Combo with "Chapter 44: Liver, Pancreas, and Biliary Tract Problems" and 1 other

NCLEX review question The family of a patient newly diagnosed with hepatitis A asks the nurse what they can do to prevent becoming ill themselves. Which response by the nurse is most appropriate?

"An injection of immunoglobulin will need to be given to prevent or minimize the effects from this exposure." Rationale: Immunoglobulin provides temporary (1-2 months) passive immunity and is effective for preventing hepatitis A if given within 2 weeks after exposure. It may not prevent infection in all persons, but it will at least modify the illness to a subclinical infection. The hepatitis vaccine is only used for preexposure prophylaxis.

NCLEX review question The patient with cirrhosis is being taught self-care. Which statement indicates the patient needs more teaching?

"If I notice a fast heart rate or irregular beats, this is normal for cirrhosis." Rationale: If the patient with cirrhosis experiences a fast or irregular heart rate, it may be indicative of hypokalemia and should be reported to the health care provider, as this is not normal for cirrhosis. Edematous tissue is subject to breakdown and needs meticulous skin care. Pillows and a semi-Fowler's or Fowler's position will increase respiratory efficiency. A scrotal support may improve comfort if there is scrotal edema.

What are causes of portal hypertension?

-Ascites -Esophageal varices

The person with bleeding esophageal varices may present with what?

-hematemesis, -melana, -general deterioration, and -shock

After a liver transplant, evidence-based guidelines are implemented to prevent the development of what? A) VAP B) ESLD C) MELD D) OLT

ANS: A Evidence-based practice guidelines are implemented to prevent the development of VAP in the postoperative liver transplant recipient. ESLD means end-stage liver disease; MELD is model of end-stage liver disease; orthotopic liver transplantation is OLT.

A patient is brought to the emergency department by ambulance. He has hematemesis and alteration in mental status. The patient has tachycardia, cool clammy skin, and hypotension. The patient has a history of alcohol abuse. What would the nurse suspect the patient has? A) Hemolytic jaundice B) Hepatic insufficiency C) Bleeding esophageal varices D) Portal hypertension

ANS: C The patient with bleeding esophageal varices may present with hematemesis, melena, or general deterioration in mental or physical status and often has a history of alcohol abuse. Signs and symptoms of shock (cool clammy skin, hypotension, tachycardia) may be present. The scenario does not describe hemolytic jaundice, hepatic insufficiency, or portal hypertension.

The nursing instructor is teaching the beginning nursing students how to palpate a liver. What technique will the student nurse use to palpate a patient's liver? A) Place hand under left lower rib cage and press down lightly with the other hand. B) Place the left hand over the abdomen and behind the left side at the 11th rib. C) Place hand under right lower rib cage and press down lightly with the other hand. D) Hold hand 90 degrees to abdomen and push down firmly.

ANS: C To palpate the liver, the examiner places one hand under the right lower rib cage and presses downward with light pressure with the other hand. Therefore options A, B, and D are incorrect.

A patient with esophageal varices is being cared for in the ICU. The varices have begun to bleed and the patient is at risk for hypovolemia. The patient has Ringer's lactate at 150 cc/hr infusing. What else might the nurse expect to have ordered to maintain volume for this patient? A) Arterial line B) Central venous catheter C) Foley catheter D) Volume expanders

ANS: D Because patients with bleeding esophageal varices have intravascular volume depletion and are subject to electrolyte imbalance, IV fluids with electrolytes and volume expanders are provided to restore fluid volume and replace electrolytes. Transfusion of blood components also may be required. An arterial catheter, a central venous catheter, and a Foley catheter will probably be ordered, but they won't maintain the patient's volume.

A young woman is being discharged after a liver transplant. The young woman asks the nurse when she will be able to try to become pregnant. What would be an appropriate response by the nurse? A) "You will never have a period after a liver transplant and you will never be able to get pregnant." B) "You can consider trying to get pregnant now. Let's start you on prenatal vitamins today." C) "You should see a fertility specialist to discuss this topic." D) "Pregnancy can be considered 1 year after transplantation, but it is considered a high-risk pregnancy and you will need to discuss this with your doctor."

ANS: D The nurse should immediately address the patient's question by stating that research indicates that pregnancy can be considered 1 year after transplantation. The patient should also be informed that successful pregnancy outcomes have been reported, but these pregnancies carry a risk for the mother and infant and are considered high-risk pregnancies. The female patient should be informed that she should use a reliable form of birth control as she will have her menses and be able to get pregnant and pregnancy should be avoided for at least 1 year.

A client with cirrhosis is at risk for developing esophageal varices. Which of the following instructions should a nurse provide the client to minimize such risk? a) Increase intake of potassium-rich food. b) Avoid intake of sodium-rich food. c) Abstain from drinking alcohol. d) Use aspirin at least once a day.

Abstain from drinking alcohol. Explanation: A soft diet and elimination of alcohol, aspirin, and other locally irritating substances minimize the risk for developing esophageal varices. Intake of sodium- or potassium-rich food has no effect on the formation of varices.

A client with liver and renal failure has severe ascites. On initial shift rounds, his primary nurse finds his indwelling urinary catheter collection bag too full to store more urine. The nurse empties more than 2,000 ml from the collection bag. One hour later, she finds the collection bag full again. The nurse notifies the physician, who suspects that a bladder rupture is allowing the drainage of peritoneal fluid. The physician orders a urinalysis to be obtained immediately. The presence of which substance is considered abnormal? a) Albumin b) Creatinine c) Urobilinogen d) Chloride

Albumin Explanation: Albumin is an abnormal finding in a routine urine specimen. Ascites present in liver failure contain albumin; therefore, if the bladder ruptured, ascites containing albumin would drain from the indwelling urinary catheter because the catheter is no longer contained in the bladder. Creatinine, urobilinogen, and chloride are normally found in urine.

NCLEX review question A 54-year-old patient admitted with diabetes mellitus, malnutrition, osteomyelitis, and alcohol abuse has a serum amylase level of 280 U/L and a serum lipase level of 310 U/L. To what diagnosis does the nurse attribute these findings?

Alcohol abuse Rationale: The patient with alcohol abuse could develop pancreatitis as a complication, which would increase the serum amylase (normal 30-122 U/L) and serum lipase (normal 31-186 U/L) levels as shown.

Lactulose (Cephulac) is administered to a patient diagnosed with hepatic encephalopathy to reduce which of the following? a) Calcium b) Alcohol c) Bicarbonate d) Ammonia

Ammonia Lactulose (Cephulac) is administered to reduce serum ammonia levels. Cephulac does not influence calcium, bicarbonate, or alcohol levels.

33. A patient with end-stage liver disease has developed hypervolemia. What nursing interventions would be most appropriate when addressing the patient's fluid volume excess? Select all that apply. A) Administering diuretics B) Administering calcium channel blockers C) Implementing fluid restrictions D) Implementing a 1500 kcal/day restriction E) Enhancing patient positioning

Ans: A, C, E Feedback: Administering diuretics, implementing fluid restrictions, and enhancing patient positioning can optimize the management of fluid volume excess. Calcium channel blockers and calorie restriction do not address this problem.

25. A patient with a diagnosis of cirrhosis has developed variceal bleeding and will imminently undergo variceal banding. What psychosocial nursing diagnosis should the nurse most likely prioritize during this phase of the patient's treatment? A) Decisional Conflict B) Deficient Knowledge C) Death Anxiety D) Disturbed Thought Processes

Ans: C Feedback: The sudden hemorrhage that accompanies variceal bleeding is intensely anxiety-provoking. The nurse must address the patient's likely fear of death, which is a realistic possibility. For most patients, anxiety is likely to be a more acute concern than lack of knowledge or decisional conflict. The patient may or may not experience disturbances in thought processes.

10. A local public health nurse is informed that a cook in a local restaurant has been diagnosed with hepatitis A. What should the nurse advise individuals to obtain who ate at this restaurant and have never received the hepatitis A vaccine? A) The hepatitis A vaccine B) Albumin infusion C) The hepatitis A and B vaccines D) An immune globulin injection

Ans: D Feedback: For people who have not been previously vaccinated, hepatitis A can be prevented by the intramuscular administration of immune globulin during the incubation period, if given within 2 weeks of exposure. Administration of the hepatitis A vaccine will not protect the patient exposed to hepatitis A, as protection will take a few weeks to develop after the first dose of the vaccine. The hepatitis B vaccine provides protection again the hepatitis B virus, but plays no role in protection for the patient exposed to hepatitis A. Albumin confers no therapeutic benefit.

What are the parenteral forms of hepatitis?

B, C, and D

Liver Biopsy

Determine changes in liver tissue

If patient is confined in bed for paracentesis what position

Fowlers position

The nurse identifies which of the following types of jaundice in an adult experiencing a transfusion reaction? a) Hemolytic b) Nonobstructive c) Hepatocellular d) Obstructive

Hemolytic Hemolytic jaundice occurs because, although the liver is functioning normally, it cannot excrete the bilirubin as quickly as it is formed. This type of jaundice is encountered in patients with hemolytic transfusion reactions and other hemolytic disorders. Obstructive jaundice is the result of liver disease. Nonobstructive jaundice occurs with hepatitis. Hepatocellular jaundice is the result of liver disease.

Which type of jaundice seen in adults is the result of increased destruction of red blood cells? a)Hemolytic b)Nonobstructive c)Hepatocellular d)Obstructive

Hemolytic Hemolytic jaundice results because, although the liver is functioning normally, it cannot excrete the bilirubin as quickly as it is formed. Obstructive jaundice is the result of liver disease. Nonobstructive jaundice occurs with hepatitis. Hepatocellular jaundice is the result of liver disease.

