A nurse is monitoring the status of a client’s fat emulsion (lipid) infusion and notes that the

infusion is 2 hours delay. The nurse should do which of the following actions?
Answer: Make sure the infusion rate is infusing at the ordered rate.

A client is receiving parenteral nutrition (PN) in the home setting has a weight gain of 5 lb in 1
week. The nurse next assesses the client to identify the presence of which of the following?
Answer: Crackles upon auscultation.

For Sliding Hiatal Hernia, all are clinical manifestations except:

a. Heartburn
b. Halitosis
c. Regurgitation
d. Dysphagia

What other symptoms will validate the diagnosis of gastric ulcer?

a. right epigastric pain
b. pain occurs when stomach is empty
c. pain occurs immediately after meal
d. pain not relieved by vomiting

The nurse would monitor for which of the following adverse reactions to aluminum-containing
antacids such as aluminum hydroxide (Amphojel)?
A. Diarrhea
B. Constipation
C. GI upset
D. Fluid retention
You’re performing an abdominal assessment on Brent who is 52 y.o. In which order do you
proceed?
A. Observation, percussion, palpation, auscultation
B. Observation, auscultation, percussion, palpation
C. Percussion, palpation, auscultation, observation
D. Palpation, percussion, observation, auscultation

All of the following are considered complications of constipation except:

A. Hemorrhoids
B. Fecal impaction
C. Hypokalemia
D. Hypertension

In a client with diarrhea, which outcome indicates that fluid resuscitation is successful?
A. The client passes formed stools at regular intervals
B. The client reports a decrease in stool frequency and liquidity
C. The client exhibits firm skin turgor
D. The client no longer experiences perianal burning.

A client is suspected of having hepatitis. Which diagnostic test result will assist in confirming
this diagnosis?
A. Elevated hemoglobin level
B. Elevated serum bilirubin level
C. Elevated blood urea nitrogen level
D. Decreased erythrocyte sedimentation rate

A patient with severe cirrhosis of the liver develops hepatorenal syndrome. Which of the
following nursing assessment
data would support this?
A. Oliguria and azotemia
B. Metabolic alkalosis
C. Decreased urinary concentration
D. Weight gain of less than 1 lb. per week

Nurse Juvy is caring for a client with cirrhosis of the liver. To minimize the effects of the
disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines
that the client has the best understanding of the dietary measures to follow if the client states an
intention to increase the intake of:
A. Pork
B. Milk
C. Chicken
D. Broccoli

The client with cirrhosis needs to consume foods high in thiamine. Thiamine is present in a
variety of foods of plant and animal origin. Pork products are especially rich in this vitamin.
Other good food sources include nuts, whole grain cereals, and legumes. Milk contains Vitamins
A, D, and B2. Poultry contains niacin. Broccoli contains Vitamins C, E, and K and folic acid.

10. 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
B. Turn and reposition every 2 hours
C. Abdominal and foot massages every 2 hours
D. Alternating air pressure mattress
E. Sit in chair for 30 minutes each shift