AH2 Exam 2 Practice Questions

A client with cirrhosis is admitted with suspected hepatic encephalopathy. Which findings does the nurse expect? Select all that apply.

A. Asterixis (Flapping tremor or hand)

B. Changes in LOC

C. Changes in sleep patterns

D. Fetor Hepaticus (musty, sweet breath)

E. Decreased serum ammonia

A. Asterixis (Flapping tremor or hand)

B. Changes in LOC

C. Changes in sleep patterns

D. Fetor Hepaticus (musty, sweet breath)

The nurse receives report on four clients. Which client should the nurse see first?

A. Client with hepatic encephalopathy who had 3 soft stools since this morning

B. Client with chronic pancreatitis who rates abdominal pain 5/10

C. Client with ascites who gained 0.5kg overnight

D. Client with cirrhosis who is vomiting bright red blood

D. Client with cirrhosis who is vomiting bright red blood (hematemesis)

• Indicates bleeding of varices in esophagus or stomach

A client with hepatic encephalopathy is receiving lactulose. Which finding best shows the treatment is effective?

A. Increased urine output

B. Decreased serum bilirubin

C. Improved orientation and a falling serum ammonia level

D. Decreased abdominal girth

C. Improved orientation and a falling serum ammonia level

While a central line cap is being changed, the client suddenly becomes short of breath, has chest pain, and becomes hypotensive. What is the nurse’s first action?

A. Apply oxygen via non-rebreather mask

B. Notify rapid response team

C. Clamp the catheter

D. Place the client on the left side in Trendelenburg

C. Clamp the catheter

• Patient is likely experiencing a venous air embolism caused by air entering the vein. Clamping catheter prevents additional air from entering the blood stream.

A client has a transjugular intrahepatic portosystemic shunt (TIPS) placed 3 months ago. Which finding tells the nurse the procedure has been effective?

A. Decreased Bilirubin

B. Improved alertness & orientation

C. Fewer episodes of bleeding esophageal varices

D. Increased serum albumin

C. Fewer episodes of bleeding esophageal varices

• Indicates that portal blood pressure is lowering

A client has a peripheral IV infusing IV antibiotic. The nurse notes pain at the site, redness, and a red streak running up the forearm, with a palpable venous cord about ½ inch long. There is no drainage. The nurse recognizes that this is _______. After stopping the infusion and removing the catheter, the nurse elevates the extremity and applies a _____ compress.

1. Phlebitis

2. Warm

Which actions are appropriate when giving IV potassium chloride? Select all that apply.

A. Assess the IV site for pain & burning during the infusion

B. Limit a peripheral infusion to no more than 10 mEq/hr

C. Infuse 40 mEq/hr peripherally if the client is symptomatic

D. Give by IV push for faster correction of severe hypokalemia

E. Confirm urine output of at least 30 mL/hr before starting

F. Treat concentrations of 60 mEq/L or higher as a vesicant.

A. Assess the IV site for pain & burning during the infusion

B. Limit a peripheral infusion to no more than 10 mEq/hr

E. Confirm urine output of at least 30 mL/hr before starting

F. Treat concentrations of 60 mEq/L or higher as a vesicant.

A client has a double-lumen PICC. IV fluids are infusing through one lumen, the other is not in use. What is the nurse’s correct action for the unused lumen?

A. Leave it alone because the infusing fluid keeps the whole catheter patent

B. Flush it with 10mL NS according to facility policy

C. Flush it only when a medication is due

D. Remove the cap so that the nurse can see backflow

B. Flush it with 10mL NS according to facility policy

What are two priority assessments for a client with acute pancreatitis?