Which type of jaundice seen in adults is the result of increased destruction of red blood cells? a) Hepatocellular b) Nonobstructive c) Obstructive d) Hemolytic

Hemolytic Explanation: Hemolytic jaundice results because, although the liver is functioning normally, it cannot excrete the bilirubin as quickly as it is formed. Obstructive jaundice is the result of liver disease. Nonobstructive jaundice occurs with hepatitis. Hepatocellular jaundice is the result of liver disease.

Complication with ESLD

Impending Encephalopathy Bleeding Susceptible to Infection

Additional Diagnostic Studies

Liver biopsy= Determines changes in liver tissue Ultrasonography= Presence of masses, changes in size CT/MRI= -Hepatic neoplasms, cysts, abscesses, hematomas -May differentiate between obstructive and non-obst jaundice ERCP= Visualize billiary structures via endo Cholangiogram= To visualize gallbladder and bile duct

Treatment of Ascites

Low-sodium diet= `Reduce fluid retention `2G NA+ diet- strict Diuretics= `Aldactone (Spironolactone) =Prevents K+loss `Lasix (Furosemide) =Used with caution `Diamox (Ammonium Chloride) =Contraindicated `Caution =Wgt loss should not exceed 1-2 kg in pts with ascites and edema =0.5-0.75 without edema =Fluid restriction not done unless Na+ is very low Bed rest Paracentesis Transjugular intrahepatic portosystemic shunt (TIPS).

When performing a physical examination on a client with cirrhosis, a nurse notices that the client's abdomen is enlarged. Which of the following interventions should the nurse consider? a) Ask the client about food intake. b) Report the condition to the physician immediately. c) Provide the client with nonprescription laxatives. d) Measure abdominal girth according to a set routine.

Measure abdominal girth according to a set routine. Explanation: If the abdomen appears enlarged, the nurse measures it according to a set routine. The nurse reports any change in mental status or signs of gastrointestinal bleeding immediately. It is not essential for the client to take laxatives unless prescribed. The client's food intake does not affect the size of the abdomen in case of cirrhosis.

A nurse educator is providing an in-service to a group of nurses working on a medical floor that specializes in liver disorders. Which of the following is an important education topic regarding ingestion of medications? a) The need for more frequently divided doses b) The need for increased drug dosages c) Medications will no longer be effective in clients with liver disease. d) Metabolism of medications

Metabolism of medications Careful evaluation of the client's response to drug therapy is important because the malfunctioning liver cannot metabolize many substances.

NCLEX review question A patient with type 2 diabetes and cirrhosis asks the nurse if it would be okay to take silymarin (milk thistle) to help minimize liver damage. The nurse responds based on what knowledge?

Milk thistle may affect liver enzymes and thus alter drug metabolism Rationale: There is good scientific evidence that there is no real benefit from using milk thistle to protect the liver cells from toxic damage in the treatment of cirrhosis. Milk thistle does affect liver enzymes and thus could alter drug metabolism. Therefore patients will need to be monitored for drug interactions. It is noted to be safe for up to 6 years, not 10 years, and it may lower, not elevate, blood glucose levels.

The complications in a liver biposy

Peritonitis caused by blood or bile

The most common cause of esophageal varices includes which of the following? a)Portal hypertension b)Jaundice c)Asterixis d)Ascites

Portal hypertension Esophageal varices are almost always caused by portal hypertension, which results from obstruction of the portal circulation within the damaged liver. Jaundice occurs when the bilirubin concentration in the blood is abnormally elevated. Ascites results from circulatory changes within the diseased liver. Asterixis is an involuntary flapping movement of the hands associated with metabolic liver dysfunction.

Management Hep B

Prevention: -Vaccine: for persons at high risk, routine vaccination of infants -Standard precautions/infection control measures -Screening of blood and blood products Bed rest Nutritional support Medications for chronic hepatitis type B include alpha interferon and antiviral agents: lamividine (Epivir), adefovir (Hepsera)

What should you monitor during procedure of paracentesis

S/S vascular collapse:(hypovolemia) pallor increased pulse rate decreased BP

Patients with chronic liver dysfunction have problems with insufficient vitamin intake. Which of the following may occur as a result of vitamin C deficiency? a) Hypoprothrombinemia b) Scurvy c) Night blindness d) Beriberi

Scurvy Scurvy may result from a vitamin C deficiency. Night blindness, hypoprothrombinemia, and beriberi do not result from a vitamin C deficiency.

What kind of meals should a pt eat with hepatitis?

Small frequent meals minimize periods without food intake Protein Calories increased

Is the following statement True or False?

The majority of blood supply to the liver, which is poor in nutrients, comes from the portal vein.

Nonsurgical Management of Liver Cancer

Underlying cirrhosis, which is prevalent in patients with liver cancer, increases risks of surgery Major effect of nonsurgical therapy may be palliative Radiation therapy Chemotherapy Percutaneous biliary drainage Other nonsurgical treatments

Which of the following medications is used to decrease portal pressure, halting bleeding of esophageal varices? a)Spironolactone (Aldactone) b)Nitroglycerin c)Vasopressin (Pitressin) d)Cimetidine (Tagamet)

Vasopressin (Pitressin) Vasopressin may be the initial therapy for esophageal varices, because it constricts the splanchnic arterial bed and decreases portal hypertension. Nitroglycerin has been used to prevent the side effects of vasopressin. Aldactone and Tagamet do not decrease portal hypertension.

What is the mode of transmission of parenteral forms of hepatitis?

Venous blood/sexual contact

Assessment of Ascites

`Record abdominal girth and weight daily `Patient may have straie, distended veins, and umbilical hernia `Assess for fluid in abdominal cavity by percussion for shifting dullness or by fluid wave `Monitor for potential fluid and electrolyte imbalances

Nursing management of the patient with acute pancreatitis includes (select all that apply)

checking for signs of hypocalcemia giving insulin based on a sliding scale Rationale: During the acute phase, it is important to monitor vital signs. Hemodynamic stability may be compromised by hypotension, fever, and tachypnea. Intravenous fluids are ordered, and the response to therapy is monitored. Fluid and electrolyte balances are closely monitored. Frequent vomiting, along with gastric suction, may result in decreased levels of chloride, sodium, and potassium. Because hypocalcemia can occur in acute pancreatitis, the nurse should observe for symptoms of tetany, such as jerking, irritability, and muscular twitching. Numbness or tingling around the lips and in the fingers is an early indicator of hypocalcemia. The patient should be assessed for Chvostek's sign or Trousseau's sign. A patient with acute pancreatitis should be observed for fever and other manifestations of infection. Respiratory infections are common because the retroperitoneal fluid raises the diaphragm, which causes the patient to take shallow, guarded abdominal breaths.

S/S of Shock

cool clammy skin hypotension tachycardia

What is hemolytic jaundice?

the result of an increased destruction of the red blood cells; the effect is that the plasma is rapidly flooded with bilirubin so that the liver, although functioning normally, cannot excrete the bilirubin as quickly

NCLEX pre-test question The nurse provides discharge instructions for a 64-year-old woman with ascites and peripheral edema related to cirrhosis. Which statement, if made by the patient, indicates teaching was effective?

"Herbs and other spices should be used to season my foods instead of salt." Rationale: A low-sodium diet is indicated for the patient with ascites and edema related to cirrhosis. Table salt is a well-known source of sodium and should be avoided. Alternatives to salt to season foods include the use of seasonings such as garlic, parsley, onion, lemon juice, and spices. Pain medications such as acetaminophen, aspirin, and ibuprofen should be avoided as these medications may be toxic to the liver. The patient should avoid potentially hepatotoxic over-the-counter drugs (e.g., acetaminophen) because the diseased liver is unable to metabolize these drugs. Spironolactone is a potassium-sparing diuretic. Lactulose results in the acidification of feces in bowel and trapping of ammonia, causing its elimination in feces.

NCLEX review question When teaching the patient with acute hepatitis C (HCV), the patient demonstrates understanding when the patient makes which statement?

"I will need to be checked for chronic HCV and other liver problems." Rationale: The majority of patients who acquire HCV usually develop chronic infection, which may lead to cirrhosis or liver cancer. HCV is not transmitted via saliva, but percutaneously and via high-risk sexual activity exposure. The treatment for acute viral hepatitis focuses on resting the body and adequate nutrition for liver regeneration. Adofevir (Hepsera) is taken for severe hepatitis B (HBV) with liver failure. Chronic HCV is treated with pegylated interferon with ribavirin. Immunity with HCV does not occur as it does with HAV and HBV, so the patient may be reinfected with another type of HCV.

NCLEX pre-test question The nurse instructs a 50-year-old woman about cholestyramine to reduce pruritis caused by gallbladder disease. Which statement by the patient to the nurse indicates she understands the instructions?

"The medication is a powder and needs to be mixed with milk or juice. Rationale: For treatment of pruritus, cholestyramine may provide relief. This is a resin that binds bile salts in the intestine, increasing their excretion in the feces. Cholestyramine is in powder form and should be mixed with milk or juice before oral administration.

A student accepted into a nursing program must begin receiving the hepatitis B series of injections. The student asks when the next two injections should be administered. What is the best response by the instructor? a) "You must have the second one in 1 year and the third the following year." b) "You must have the second one in 2 weeks and the third in 1 month." c) "You must have the second one in 1 month and the third in 6 months." d) "You must have the second one in 6 months and the third in 1 year."

