SOLVED

 Question 11 A patient has been admitted to the intensive care unit with the diagnosis of hyperacute liver failure. Which assessment findings would the nurse anticipate in this patient? 1. INR greater than 1.5 2. History of alcohol abuse 3. Jaundice 4. Mental status changes 5. Serum glucose greater than 125 mg/dL Question 12 A patient reports taking two 500 mg acetaminophen tablets “at least 3 or 4 times a day” to treat muscle pain in his back. What nursing assessment question is priority? 1. “Do you drink plenty of water when you take these pills?” 2. “What other medications do you take?” 3. “Have you had your back reassessed lately?” 4. “What other measures do you take to relieve your back pain?” Question 13 A pregnant woman is admitted to the high risk maternity unit with HELLP syndrome. The nurse would provide which interventions? 1. Protect the woman from inadvertent injury. 2. Monitor IV sticks for bleeding. 3. Monitor the woman for development of seizure. 4. Monitor the patient for the development of hypernatremia. 5. Prepare the woman for immediate intubation and mechanical ventilation. Question 14 A teenage girl is admitted to the intensive care unit after taking an overdose of acetaminophen. What nursing assessment question is priority? 1. “Did you take the pills on purpose?” 2. “Are you diabetic?” 3. “Could you be pregnant?” 4. “Do you feel at all sick to your stomach?” Question 15 A patient is prescribed N-acetylcysteine (NAC) 140 mg/kg via nasogastric tube. What is the priority nursing intervention? 1. Give the dose slowly over at least 15 minutes. 2. Warn the patient that the medication smells like burning rubber. 3. Give all follow-up doses exactly on time. 4. Ask the patient what he weighs. Question 16 The nurse is assessing a patient admitted with acute liver failure of unknown etiology. Which statement made by the family requires additional investigation? 1. “I thought her skin color change was due to going to the indoor tanning booth.” 2. “She has been exercising by gathering wild berries and greens for salads.” 3. “We went to the mall last week and she got pretty tired while shopping.” 4. “She was exposed to influenza last week when she went to visit her sister.” Question 17 The nurse is monitoring a patient for progression through the grades of hepatic encephalopathy (HE). This morning the patient is exhibiting a positive Babinski reflex. The nurse would conduct additional assessment about with HE grade? 1. I 2. II 3. HE grade IVa 4. HE grade IVb Question 18 A patient is admitted to the intensive care unit following lower extremity injury in a motor vehicle accident. The patient has history of chronic renal failure. Which nutritional support would the nurse provide? 1. High fat 2. Moderate protein 3. Fluids only for the first 24 hours 4. Low carbohydrate Question 19 A patient will be given rifaximin (Xifaxan) to reduce ammonia production by intestinal bacteria. The nurse would add which intervention to this patient’s plan of care? 1. Monitor IV site for infiltration. 2. Monitor for development of abdominal cramping. 3. Increase fluids to reduce risk of constipation. 4. Monitor serum potassium levels daily. Question 20 A patient in acute liver failure has developed increased intracranial pressure. Hypothermia has been induced. Which nursing intervention should be added to the patient’s plan of care? 1. Keep the patient’s temperature below 33° C. 2. Monitor the patient for development of frostbite. 3. Stimulate the patient at least every 1 hour to assess for neurological changes. 4. Monitor for the development of infection.