A. Pain level & hydration status

B. Hyperglycemia & mental status

C. Vital signs & oral care

D. Paralytic ileus & renal failure

A. Pain level & hydration status

A client with cirrhosis is scheduled for a paracentesis for severe ascites. Which action should the nurse take? Select all that apply

A. Position the client flat & supine

B. Have the client void before the procedure

C. Monitor blood pressure and heart rate after fluid removal

D. Measure abdominal girth & weight before and after

E. Anticipate IV albumin after a large volume is removed.

B. Have the client void before the procedure

C. Monitor blood pressure and heart rate after fluid removal

D. Measure abdominal girth & weight before and after

E. Anticipate IV albumin after a large volume is removed.

• Paracentesis → VAMP

  • V: Void before procedure

  • A: Assess the vitals

  • M: Measure abdominal girth & weight

  • P: Position upright

A client with cirrhosis is admitted with suspected hepatic encephalopathy. Which findings does the nurse expect? Select all that apply.

A. Changes in LOC

B. Fetor hepaticus (musty, sweet breath)

C. Changes in sleep pattern

D. Asterixis (flapping tremor of hand)

A. Changes in LOC

B. Fetor hepaticus (musty, sweet breath)

C. Changes in sleep pattern

D. Asterixis (flapping tremor of hand)

Match each burn description to its depth

1. Red, dry, painful; blanches with pressure; no blisters

2. Moist, pink, & blistered; very painful

3. Dry, leathery, tan, or white; the patient feels no pain when the area is touched

4. Blackened and charred, with exposed muscle and bone

1. Superficial (1st degree)

2. Partial Thickness (2nd degree)

3. Full Thickness (3rd degree)

4. Deep Full Thickness (4th degree)

15 mins into a unit of packed RBCs, the patient develops chills and a temperature of 101.1F. Match each nursing action to the order the nurse should perform it, first to last.

• Notify provider

• Keep the IV open with 0.9% NaCl through new tubing

• Send the blood bag and tubing to the blood bank

• Stop the transfusion

• Give medication as prescribed

1. Stop the transfusion

2. Keep the IV open with 0.9% NaCl through new tubing

3. Notify provider and the blood bank

4. Give medications as prescribed

5. Send the blood bag and tubing to the blood bank

A patient with hepatic encephalopathy is receiving lactulose 30mL PO q6h. Which finding shows the drug is having the desired effect? Select all that apply.

A. The patient has one formed stool every 2 days

B. Serum albumin is within normal limits

C. The patient is oriented to person, place, and time

D. Asterixis is no longer present

E. Serum ammonia has dropped from 110 to 40 mcg/dL

F. Abdominal girth has decreased by 3 cm.

C. The patient is oriented to person, place, and time

D. Asterixis is no longer present

E. Serum ammonia has dropped from 110 to 40 mcg/dL

A patient’s PICC was placed at the bedside 1 hour ago. A new grad nurse is preparing to use the line. Which statement by the new nurse shows correct understanding?

A. “I can use the PICC now because I got blood return”

B. “If the line flushes without resistance, the tip is in the right spot”

C. “I will measure the external catheter length to confirm the tip placement”

D. “I will wait for the chest X-ray report confirming the tip placement before I used the time”

D. “I will wait for the chest X-ray report confirming the tip placement before I used the time”

An adult has deep partial-thickness and full thickness burns on the entire head, the front trunk, and the entire right leg. using the Rule of 9’s, what is the estimated percentage of total body surface area burned?

A. 48%

B. 45%

C. 32%

D. 36%

B. 45%

• 9 (head) +18 (front trunk) +18 (entire right leg) = 45%

The nurse is teaching a patient with cirrhosis who is scheduled for a transjugular intrahepatic portosystemic shunt (TIPS). Which statements are accurate? Select all that apply.

A. It cures cirrhosis by repairing liver tissue

B. It can increase the risk of confusion from hepatic encephalopathy

C. It lowers pressure in the portal vein system

D. It reduces the risk of bleeding from esophageal varices

E. It filters ammonia out of the blood.

B. It can increase the risk of confusion from hepatic encephalopathy

C. It lowers pressure in the portal vein system

D. It reduces the risk of bleeding from esophageal varices

A patient arrives in the emergency department with burns to the face, neck, and upper chest from a kitchen fire. Which assessment findings shoulder the nurse act on first?

A. Hoarse voice & new stridor

B. Urine output of 40mL in the last hour

C. Pain rated 9/10

D. Large blistered on upper chest

A. Hoarse voice & new stridor

• Indicates inhalation burns/injury (airway first!)