"You must have the second one in 1 month and the third in 6 months." Both forms of the hepatitis B vaccine are administered intramuscularly in three doses; the second and third doses are given 1 and 6 months, respectively, after the first dose.

A patient with end-stage liver disease who is scheduled to undergo a liver transplant tells the nurse, "I am worried that my body will reject the liver." Which of the following statements is the nurse's best response to the patient? a) "You will need to take daily medication to prevent rejection of the transplanted liver. The new liver has a good chance of survival with the use of these drugs." b) "It is easier to get a good tissue match with liver transplants than with other types of transplants." c) "The problem of rejection is not as common in liver transplants as in other organ transplants." d) "You would not be scheduled for a transplant if there was a concern about rejection."

"You will need to take daily medication to prevent rejection of the transplanted liver. The new liver has a good chance of survival with the use of these drugs." Rejection is a primary concern. A transplanted liver is perceived by the immune system as a foreign antigen. This triggers an immune response, leading to the activation of T lymphocytes that attack and destroy the transplanted liver. Immunosuppressive agents are used as long-term therapy to prevent this response and rejection of the transplanted liver. These agents inhibit the activation of immunocompetent T lymphocytes to prevent the production of effector T cells. Although the 1- and 5-year survival rates have increased dramatically with the use of new immunosuppressive therapies, these advances are not without major side effects. The other statements are inaccurate or will not decrease the patient's anxiety.

NCLEX review question The patient with cirrhosis has an increased abdominal girth from ascites. The nurse should know that this fluid gathers in the abdomen for which reasons (select all that apply)?

- There is decreased colloid oncotic pressure from the liver's inability to synthesize albumin. - Hyperaldosteronism related to damaged hepatocytes increases sodium and fluid retention. - Portal hypertension pushes proteins from the blood vessels, causing leaking into the peritoneal cavity. Rationale: The ascites related to cirrhosis are caused by decreased colloid oncotic pressure from the lack of albumin from liver inability to synthesize it and the portal hypertension that shifts the protein from the blood vessels to the peritoneal cavity, and hyperaldosteronism which increases sodium and fluid retention. The intake of fluids orally and the removal of blood cells by the spleen do not directly contribute to ascites.

NCLEX review question When caring for a patient with liver disease, the nurse recognizes the need to prevent bleeding resulting from altered clotting factors and rupture of varices. Which nursing interventions would be appropriate to achieve this outcome (select all that apply)?

- Use smallest gauge needle possible when giving injections or drawing blood. - Teach patient to avoid straining at stool, vigorous blowing of nose, and coughing. - Advise patient to use soft-bristle toothbrush and avoid ingestion of irritating food. - Apply gentle pressure for the shortest possible time period after performing venipuncture. Rationale: Using the smallest gauge needle for injections will minimize the risk of bleeding into the tissues. Avoiding straining, nose blowing, and coughing will reduce the risk of hemorrhage at these sites. The use of a soft-bristle toothbrush and avoidance of irritating food will reduce injury to highly vascular mucous membranes. The nurse should apply gentle but prolonged pressure to venipuncture sites to minimize the risk of bleeding. Aspirin and NSAIDs should not be used in patients with liver disease because they interfere with platelet aggregation, thus increasing the risk for bleeding.

What are clinical manifestations of hepatitis?

-Abdominal pain -Arthralgia and myalgia -Diarrhea/constipation -Fever -Irritability -Lethargy -Malaise -Nausea/vomiting -Rash

Obstructive Jaundice

-Dark orange-brown urine and light clay-colored stools -Dyspepsia and intolerance of fats, impaired digestion -Pruritis

What are signs and symptoms of obstructive jaundice?

-Dark orange-brown urine, clay-colored stools -Dyspepsia and intolerance of fats, impaired digestion -Pruritis

What are manifestations of hepatic encephalopathy?

-Early: minor mental and monitor changes; increased DTR -Sleeps during day, restlessness and insomnia at night -Asterixis (liver flap) -Progressive decline in ability to write -Constructional apraxia (inability to reproduce a simple figure in two or three dimensions) -Absent DTR, flaccidity

Nursing Process: The Care of the Patient with Cirrhosis of the Liver—Assessment

-Focus upon onset of symptoms and history of precipitating factors -Alcohol use/abuse -Dietary intake and nutritional status -Exposure to toxic agents and drugs -Assess mental status -Abilities to carry on ADL/IADLs, maintain a job, and maintain social relationships -Monitor for signs and symptoms related to the disease including indicators for bleeding, fluid volume changes, and lab data

What are clinical manifestations of bleeding esophageal varices?

-Hematemesis -Melena -General deterioration in mental or physical status -Often history of alcoholism -Signs of shock -Cool, clammy skin -Hypotension -Tachycardia

What are clinical manifestations of ascites?

-Increased abdominal girth -Rapid weight gain -Shortness of breath -Striae -Distended veins -Umbilical hernias -Electrolyte imbalances

What are indications for liver transplantation?

-Irreversible advanced chronic liver disease -Fulminant hepatic failure -Metabolic liver diseases -Some hepatic malignancies

What are clinical manifestations of hepatic cirrhosis?

-Liver enlargement -Portal obstruction and Ascites -Infection and peritonitis -Gastrointestinal varices -Edema -Vitamin deficiency and anemia -Mental deterioration

Hepatocellular jauncide

-May appear mildly or severely ill -Lack of appetite, nausea, weight loss -Malaise, fatigue, weakness -Headache chills and fever if infectious in origin

What are signs and symptoms of hepatocellular jaundice?

-Mild or severely ill -Anorexic, nausea or vomiting, weight loss -Malaise, fatigue, weakness -Headache, chills, fever, infection

What is included in nursing management of cancer of the liver?

-Monitor for and manage potential complications -If cryosurgery- monitor closely for hypothermia, hemorrhage, bile leak, myoglobinurias -May go home with biliary drainage -May have hepatic artery port for chemotherapy

What is included in nursing management of esophageal varices?

-Monitor for aspiration, VS changes, emotional response, & cognitive status -Monitor for associated complications -Hepatic encephalopathy, delerium -Oral care, tube care, GI suction -Measures to decrease anxiety and agitation -Education and support for patient and family

Nursing Management of the Patient with Bleeding Esophageal Varices

-Monitor patient condition frequently, including emotional responses and cognitive status. -Monitor for associated complications such as hepatic encephalopathy resulting form blood breakdown in the GI tract and delirium related to alcohol withdrawal. -Monitor treatments including tube care and GI suction. -Oral care -Quiet clam environment and reassuring manner -Implement measures to reduce anxiety and agitation -Teaching and support of patient and family

What are functions of the liver?

-Nutrient metabolism -Protein and fat -Glucose metabolism/regulation -Drug metabolism -Ammonia conversion -Vitamin and iron storage -Bile formation -Bilirubin excretion

What are clinical manifestations of cancer of the liver?

-Pain- dull persistent; RUQ, back or epigastrium -Weight loss -Weakness -Anorexia -Anemia -Enlarged, irregular liver -Jaundice; occluded bile ducts -Ascites; obstructed portal veins

What are complications of hepatic cirrhosis?

-Portal hypertension -Ascites -Bleeding esophageal varices -Coagulation defects -Jaundice -Portal systemic encephalopathy with hepatic coma -Hepatorenal syndrome

Management Hep C

-Prevention -Screening of blood -Prevention of needle sticks for health care workers -Measures to reduce spread of infection as with hepatitis B -Alcohol encourages the progression of the disease, so alcohol and medications that effect the liver should be avoided -Antiviral agents: telaprevir (Incivek); boceprevir(Victrelis)

Postprocedure paracentesis

-Return pt to bed or comfortable sitting position -desrcribe measure record fluid -Label samples -Assess for hypovolemia, electrolyte shifts,temp, changes in mental status,encephalopathy -check puncture site for bleeding or leakage -Educate

The nurse is preparing a care plan for a pt with hepatic cirrhosis which would be...

-Risk for injury related to altered clotting mech. -Activity Intolerance R/T fatigue general dability muscle wasting and discomfort -Disturbed body images R/T changes in appearance, sexual dysfunction and role function *Urinary incontonuce IS NOT one

Hepatitis C

-Transmitted by blood and sexual contact, including needle sticks and sharing of needles -The most common blood-borne infection -A cause of 1/3 of cases of liver cancer and the most common reason for liver transplant --Same as HBV -Incubation period is variable -Symptoms are usually mild -Chronic carrier state frequently occurs

Hepatitis B (HBV)

-Transmitted through blood found in blood, saliva, semen, sexually transmitted, transmitted to infant at the time of birth -A major worldwide cause of cirrhosis and liver cancer =Health care workers, IV drug use, mult. Sexual partners, recipient of blood products -Long incubation period; 1-6 months -Manifestations: similar to hepatitis A -The virus has antigenic particles that elicit specific antibody markers during different stages of the disease *Vaccine for pt who travels and infant

Symptoms of Hepatitis A

-mild flu-like symptoms, low-grade fever, anorexia, later jaundice and dark urine, indigestion and epigastric distress, enlargement of liver and spleen

Hepatitis

2 Types: 1. Viral hepatitis: a systemic viral infection that causes necrosis and inflammation of liver cells with characteristic symptoms and cellular and biochemical changes. A B C D E Hepatitis G and GB virus-C 2. Nonviral hepatitis—toxic and drug induced.

