Ch 43: Liver, Biliary Tract, and Pancreas Problems

A patient with acute pancreatitis is NPO and has a nasogastric (NG) tube to suction. Which information obtained by the nurse indicates that these therapies have been effective?

Abdominal pain is decreased.

The nurse is caring for a patient with pancreatic cancer. Which nursing action is the highest priority?

Administer prescribed opioids to relieve pain as needed.

A serum potassium level of 3.2 mEq/L (3.2 mmol/L) is reported for a patient with cirrhosis who has scheduled doses of spironolactone (Aldactone) and furosemide (Lasix) due. Which action should the nurse take?

Administer the spironolactone.

Which focused data should the nurse assess after identifying 4+ pitting edema on a patient who has cirrhosis?

Albumin level

What is most important for the nurse to monitor to detect possible complications in a patient with severe cirrhosis who has bleeding esophageal varices?

Ammonia levels

A young adult contracts hepatitis from contaminated food. What should the nurse expect serologic testing to reveal during the acute (icteric) phase of the patient's illness?

Anti-hepatitis A virus immunoglobulin M (anti-HAV IgM)

How should the nurse prepare a patient with ascites for paracentesis?

Ask the patient to empty the bladder.

Which action should the nurse take to evaluate treatment effectiveness for a patient who has hepatic encephalopathy?

Ask the patient to extend both arms forward.

A patient born in 1955 had hepatitis A infection 1 year ago. According to Centers for Disease Control and Prevention (CDC) guidelines, which action should the nurse include in care when the patient is seen for a routine annual physical examination?

Ask whether the patient has been screened for hepatitis C.

A patient has been admitted with acute liver failure. Which assessment data are most important for the nurse to communicate to the health care provider?

Asterixis and lethargy

Which finding is most important for the nurse to communicate to the health care provider about a patient who received a liver transplant 1 week ago?

Temperature 100.8° F (38.2° C)

Which response by the nurse best explains the purpose of ranitidine (Zantac) for a patient who was admitted with bleeding esophageal varices?

The medication will prevent irritation of the enlarged veins.

Which finding indicates to the nurse that lactulose is effective for an older adult who has advanced cirrhosis?

The patient is alert and oriented.

The nurse evaluates that administration of hepatitis B vaccine to a healthy patient has been effective when the patient's blood specimen reveals:

anti-HBs.

A patient admitted with an abrupt onset of jaundice and nausea has abnormal liver function studies, but serologic testing is negative for viral causes of hepatitis. Which question by the nurse is appropriate?

"Do you use any over-the-counter drugs?"

The nurse recognizes that teaching a patient following a laparoscopic cholecystectomy has been effective when the patient makes which statement?

"I can take a shower and walk around the house tomorrow."

During change-of-shift report, the nurse learns about the following four patients. Which patient requires assessment first?

A 55-yr-old patient with cirrhosis and ascites who has an oral temperature of 102° F (38.8° C)

A patient had an incisional cholecystectomy 6 hours ago. The nurse will place the highest priority on assisting the patient to:

turn, cough, and deep breathe every 2 hours.

Which topic is most important to include in teaching for a 41-yr-old patient diagnosed with early alcoholic cirrhosis?

Avoiding all alcohol use

What risk factor will the nurse specifically ask about when a patient is being admitted with acute pancreatitis?

Cigarette smoking

Which information from a 70-yr-old patient during a health history indicates to the nurse that the patient should be screened for hepatitis C?

The patient used IV drugs about 20 years ago.

Which action should the nurse in the emergency department take first for a new patient who is vomiting blood?

Check blood pressure and heart rate.

When taking the blood pressure (BP) on the right arm of a patient who has severe acute pancreatitis, the nurse notices carpal spasms of the patient's right hand. Which action should the nurse take next?

Check the calcium level in the chart.

Which finding indicates to the nurse that a patient's transjugular intrahepatic portosystemic shunt (TIPS) placed 3 months ago has been effective?

Fewer episodes of bleeding varices

Which laboratory test result will the nurse monitor to evaluate the effects of therapy for a patient who has acute pancreatitis?

Lipase

Which goal has the highest priority in the plan of care for a 26-yr-old patient who was admitted with viral hepatitis, has severe anorexia and fatigue, and is homeless?

Maintain adequate nutrition.

The nurse is planning care for a patient with acute severe pancreatitis. What is the highest priority patient outcome?

Maintaining normal respiratory function

What should the nurse teach a patient with chronic pancreatitis is the time to take the prescribed pancrelipase (Viokase)?

Mealtime

What topic should the nurse plan to teach the patient diagnosed with acute hepatitis B?

Measures for improving appetite

A patient is being treated for bleeding esophageal varices with balloon tamponade. Which nursing action will be included in the plan of care?

Monitor the patient for shortness of breath.

Which assessment finding would the nurse need to report most quickly to the health care provider regarding a patient who has acute pancreatitis?

Muscle twitching and finger numbness

Which assessment finding is of most concern for a patient with acute pancreatitis?

Palpable abdominal mass

A nurse is considering which patient to admit to the same room as a patient who is hospitalized with acute rejection 3 weeks after a liver transplant. Which patient would be the best choice?

Patient who requires pain management for chronic pancreatitis

A patient with chronic hepatitis B infection has several medications prescribed. Which medication order requires clarification with the health care provider before administration?

Pegylated -interferon (Pegasys) orally once daily

A patient with cirrhosis has ascites and 4+ edema of the feet and legs. Which nursing action will be included in the plan of care?

Place the patient on a pressure-relief mattress.

A 36-yr-old female patient is receiving treatment for chronic hepatitis B with pegylated interferon (Pegasys). Which finding is important to communicate to the health care provider to suggest a change in therapy?

Positive urine pregnancy test

For a patient who has cirrhosis, which nursing action can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP)?

Providing oral hygiene after a meal

Which action will be included in the care for a patient who has recently been diagnosed with asymptomatic nonalcoholic fatty liver disease (NAFLD)?

Review the patient's current medication list.

Which action will the nurse include in the plan of care for a patient who has been diagnosed with chronic hepatitis B?

Schedule for liver cancer screening every 6 months.

A patient in the outpatient clinic is diagnosed with acute hepatitis C (HCV) infection. Which action by the nurse is appropriate?

Schedule the patient for HCV genotype testing.

A patient who has cirrhosis and esophageal varices is being treated with propranolol (Inderal). Which finding is the best indicator to the nurse that the medication has been effective?

Stools test negative for occult blood.

The nurse is caring for a patient who has cirrhosis. Which data obtained by the nurse during the assessment will be of most concern?

The patient's hands flap back and forth when the arms are extended.

Which assessment information will be most important for the nurse to report to the health care provider about a patient who has acute cholecystitis?

The patient's stools are tan colored.

The nurse administering -interferon and ribavirin (Rebetol) to a patient with chronic hepatitis C will plan to monitor for:

leukopenia.