Dialysis is a treatment that helps remove waste and excess fluid from the blood when a patient’s kidneys can no longer filter adequately.

• True or False

True

A patient with T1DM has a blood glucose of 520 mg/dL and deep respirations. ABGs: pH: 7.22, PaCO2: 25, HCO3: 10, PaO2: 96. The nurse recognizes that the patient’s breathing pattern is ______.

A. A sign of respiratory alkalosis from anxiety

B. Causing the acidosis by retaining CO2

C. Compensating for metabolic acidosis by blowing off CO2

D. An expected finding that needs no further monitoring

C. Compensating for metabolic acidosis by blowing off CO2

The nurse assesses a patient who is breathing spontaneously with a chest tube to water seal. The chest tube was placed 2 days ago and has had no bubbling. One assessment today, the nurse notes continuous bubbling in the water-seal chamber. Which action should the nurse take?

A. Document the findings as expected

B. Increase the suction to re-expand the lungs

C. Clamp the chest tube until the provider arrives

D. Check the tubing connections and dressing for a leak

D. Check the tubing connections and dressing for a leak

A patient with thrombocytopenia is given 7 units of platelets. if the platelets are effective _____.

A. The patient’s hemoglobin with increased by 1-2 g/dL

B. The platelet count increases by 10K-20K

C. The patient’s prothrombin time returns to normal

D. The platelet count will increased by 30K - 60K

D. The platelet count will increased by 30K - 60K

A patient on morphine PCA after surgery is difficult to arouse. RR is 8bpm and shallow. ABGs: pH: 7.29, PaCO2: 56, HCO3 25, PaO2 is 68. How should the nurse interpret these results?

A. Partially compensated respiratory acidosis with normal oxygenation

B. Uncompensated metabolic acidosis with hypoxemia

C. Fully compensated respiratory acidosis with hypoxemia

D. Uncompensated respiratory acidosis with hypoxemia

D. Uncompensated respiratory acidosis with hypoxemia

• pH & PaCO2 → abnormal, HCO3 → Normal = uncompensates

A patient has a chest tube inserted for a left pneumothorax. Which of the following statements by the patient indicates that more teaching is needed? Select all that apply.

A. “It delivers medication directly into your lung tissue”

B. “It increases the pressure around your lungs to keep it inflated”

C. “It measures how much oxygen is in your blood

D. “It removes air from around your lung so that the lung can re-expand”

A. “It delivers medication directly into your lung tissue”

B. “It increases the pressure around your lungs to keep it inflated”

C. “It measures how much oxygen is in your blood

While a patient is coughing, the chest tube becomes disconnected from the drainage system tubing and contacts the bedding. What is the nurse’s best immediate action?

A. Submerge the end of the chest tube 2- 3 cm into a bottle of sterile saline

B. Cover the open end of the tube with sterile petroleum gauze

C. Clean the tubing tip with alcohol and reattach it

D. Clamp the chest tube until a medical provider is consulted

A. Submerge the end of the chest tube 2- 3 cm into a bottle of sterile saline

A patient rescued from a house fire presents to the emergency department with burn injuries to the chest. The affected skin appears dry, hard, and charred dark brown with no pain upon light touch. What degree of burn does this patient have?

A. Partial-thickness burn (2nd degree)

B. Full-thickness burn (3rd degree)

C. Superficial burn (1st degree)

D. Deep full-thickness burn (4th degree)

B. Full-thickness burn (3rd degree)

Interpret the following ABG: pH: 7.33, PaCO2: 30, HCO3: 16, PaO2 94

A. Partially compensated respiratory alkalosis

B. Uncompensated metabolic acidosis

C. Partially compensated metabolic acidosis

D. Fully compensated metabolic alkalosis

C. Partially compensated metabolic acidosis

• ph: 7.33 → acidotic

• PaCO2: 30 → Slightly lower (if it was resp acidosis, pH is low & Co2 is high. But due to partial compensation, it is the opposite, so CO2 is also low)

• HCO3: 16 → Low