Hepatic Dysfunction

=Acute or chronic =Cirrhosis of the liver Causes: Most common cause is malnutrition related to alcoholism Infection Anoxia Metabolic disorders Nutritional deficiencies

Hepatitis A (HAV)

=Fecal-oral transmission =Spread primarily by poor hygiene; hand-to-mouth contact, close contact, or through food and fluids =Incubation: 15-50 days =Illness may last 4-8 weeks =Mortality is 0.5% for younger than age 40 and 1-2% for those over age 40 =Anti-HAV antibody in serum after symptoms appear

NCLEX pre-test question The nurse is caring for a group of patients. Which patient is at highest risk for pancreatic cancer?

A 72-year-old African American male who has smoked cigarettes for 50 years Rationale: Risk factors for pancreatic cancer include chronic pancreatitis, diabetes mellitus, age, cigarette smoking, family history of pancreatic cancer, high-fat diet, and exposure to chemicals such as benzidine. African Americans have a higher incidence of pancreatic cancer than whites. The most firmly established environmental risk factor is cigarette smoking. Smokers are two or three times more likely to develop pancreatic cancer as compared with nonsmokers. The risk is related to duration and number of cigarettes smoked.

What are the enteral forms of hepatitis?

A and E

NCLEX pre-test question The nurse is caring for a woman recently diagnosed with viral hepatitis A. Which individual should the nurse refer for an immunoglobin (IG) injection?

A caregiver who lives in the same household with the patient Rationale: IG is recommended for persons who do not have anti-HAV antibodies and are exposed as a result of close contact with persons who have HAV or foodborne exposure. Persons who have received a dose of HAV vaccine more than 1 month previously or who have a history of HAV infection do not require IG.

Hepatic Encephalopathy and Coma

A life-threatening complication of liver disease. May result form the accumulation of ammonia and other toxic metabolites in the blood. Cause: Excessive nitrogen load Electrolyte or metabolic disturbance Drugs Infection

A client is suspected of having cirrhosis of the liver. What diagnostic procedure will the nurse prepare the client for in order to obtain a confirmed diagnosis? a) Platelet count b) A liver biopsy c) A CT scan d) A prothrombin time

A liver biopsy A liver biopsy, which reveals hepatic fibrosis, is the most conclusive diagnostic procedure. It can be performed in the radiology department with ultrasound or CT to identify appropriate placement of the trocar or biopsy needle. A prothrombin time and platelet count will assist with determining if the client is at increased risk for bleeding.

A client is suspected of having cirrhosis of the liver. What diagnostic procedure will the nurse prepare the client for in order to obtain a confirmed diagnosis? a) A CT scan b) Platelet count c) A liver biopsy d) A prothrombin time

A liver biopsy A liver biopsy, which reveals hepatic fibrosis, is the most conclusive diagnostic procedure. It can be performed in the radiology department with ultrasound or CT to identify appropriate placement of the trocar or biopsy needle. A prothrombin time and platelet count will assist with determining if the client is at increased risk for bleeding.

NCLEX review question When providing discharge teaching for the patient after a laparoscopic cholecystectomy, what information should the nurse include?

A lower-fat diet may be better tolerated for several weeks Rationale: Although the usual diet can be resumed, a low-fat diet is usually better tolerated for several weeks following surgery. Normal activities can be gradually resumed as the patient tolerates. Bile-colored drainage or pus, redness, swelling, severe pain, and fever may all indicate infection. The bandage may be removed the day after surgery, and the patient can shower.

The nursing instructor is talking about hepatitis with her clinical group. What would the instructor teach the students is the best method to prevent the transmission of the hepatitis E virus? A) Following proper hand-washing techniques B) Avoiding chemicals that are toxic to the liver C) Wearing a condom during sexual relations D) Isolating yourself from your family members

ANS: A Avoiding contact with the hepatitis E virus through good hygiene, including hand-washing, is the major method of prevention. Hepatitis E is transmitted by the fecal-oral route, principally through contaminated water in areas with poor sanitation. It is not necessary for the patient to isolate himself or herself from family members. Condom use is advised for patients with blood-borne hepatitis, such as hepatitis B, C, and D. Nonviral hepatitis is caused by the toxic effects of certain chemicals on the body and does not require transmission precautions.

The triage nurse in the emergency department is assessing a patient who presented with complaints of not feeling well. The patient has ascites and an enlarged liver. The patient reports a history of drinking a 12 pack of beer every evening for the past 15 years. The nurse is aware that the patient is at risk for which disease? A) Cirrhosis B) Renal failure C) Hepatitis D) Cardiovascular disease

ANS: A Cirrhosis is a chronic disease characterized by replacement of normal liver tissue with diffuse fibrosis that disrupts the structure and function of the liver. There are three types of cirrhosis or scarring of the liver. This is most frequently due to chronic alcoholism. This patient's history does not put him or her at risk for renal failure, hepatitis, or cardiovascular disease.

A patient with a liver mass is undergoing a percutaneous liver biopsy. After the procedure the nurse assists the physician in positioning the patient. What position should they position the patient in? A) On the right side with a pillow under the costal margin B) Supine position C) On the left side with a pillow under the knees D) Trendelenberg position

ANS: A Immediately after a percutaneous liver biopsy, assist the patient to turn onto the right side and place a pillow under the costal margin. Instruct the patient to remain in this position, recumbent and immobile, for several hours. The patient will not be placed in the supine or the Trendelenberg position. Option C is incorrect.

A patient with a history of postnecrotic cirrhosis is being cared for on your unit. What is this type of cirrhosis often the result of? A) A previous bout of acute viral hepatitis B) Chronic alcoholism C) Bilary obstruction D) Cholangitis

ANS: A Postnecrotic cirrhosis involves broad bands of scar tissue and is the result of a previous bout of acute viral hepatitis. Alcoholic cirrhosis is most frequently due to chronic alcoholism. Biliary cirrhosis usually results from chronic biliary obstruction and infection (cholangitis).

A patient with liver cancer is undergoing radiation therapy. The patient asks the nurse if the radiation therapy is going to cure the cancer. What is the best answer the nurse could give? A) "The radiation therapy will hopefully prolong your life, but the major effect is palliative." B) "The radiation therapy is going to give you a second chance at life." C) "The radiation therapy will cure your cancer." D) "The radiation therapy will take away your pain and discomfort."

ANS: A Radiation therapy and chemotherapy have been used to treat cancer of the liver with varying degrees of success. Although these therapies may prolong survival and improve quality of life by reducing pain and discomfort, their major effect is palliative. The only complete answer is option

A patient has been admitted to the step-down unit with a diagnosis of liver malignancy. The critical care nurse caring for this patient is aware that an early manifestation of liver malignancy, in addition to pain, is what? A) A continuous dull ache in the right upper quadrant, epigastrium, or back B) Weight gain C) An increase in appetite D) Jaundice

ANS: A The early manifestations of malignancy of the liver include pain and a continuous dull ache in the right upper quadrant epigastrium or back. Weight loss, anorexia, and anemia may occur. Jaundice is present only if the larger bile ducts are occluded by the pressure of malignant nodules in the hilum of the liver.

The nurse is caring for a patient with hepatic encephalopathy. While making the initial shift assessment the nurse notes that the patient has a flapping tremor of the hands. What will the nurse document this condition as in the patient's chart? A) Asterixis B) Constructional apraxia C) Fetor hepaticus D) Palmar erythema

ANS: A The nurse will document that a patient exhibiting a flapping tremor of the hands is demonstrating asterixis. While constructional apraxia is a motor disturbance, it is the inability to reproduce a simple figure. Fetor hepaticus is a sweet, slightly fecal odor to the breath and not associated with a motor disturbance. Skin changes associated with liver dysfunction may include palmar erythema, which is a reddening of the palms, but is not a flapping tremor.

The nurse is caring for a patient with cancer of the liver. The patient has a percutaneous biliary drainage system. What assessments should the nurse record in the patient's chart? A) Amount and color of drainage B) Temperature of drainage C) Odor of drainage D) Consistency of drainage

ANS: A The percutaneous biliary system is open to external drainage. The bile is observed closely for the amount, color, and presence of blood and debris. The nurse would not record the temperature, odor, and consistency of the drainage.

How is hepatitis C transmitted? A) Unintentional needlesticks B) Fecal-oral route C) Contaminated food D) Airborne route

ANS: A Whereas blood transfusions and sexual contact once accounted for most cases of hepatitis C in the United States, other parenteral means, such as sharing contaminated needles by IV/injection drug users and unintentional needlesticks and other injuries in health care workers, now account for a significant number of cases. Hepatitis C is not spread by the fecal-oral or airborne route, and it is not spread by contaminated food.

A student asks the pathophysiology instructor what causes ascites. What would the instructor tell the student is involved in the physiologic process that causes ascites? (Mark all that apply.) A) Sodium and water retention B) A damaged liver C) Insufficient renal flow D) Increased lymphatic flow E) Decreased synthesis of immunoglobulin G

ANS: A, B, D Sodium and water retention, increased intravascular fluid volume, increased lymphatic flow, and decreased synthesis of albumin by the damaged liver all contribute to the movement of fluid from the vascular system into the peritoneal space. Insufficient renal blood flow and a decreased synthesis of immunoglobulin G do not play a part in the formation of ascites.

In end-stage liver disease, hypervolemia is always a problem. What nursing interventions would be most appropriate when caring for these patients? (Mark all that apply.) A) Administering diuretics B) Giving pain medications C) Implementing fluid restrictions D) Teaching nutrition E) Enhancing patient positioning

ANS: A, C, E Pulmonary compromise, which is always a potential complication of ESLD because of plasma volume excess, makes prevention of pulmonary complications an important role for the nurse. Administering diuretics, implementing fluid restrictions, and enhancing patient positioning can optimize pulmonary function.

