rupture these vessels, such as excessive
cough, vomiting, drinking alcohol, and constipation (straining increases thoracic pressure.)

10. While providing mouth care to a patient with late-stage cirrhosis, you note a pungent, sweet, musty
smell to the breath. This is known as:

 A. Metallic Hepatico
 B. Fetor Hepaticus
 C. Hepaticoacidosis

 D. Asterixis

The answer is B.
11. The physician orders Lactulose 30 mL by mouth per day for a patient with cirrhosis. What findings below
demonstrates the medication is working effectively? Select all that apply:

 A. Decrease albumin levels

 B. Decrease in Fetor Hepaticus

 C. Patient is stuporous.

 D. Decreased ammonia blood level

 E. Presence of asterixis
The answer is B and D. A patient with cirrhosis may experience a complication called hepatic encephalopathy.
This will cause the patient to become confused (they may enter into a coma), have pungent, musty smelling
breath (fetor hepaticus), asterixis (involuntary flapping of the hands) etc. This is due to the buildup of
ammonia in the blood, which affects the brain. Lactulose can be prescribed to help decrease the ammonia
levels. Therefore, if the medication is working properly to decrease the level of ammonia the patient would
have improving mental status (NOT stuporous), decreased ammonia blood level, decreasing or absence of
asterixis, and decreased ammonia blood level.

12. ________ reside in the liver and help remove bacteria, debris, and old red blood cells.

 A. Hepatocytes
 B. Langerhan cells
 C. Enterocytes

 D. Kupffer cells

The answer is D. Kupffer cells perform this function and are one of the two types of cells found in the liver
lobules (the functional units of the liver). These cells play a role in helping the hepatocytes turn parts of the
old red blood cells into bilirubin.

13. Which of the following is NOT a role of the liver?

 A. Removing hormones from the body

 B. Producing bile
 C. Absorbing water
 D. Producing albumin
The answer is C. The liver does not absorb water. The intestines are responsible for this function.