A patient with bleeding esophageal varices is brought to the emergency department by the paramedics. An immediate endoscopy is performed. What nursing intervention is appropriate? A) Keep patient NPO until results of test are known. B) Keep patient NPO until gag reflex returns. C) Give anesthetic gargles until post-procedure soreness goes away. D) Give anesthetic lozenges 10 minutes before meals.

ANS: B After the examination, fluids are not given until the patient's gag reflex returns. Lozenges and gargles may be used to relieve throat discomfort if the patient's physical condition and mental status permit. Appropriate nursing interventions do not include option A, as the result of the test is known immediately; anesthetic gargles and lozenges are contraindicated until the gag reflex returns.

A patient with liver cancer is at the clinic to talk with the physician. The physician tells the patient that it is to risky to do surgery on their hepatic tumor. The patient asks the nurse why surgery is so risky for them. The nurse explains that while surgical resection of the liver tumor is possible in some patients, the risks associated with this procedure increase when the patient has a history of what? A) Oral contraceptive use B) Cirrhosis C) Hypertension D) Prior abdominal surgery

ANS: B Although surgical resection of the liver tumor is possible in some patients, the underlying cirrhosis is so prevalent in cancer of the liver that it increases the risks associated with surgery. Oral contraceptive use is associated with benign liver tumors not malignant tumors. Prior abdominal surgery may have resulted in abdominal scar tissue formation, but poses minor if any risk to the patient. Hypertension can be controlled by use of anti-hypertensive drugs and again, poses a minor risk to the patient.

The nurse is caring for a patient with metastasis of her cancer to the liver. The patient is undergoing chemotherapy by TACE. What does this chemotherapy procedure cause? A) Necrosis of tumor cells B) Embolization of tumor vessels C) Necrosis of tumor vessels D) Embolization of tumor cells

ANS: B Embolization of tumor vessels with chemotherapy (a process known as transarterial chemoembolization [TACE]) produces anoxic necrosis with high concentrations of trapped chemotherapeutic agents. This procedure does not work on the cellular level of the tumor.

You are caring for a patient with a blocked bile duct from a tumor. What would you document about the patient's urine? A) Urine is dark amber and concentrated. B) Urine is orange and foamy. C) Urine is rust colored and concentrated. D) Urine is pale yellow and dilute.

ANS: B If the bile duct is obstructed, the bile will be reabsorbed into the blood and carried throughout the entire body. It is excreted in the urine, which becomes deep orange and foamy. Therefore options A, C, and D are incorrect.

A 55-year-old female patient is undergoing radiofrequency thermal ablation of her primary liver tumor. What does this treatment entail? A) A tube is inserted into the tumor and ablation is done by superheated water. B) A needle electrode is inserted into the tumor and heated by radiofrequency. C) A tube is inserted into the tumor and chemotherapy is placed into the tumor. D) A needle electrode is inserted into the tumor and killed by laser.

ANS: B In radiofrequency thermal ablation, a needle electrode is inserted into the liver tumor under imaging guidance. Radiofrequency energy passes through to the noninsulated needle tip, causing heat and tumor cell death from coagulation necrosis. No tube is inserted into the tumor.

You are caring for a patient with advanced cirrhosis. You know that the most significant source of bleeding in a patient with cirrhosis is what? A) Portal hypertension B) Esophageal varices C) Hemolytic jaundice D) Ascites

ANS: B Once esophageal varices form, they are increase in size and eventually bleed; in cirrhosis, they are the most significant source of bleeding. Portal hypertension, hemolytic jaundice, and ascites are not sources of bleeding.

A nurse practitioner is teaching a health class in the local high school. The nurse practitioner informs the class about hepatitis B. What occupation does the nurse practitioner inform the class is at the greatest risk for contracting hepatitis B? A) Flight attendants B) Health care workers C) Fire fighters D) Educators

ANS: B People who are at high risk, including nurses and other health care personnel exposed to blood or blood products, should receive active immunization. Health care workers who have had frequent contact with blood are screened for anti-HBs to determine whether immunity is already present from previous exposure. Flight attendants, fire fighters and educators are not at high risk for hepatitis B.

A patient with esophageal varices has medication ordered to decrease portal pressure and aid in preventing a first bleeding episode. What type of drug would the physician order? A) Antihypertensive agents B) Beta-blocking agents C) Calcium channel blockers D) Histamine-2 antagonists

ANS: B Propranolol (Inderal) and nadolol (Corgard), beta-blocking agents that decrease portal pressure, are the most common medications used both to prevent a first bleeding episode in patients with known varices and to prevent rebleeding. This makes options A, C, and D incorrect.

Toxic hepatitis has a poor prognosis if there is a prolonged period between the exposure to the toxin and the onset of symptoms. There are no effective antidotes. What is the clinical course of toxic hepatitis? 1. Fever rises. 2. Hematemisis. 3. Clotting abnormalities. 4. Vascular collapse. 5. Coma. A) 12543 B) 12345 C) 23145 D) 31254

ANS: B Recovery from acute toxic hepatitis is rapid if the hepatotoxin is identified early and removed or if exposure to the agent has been limited. Recovery is unlikely if there is a prolonged period between exposure and onset of symptoms. There are no effective antidotes. The fever rises; the patient becomes toxic and prostrated. Vomiting may be persistent, with the emesis containing blood. Clotting abnormalities may be severe, and hemorrhages may appear under the skin. The severe GI symptoms may lead to vascular collapse. Delirium, coma, and seizures develop, and within a few days the patient may die of fulminant hepatic failure (discussed later) unless he or she receives a liver transplant.

What liver function test is a sensitive indicator of injury to liver cells and useful in detecting acute liver disease such as hepatitis? A) Clotting factors B) Serum aminotransferases C) GGT D) Alkaline phosphatase

ANS: B Serum aminotransferases (previously called transaminases) are sensitive indicators of injury to the liver cells and are useful in detecting acute liver disease such as hepatitis.

A patient has come to the clinic with vague complaints that made the physician suspect liver disease. Laboratory work shows elevated GGT levels. What can elevated GGT levels indicate? A) Hemolytic jaundice B) Cirrohsis C) Liver cell dysfunction D) Viral hepatitis

ANS: C Increased GGT levels are associated with cholestasis but can also be due to alcoholic liver disease. Although the kidney has the highest level of the enzyme, the liver is considered the source of normal serum activity. The test determines liver cell dysfunction and is a sensitive indicator of cholestasis. An elevated GGT would not indicate hemolytic jaundice, cirrohsis, or viral hepatitis.

A critical care nurse is caring for a patient post liver transplantation. The patient has a fall in blood glucose level. What would the nurse do in this instance? A) Give an ampule of D50 every 4 hours B) Monitor an infusion of 5% glucose for the first 24 hours C) Monitor an infusion of 10% glucose for the first 48 hours D) Give an ampule of D50 every 2 hours

ANS: C Metabolic abnormalities require careful attention. A constant infusion of 10% glucose may be required in the first 48 hours to prevent a precipitous fall in the blood glucose level that results from decreased gluconeogenesis. Options A, B, and D are incorrect.

A patient with portal hypertension has been admitted to the floor you work on. What will you assess for related to portal hypertension? A) Bowel obstruction B) Vitamin A deficiency C) Ascites D) Hepatic encephalopathy

ANS: C Obstruction to blood flow through the damaged liver results in increased blood pressure (portal hypertension) throughout the portal venous system. This can result in varices and ascites in the abdominal cavity. Portal hypertension does not generally cause bowel obstruction. Vitamin A deficiency is not something the nurse assesses for. Hepatic encephalopathy is a complication of cirrohsis.

The nurse is caring for a patient with hepatic encephalopathy. The nurse's assessment reveals that the patient exhibits episodes of confusion, is difficult to arouse from sleep, has rigid extremities, and shows EEG abnormalities. Based upon these clinical findings, what is the patient's stage of hepatic encephalopathy? A) Stage 1 B) Stage 2 C) Stage 3 D) Stage 4

ANS: C Patients in the third stage of hepatic encephalopathy exhibit the following symptoms: stuporous; difficult to arouse; sleeps most of the time; exhibits marked confusion; incoherent in speech; asterixis; increased deep tendon reflexes; rigidity of extremities; marked EEG abnormalities. Patients in stages 1 and 2 exhibit clinical symptoms that are not as advanced as found in stage 3, and patients in stage 4 are comatose. In stage 4, there is an absence of asterixis, absence of deep tendon reflexes, flaccidity of extremities, and EEG abnormalities.

Postnectrotic cirrhosis is a late result of what? A) Acute bacterial hepatitis B) Hemolytic jaundice C) Acute viral hepatitis D) Chronic biliary obstruction

ANS: C Postnecrotic cirrhosis, in which there are broad bands of scar tissue, is a late result of a previous bout of acute viral hepatitis. Therefore options A, B, and D are incorrect.

A nurse is caring for a patient with severe hemolytic jaundice. Laboratory tests show free bilirubin to be 24 mg/dL. What is this patient at risk for? A) Chronic jaundice B) Pigment stones in portal circulation C) Brainstem damage D) Hepatomegaly

ANS: C Prolonged jaundice, even if mild, predisposes to the formation of pigment stones in the gallbladder, and extremely severe jaundice (levels of free bilirubin exceeding 20 to 25 mg/dL) poses a risk for brainstem damage.

The nursing instructor is teaching the senior nursing students about liver disease. What would the instructor teach the students is the most common surgical procedure for liver cancer? A) Cryosurgery B) Liver transplantation C) A lobectomy D) Laser hyperthermia

ANS: C Removal of a lobe of the liver (lobectomy) is the most common surgical procedure for excising a liver tumor. While liver transplantation and cryosurgery are other surgical options for management of liver cancer, these procedures are not performed at the same frequency as a lobectomy. Laser hyperthermia is a nonsurgical treatment for liver cancer.

A patient who has undergone liver transplantation is ready to be discharged home. The nurse is providing discharge teaching. Which topic will the nurse emphasize the most related to discharge teaching? A) The patient will obtain measurement of drainage from the T-tube. B) The patient will exercise three times a week. C) The patient will take immunosuppressive agents as required. D) The patient will monitor for signs of liver dysfunction.

ANS: C The patient is given written and verbal instructions about immunosuppressive agent doses and dosing schedules. The patient is also instructed on steps to follow to assure that an adequate supply of medication is available so that there is no chance of running out of the medication or skipping a dose. Failure to take medications as instructed may precipitate rejection. The nurse would not teach the patient to measure drainage from a T-tube as they wouldn't go home with a T-tube. The nurse may teach the patient about the need to exercise or what the signs of liver dysfunction are, but the nurse would not stress them like they would stress the immunosuppressive drug regimen.

The nurse is reviewing the history of a patient newly admitted to the unit. This patient has been ordered vasopressin for bleeding esophageal varices. The nurse calls the physician to question the use of vasopressin when she reads that the patient has a history of what? A) Diabetes mellitus B) Chronic kidney disease C) Arthritis D) Coronary artery disease

ANS: D Coronary artery disease is a contraindication to the use of vasopressin, because coronary vasoconstriction is a side effect that may precipitate myocardial infarction. A history of diabetes, chronic kidney disease, or arthritis does not contraindicate the use of vasopressin.

A local public health nurse is informed that a cook in a local restaurant has been diagnosed with hepatitis A. What should the nurse advise individuals who ate at this restaurant and have never received the hepatitis A vaccine? A) The hepatitis A vaccine B) The hepatitis B vaccine C) The hepatitis A and B vaccines D) An immune globulin injection

ANS: D For people who have not been previously vaccinated, hepatitis A can be prevented by the intramuscular administration of globulin during the incubation period, if given within 2 weeks of exposure. Administration of the hepatitis A vaccine will not protect the patient exposed to hepatitis A, as protection will take a few weeks to develop after the first dose of the vaccine. The hepatitis B vaccine provides protection again the hepatitis B virus, but plays no role in protection for the patient exposed to hepatitis A.

A patient is being discharged home after liver transplantation. The patient still has a hepatic artery catheter in place. What is this hepatic artery catheter for? A) To monitor portal hypertension B) To give immunosuppressive drugs during the first weeks after transplantation C) To monitor vascular changes in the hepatic system D) To deliver a continuous chemotherapeutic dose until completed

ANS: D In most cases, the hepatic artery catheter has been inserted surgically and has a prefilled infusion pump that delivers a continuous chemotherapeutic dose until completed. The hepatic artery catheter does not monitor portal hypertension, deliver immunosuppressive drugs, or monitor vascular changes in the hepatic system.

The critical care nurse is caring for a patient with cirrhosis. What is an essential nursing function when caring for a patient with cirrhosis? A) Monitoring the patient's oral intake B) Monitoring the patient's support network C) Monitoring the patient for signs of hypervolemia D) Monitoring the patient's mental status

ANS: D Monitoring is an essential nursing function to identify early deterioration in mental status. The nurse monitors the patient's mental status closely and reports changes so that treatment of encephalopathy can be initiated promptly. An extensive neurologic evaluation is key to identify progression through the four stages of encephalopathy. The nurse would monitor the oral intake and watch for signs of hypervolemia, but they are not as essential as the patient's mental status because of the encephalopathy that goes with cirrhosis. Monitoring the support network is not essential at this time.

The nurse is caring for a patient with liver failure. The nurse understands that patients in liver failure often require vitamin therapy. Which vitamin does the liver require for the synthesis of prothrombin? A) Vitamin B12 B) Vitamin A C) Vitamin D D) Vitamin K

ANS: D The liver requires vitamin K for the synthesis of prothrombin and some of the other clotting factors. Breakdown of fatty acids into ketone bodies occurs primarily when the availability of metabolism is limited, as during starvation or in uncontrolled diabetes. Vitamins stored in the liver include A, B12, D, and several of the B-complex vitamins.

A nurse is assessing a 77-year-old male admitted to the unit for suspected liver dysfunction. What assessment finding will the nurse expect to find? A) Liver function results change dramatically in the older adult. B) Metabolism of medications is delayed primarily by the liver. C) The liver is enlarged with hard edges. D) The liver is decreased in size and weight.

ANS: D The most common change in the liver is a decrease in size and weight. Results of liver function test results do not normally change in the elderly. Metabolism of medication is decreased by intestinal absorption, renal excretion, and altered body distribution of fat, as well as a decrease in liver function.

Which diuretic medication would most often be used for a patient with ascites?

Actazolamide (Diamox) Ammonium chloride Furosemide (Lasix) Spironolactone (Aldactone)

NCLEX review question A patient with cholelithiasis needs to have the gallbladder removed. Which patient assessment is a contraindication for a cholecystectomy?

Activated partial thromboplastin time (aPTT) of 54 seconds Rationale: An aPTT of 54 seconds is above normal and indicates insufficient clotting ability. If the patient had surgery, significant bleeding complications postoperatively are very likely. Fluids can be given to eliminate the dehydration; the abscess can be assessed, and the obstructions in the cystic and common bile duct would be relieved with the cholecystectomy.

Nursing Process: The Care of the Patient with Cirrhosis of the Liver—Diagnoses

Activity intolerance Imbalanced nutrition Impaired skin integrity Risk for injury and bleeding

Postoperatively, a patient with an incisional cholecystectomy has a nursing diagnosis of ineffective breathing pattern related to splinted respirations secondary to a high abdominal incision. Which action should the nurse take first?

Administer the prescribed analgesic Rationale: Postoperative nursing care for incisional cholecystectomy focuses on adequate ventilation and prevention of respiratory complications. The patient will need adequate pain control for optimum coughing and deep breathing to prevent postoperative atelectasis.

A patient complaining of shortness of breath is admitted with the diagnosis of cirrhosis. A nursing assessment reveals an enlarged abdomen with striae, an umbilical hernia, and 4+ pitting edema of the feet and legs. What is the most important data for the nurse to monitor? a)Bilirubin b)Temperature c)Albumin d)Hemoglobin

Albumin With the movement of albumin from the serum to the peritoneal cavity, the osmotic pressure of the serum decreases. This, combined with increased portal pressure, results in movement of fluid into the peritoneal cavity. The low oncotic pressure caused by hypoalbuminemia is a major pathophysiologic factor in the development of ascites and edema.

Which of the following terms is used to describe a chronic liver disease in which scar tissue surrounds the portal areas? a) Postnecrotic cirrhosis b) Compensated cirrhosis c) Alcoholic cirrhosis d) Biliary cirrhosis

Alcoholic cirrhosis This type of cirrhosis is due to chronic alcoholism and is the most common type of cirrhosis. In postnecrotic cirrhosis, there are broad bands of scar tissue, which are a late result of a previous acute viral hepatitis. In biliary cirrhosis, scarring occurs in the liver around the bile ducts. Compensated cirrhosis is a general term given to the state of liver disease in which the liver continues to be able to function effectively.

An 87-year-old client is in the ICU where you practice nursing. He was admitted for critical care due to his esophageal varices and his precarious physical condition. Which of the following could result in causing his varices to hemorrhage? a) All options are correct b) Little protective tissue to protect fragile veins c) Chemical irritation d) Rough food

All options are correct Explanation: Esophageal varices overfill as a result of portal hypertension. They are especially vulnerable to bleeding because they lie superficially in the mucosa, contain little protective elastic tissue, and are easily traumatized by rough food or chemical irritation.

20. During a health education session, a participant has asked about the hepatitis E virus. What prevention measure should the nurse recommend for preventing infection with this virus? A) Following proper hand-washing techniques B) Avoiding chemicals that are toxic to the liver C) Wearing a condom during sexual contact D) Limiting alcohol intake

Ans: A Feedback: Avoiding contact with the hepatitis E virus through good hygiene, including hand-washing, is the major method of prevention. Hepatitis E is transmitted by the fecal-oral route, principally through contaminated water in areas with poor sanitation. Consequently, none of the other listed preventative measures is indicated.

5. A nurse is caring for a patient with cancer of the liver whose condition has required the insertion of a percutaneous biliary drainage system. The nurse's most recent assessment reveals the presence of dark green fluid in the collection container. What is the nurse's best response to this assessment finding? A) Document the presence of normal bile output. B) Irrigate the drainage system with normal saline as ordered. C) Aspirate a sample of the drainage for culture. D) Promptly report this assessment finding to the primary care provider.

Ans: A Feedback: Bile is usually a dark green or brownish-yellow color, so this would constitute an expected assessment finding, with no other action necessary.

29. A group of nurses have attended an inservice on the prevention of occupationally acquired diseases that affect healthcare providers. What action has the greatest potential to reduce a nurse's risk of acquiring hepatitis C in the workplace? A) Disposing of sharps appropriately and not recapping needles B) Performing meticulous hand hygiene at the appropriate moments in care C) Adhering to the recommended schedule of immunizations D) Wearing an N95 mask when providing care for patients on airborne precautions

Ans: A Feedback: HCV is bloodborne. Consequently, prevention of needlestick injuries is paramount. Hand hygiene, immunizations and appropriate use of masks are important aspects of overall infection control, but these actions do not directly mitigate the risk of HCV.

15. A patient with a liver mass is undergoing a percutaneous liver biopsy. What action should the nurse perform when assisting with this procedure? A) Position the patient on the right side with a pillow under the costal margin after the procedure. B) Administer 1 unit of albumin 90 minutes before the procedure as ordered. C) Administer at least 1 unit of packed red blood cells as ordered the day before the scheduled procedure. D) Confirm that the patient's electrolyte levels have been assessed prior to the procedure.

Ans: A Feedback: Immediately after a percutaneous liver biopsy, assist the patient to turn onto the right side and place a pillow under the costal margin. Prior administration of albumin or PRBCs is unnecessary. Coagulation tests should be performed, but electrolyte analysis is not necessary.

38. A nurse on a solid organ transplant unit is planning the care of a patient who will soon be admitted upon immediate recovery following liver transplantation. What aspect of nursing care is the nurse's priority? A) Implementation of infection-control measures B) Close monitoring of skin integrity and color C) Frequent assessment of the patient's psychosocial status D) Administration of antiretroviral medications

Ans: A Feedback: Infection control is paramount following liver transplantation. This is a priority over skin integrity and psychosocial status, even though these are valid areas of assessment and intervention. Antiretrovirals are not indicated.

14. A patient is being discharged after a liver transplant and the nurse is performing discharge education. When planning this patient's continuing care, the nurse should prioritize which of the following risk diagnoses? A) Risk for Infection Related to Immunosuppressant Use B) Risk for Injury Related to Decreased Hemostasis C) Risk for Unstable Blood Glucose Related to Impaired Gluconeogenesis D) Risk for Contamination Related to Accumulation of Ammonia

Ans: A Feedback: Infection is the leading cause of death after liver transplantation. Pulmonary and fungal infections are common; susceptibility to infection is increased by the immunosuppressive therapy that is needed to prevent rejection. This risk exceeds the threats of injury and unstable blood glucose. The diagnosis of Risk for Contamination relates to environmental toxin exposure.

17. A patient has developed hepatic encephalopathy secondary to cirrhosis and is receiving care on the medical unit. The patient's current medication regimen includes lactulose (Cephulac) four times daily. What desired outcome should the nurse relate to this pharmacologic intervention? A) Two to 3 soft bowel movements daily B) Significant increase in appetite and food intake C) Absence of nausea and vomiting D) Absence of blood or mucus in stool

Ans: A Feedback: Lactulose (Cephulac) is administered to reduce serum ammonia levels. Two or three soft stools per day are desirable; this indicates that lactulose is performing as intended. Lactulose does not address the patient's appetite, symptoms of nausea and vomiting, or the development of blood and mucus in the stool.

7. A triage nurse in the emergency department is assessing a patient who presented with complaints of general malaise. Assessment reveals the presence of jaundice and increased abdominal girth. What assessment question best addresses the possible etiology of this patient's presentation? A) "How many alcoholic drinks do you typically consume in a week?" B) "To the best of your knowledge, are your immunizations up to date?" C) "Have you ever worked in an occupation where you might have been exposed to toxins?" D) "Has anyone in your family ever experienced symptoms similar to yours?"

Ans: A Feedback: Signs or symptoms of hepatic dysfunction indicate a need to assess for alcohol use. Immunization status, occupational risks, and family history are also relevant considerations, but alcohol use is a more common etiologic factor in liver disease.

9. A nurse is caring for a patient with hepatic encephalopathy. While making the initial shift assessment, the nurse notes that the patient has a flapping tremor of the hands. The nurse should document the presence of what sign of liver disease? A) Asterixis B) Constructional apraxia C) Fetor hepaticus D) Palmar erythema

Ans: A Feedback: The nurse will document that a patient exhibiting a flapping tremor of the hands is demonstrating asterixis. While constructional apraxia is a motor disturbance, it is the inability to reproduce a simple figure. Fetor hepaticus is a sweet, slightly fecal odor to the breath and not associated with a motor disturbance. Skin changes associated with liver dysfunction may include palmar erythema, which is a reddening of the palms, but is not a flapping tremor.

39. A 55-year-old female patient with hepatocellular carcinoma (HCC) is undergoing radiofrequency ablation. The nurse should recognize what goal of this treatment? A) Destruction of the patient's liver tumor B) Restoration of portal vein patency C) Destruction of a liver abscess D) Reversal of metastasis

Ans: A Feedback: Using radiofrequency ablation, a tumor up to 5 cm in size can be destroyed in one treatment session. This technique does not address circulatory function or abscess formation. It does not allow for the reversal of metastasis.

4. A nurse educator is teaching a group of recent nursing graduates about their occupational risks for contracting hepatitis B. What preventative measures should the educator promote? Select all that apply. A) Immunization B) Use of standard precautions C) Consumption of a vitamin-rich diet D) Annual vitamin K injections E) Annual vitamin B12 injections

Ans: A, B Feedback: People who are at high risk, including nurses and other health care personnel exposed to blood or blood products, should receive active immunization. The consistent use of standard precautions is also highly beneficial. Vitamin supplementation is unrelated to an individual's risk of HBV.

21. A patient's physician has ordered a "liver panel" in response to the patient's development of jaundice. When reviewing the results of this laboratory testing, the nurse should expect to review what blood tests? Select all that apply. A) Alanine aminotransferase (ALT) B) C-reactive protein (CRP) C) Gamma-glutamyl transferase (GGT) D) Aspartate aminotransferase (AST) E) B-type natriuretic peptide (BNP)

Ans: A, C, D Feedback: Liver function testing includes GGT, ALT, and AST. CRP addresses the presence of generalized inflammation and BNP is relevant to heart failure; neither is included in a liver panel.

26. A patient with a diagnosis of esophageal varices has undergone endoscopy to gauge the progression of this complication of liver disease. Following the completion of this diagnostic test, what nursing intervention should the nurse perform? A) Keep patient NPO until the results of test are known. B) Keep patient NPO until the patient's gag reflex returns. C) Administer analgesia until post-procedure tenderness is relieved. D) Give the patient a cold beverage to promote swallowing ability.

Ans: B Feedback: After the examination, fluids are not given until the patient's gag reflex returns. Lozenges and gargles may be used to relieve throat discomfort if the patient's physical condition and mental status permit. The result of the test is known immediately. Food and fluids are contraindicated until the gag reflex returns.

11. A participant in a health fair has asked the nurse about the role of drugs in liver disease. What health promotion teaching has the most potential to prevent drug-induced hepatitis? A) Finish all prescribed courses of antibiotics, regardless of symptom resolution. B) Adhere to dosing recommendations of OTC analgesics. C) Ensure that expired medications are disposed of safely. D) Ensure that pharmacists regularly review drug regimens for potential interactions.

Ans: B Feedback: Although any medication can affect liver function, use of acetaminophen (found in many over-the-counter medications used to treat fever and pain) has been identified as the leading cause of acute liver failure. Finishing prescribed antibiotics and avoiding expired medications are unrelated to this disease. Drug interactions are rarely the cause of drug-induced hepatitis.

24. A nurse is caring for a patient who has been admitted for the treatment of advanced cirrhosis. What assessment should the nurse prioritize in this patient's plan of care? A) Measurement of abdominal girth and body weight B) Assessment for variceal bleeding C) Assessment for signs and symptoms of jaundice D) Monitoring of results of liver function testing

Ans: B Feedback: Esophageal varices are a major cause of mortality in patients with uncompensated cirrhosis. Consequently, this should be a focus of the nurse's assessments and should be prioritized over the other listed assessments, even though each should be performed.

19. A nurse is caring for a patient with a blocked bile duct from a tumor. What manifestation of obstructive jaundice should the nurse anticipate? A) Watery, blood-streaked diarrhea B) Orange and foamy urine C) Increased abdominal girth D) Decreased cognition

Ans: B Feedback: If the bile duct is obstructed, the bile will be reabsorbed into the blood and carried throughout the entire body. It is excreted in the urine, which becomes deep orange and foamy. Bloody diarrhea, ascites, and cognitive changes are not associated with obstructive jaundice.

32. A nurse is caring for a patient with cirrhosis secondary to heavy alcohol use. The nurse's most recent assessment reveals subtle changes in the patient's cognition and behavior. What is the nurse's most appropriate response? A) Ensure that the patient's sodium intake does not exceed recommended levels. B) Report this finding to the primary care provider due to the possibility of hepatic encephalopathy. C) Inform the primary care provider that the patient should be assessed for alcoholic hepatitis. D) Implement interventions aimed at ensuring a calm and therapeutic care environment.

Ans: B Feedback: Monitoring is an essential nursing function to identify early deterioration in mental status. The nurse monitors the patient's mental status closely and reports changes so that treatment of encephalopathy can be initiated promptly. This change in status is likely unrelated to sodium intake and would not signal the onset of hepatitis. A supportive care environment is beneficial, but does not address the patient's physiologic deterioration.

30. A patient has been admitted to the critical care unit with a diagnosis of toxic hepatitis. When planning the patient's care, the nurse should be aware of what potential clinical course of this health problem? Place the following events in the correct sequence. 1. Fever rises. 2. Hematemesis. 3. Clotting abnormalities. 4. Vascular collapse. 5. Coma. A) 1, 2, 5, 4, 3 B) 1, 2, 3, 4, 5 C) 2, 3, 1, 4, 5 D) 3, 1, 2, 5, 4

Ans: B Feedback: Recovery from acute toxic hepatitis is rapid if the hepatotoxin is identified early and removed or if exposure to the agent has been limited. Recovery is unlikely if there is a prolonged period between exposure and onset of symptoms. There are no effective antidotes. The fever rises; the patient becomes toxic and prostrated. Vomiting may be persistent, with the emesis containing blood. Clotting abnormalities may be severe, and hemorrhages may appear under the skin. The severe GI symptoms may lead to vascular collapse. Delirium, coma, and seizures develop, and within a few days the patient may die of fulminant hepatic failure unless he or she receives a liver transplant.

13. A patient has been diagnosed with advanced stage breast cancer and will soon begin aggressive treatment. What assessment findings would most strongly suggest that the patient may have developed liver metastases? A) Persistent fever and cognitive changes B) Abdominal pain and hepatomegaly C) Peripheral edema unresponsive to diuresis D) Spontaneous bleeding and jaundice

Ans: B Feedback: The early manifestations of malignancy of the liver include pain—a continuous dull ache in the right upper quadrant, epigastrium, or back. Weight loss, loss of strength, anorexia, and anemia may also occur. The liver may be enlarged and irregular on palpation. Jaundice is present only if the larger bile ducts are occluded by the pressure of malignant nodules in the hilum of the liver. Fever, cognitive changes, peripheral edema, and bleeding are atypical signs.

35. A patient with cirrhosis has experienced a progressive decline in his health; and liver transplantation is being considered by the interdisciplinary team. How will the patient's prioritization for receiving a donor liver be determined? A) By considering the patient's age and prognosis B) By objectively determining the patient's medical need C) By objectively assessing the patient's willingness to adhere to post-transplantation care D) By systematically ruling out alternative treatment options

Ans: B Feedback: The patient would undergo a classification of the degree of medical need through an objective determination known as the Model of End-Stage Liver Disease (MELD) classification, which stratifies the level of illness of those awaiting a liver transplant. This algorithm considers multiple variables, not solely age, prognosis, potential for adherence, and the rejection of alternative options.

28. A patient with a history of injection drug use has been diagnosed with hepatitis C. When collaborating with the care team to plan this patient's treatment, the nurse should anticipate what intervention? A) Administration of immune globulins B) A regimen of antiviral medications C) Rest and watchful waiting D) Administration of fresh-frozen plasma (FFP)

Ans: B Feedback: There is no benefit from rest, diet, or vitamin supplements in HCV treatment. Studies have demonstrated that a combination of two antiviral agents, Peg-interferon and ribavirin (Rebetol), is effective in producing improvement in patients with hepatitis C and in treating relapses. Immune globulins and FFP are not indicated.

36. A nurse has entered the room of a patient with cirrhosis and found the patient on the floor. The patient states that she fell when transferring to the commode. The patient's vital signs are within reference ranges and the nurse observes no apparent injuries. What is the nurse's most appropriate action? A) Remove the patient's commode and supply a bedpan. B) Complete an incident report and submit it to the unit supervisor. C) Have the patient assessed by the physician due to the risk of internal bleeding. D) Perform a focused abdominal assessment in order to rule out injury.

Ans: C Feedback: A fall would necessitate thorough medical assessment due to the patient's risk of bleeding. The nurse's abdominal assessment is an appropriate action, but is not wholly sufficient to rule out internal injury. Medical assessment is a priority over removing the commode or filling out an incident report, even though these actions are appropriate.

31. A previously healthy adult's sudden and precipitous decline in health has been attributed to fulminant hepatic failure, and the patient has been admitted to the intensive care unit. The nurse should be aware that the treatment of choice for this patient is what? A) IV administration of immune globulins B) Transfusion of packed red blood cells and fresh-frozen plasma (FFP) C) Liver transplantation D) Lobectomy

Ans: C Feedback: Liver transplantation carries the highest potential for the resolution of fulminant hepatic failure. This is preferred over other interventions, such as pharmacologic treatments, transfusions, and surgery.

3. A patient with portal hypertension has been admitted to the medical floor. The nurse should prioritize which of the following assessments related to the manifestations of this health problem? A) Assessment of blood pressure and assessment for headaches and visual changes B) Assessments for signs and symptoms of venous thromboembolism C) Daily weights and abdominal girth measurement D) Blood glucose monitoring q4h

Ans: C Feedback: Obstruction to blood flow through the damaged liver results in increased blood pressure (portal hypertension) throughout the portal venous system. This can result in varices and ascites in the abdominal cavity. Assessments related to ascites are daily weights and abdominal girths. Portal hypertension is not synonymous with cardiovascular hypertension and does not create a risk for unstable blood glucose or VTE.

16. A nurse is caring for a patient with hepatic encephalopathy. The nurse's assessment reveals that the patient exhibits episodes of confusion, is difficult to arouse from sleep and has rigid extremities. Based on these clinical findings, the nurse should document what stage of hepatic encephalopathy? A) Stage 1 B) Stage 2 C) Stage 3 D) Stage 4

Ans: C Feedback: Patients in the third stage of hepatic encephalopathy exhibit the following symptoms: stuporous, difficult to arouse, sleeps most of the time, exhibits marked confusion, incoherent in speech, asterixis, increased deep tendon reflexes, rigidity of extremities, marked EEG abnormalities. Patients in stages 1 and 2 exhibit clinical symptoms that are not as advanced as found in stage 3, and patients in stage 4 are comatose. In stage 4, there is an absence of asterixis, absence of deep tendon reflexes, flaccidity of extremities, and EEG abnormalities.

22. A patient with liver disease has developed jaundice; the nurse is collaborating with the patient to develop a nutritional plan. The nurse should prioritize which of the following in the patient's plan? A) Increased potassium intake B) Fluid restriction to 2 L per day C) Reduction in sodium intake D) High-protein, low-fat diet

Ans: C Feedback: Patients with ascites require a sharp reduction in sodium intake. Potassium intake should not be correspondingly increased. There is no need for fluid restriction or increased protein intake.

40. A nurse is caring for a patient with severe hemolytic jaundice. Laboratory tests show free bilirubin to be 24 mg/dL. For what complication is this patient at risk? A) Chronic jaundice B) Pigment stones in portal circulation C) Central nervous system damage D) Hepatomegaly

Ans: C Feedback: Prolonged jaundice, even if mild, predisposes to the formation of pigment stones in the gallbladder, and extremely severe jaundice (levels of free bilirubin exceeding 20 to 25 mg/dL) poses a risk for CNS damage. There are not specific risks of hepatomegaly or chronic jaundice resulting from high bilirubin.

12. Diagnostic testing has revealed that a patient's hepatocellular carcinoma (HCC) is limited to one lobe. The nurse should anticipate that this patient's plan of care will focus on what intervention? A) Cryosurgery B) Liver transplantation C) Lobectomy D) Laser hyperthermia

Ans: C Feedback: Surgical resection is the treatment of choice when HCC is confined to one lobe of the liver and the function of the remaining liver is considered adequate for postoperative recovery. Removal of a lobe of the liver (lobectomy) is the most common surgical procedure for excising a liver tumor. While cryosurgery and liver transplantation are other surgical options for management of liver cancer, these procedures are not performed at the same frequency as a lobectomy. Laser hyperthermia is a nonsurgical treatment for liver cancer.

6. A patient who has undergone liver transplantation is ready to be discharged home. Which outcome of health education should the nurse prioritize? A) The patient will obtain measurement of drainage from the T-tube. B) The patient will exercise three times a week. C) The patient will take immunosuppressive agents as required. D) The patient will monitor for signs of liver dysfunction.

Ans: C Feedback: The patient is given written and verbal instructions about immunosuppressive agent doses and dosing schedules. The patient is also instructed on steps to follow to ensure that an adequate supply of medication is available so that there is no chance of running out of the medication or skipping a dose. Failure to take medications as instructed may precipitate rejection. The nurse would not teach the patient to measure drainage from a T-tube as the patient wouldn't go home with a T-tube. The nurse may teach the patient about the need to exercise or what the signs of liver dysfunction are, but the nurse would not stress these topics over the immunosuppressive drug regimen.

2. A nurse is performing an admission assessment of a patient with a diagnosis of cirrhosis. What technique should the nurse use to palpate the patient's liver? A) Place hand under the right lower abdominal quadrant and press down lightly with the other hand. B) Place the left hand over the abdomen and behind the left side at the 11th rib. C) Place hand under right lower rib cage and press down lightly with the other hand. D) Hold hand 90 degrees to right side of the abdomen and push down firmly.

Ans: C Feedback: To palpate the liver, the examiner places one hand under the right lower rib cage and presses downward with light pressure with the other hand. The liver is not on the left side or in the right lower abdominal quadrant.

27. A patient with esophageal varices is being cared for in the ICU. The varices have begun to bleed and the patient is at risk for hypovolemia. The patient has Ringer's lactate at 150 cc/hr infusing. What else might the nurse expect to have ordered to maintain volume for this patient? A) Arterial line B) Diuretics C) Foley catheter D) Volume expanders

Ans: D Feedback: Because patients with bleeding esophageal varices have intravascular volume depletion and are subject to electrolyte imbalance, IV fluids with electrolytes and volume expanders are provided to restore fluid volume and replace electrolytes. Diuretics would reduce vascular volume. An arterial line and Foley catheter are likely to be ordered, but neither actively maintains the patient's volume.

1. A nurse is caring for a patient with liver failure and is performing an assessment in the knowledge of the patient's increased risk of bleeding. The nurse recognizes that this risk is related to the patient's inability to synthesize prothrombin in the liver. What factor most likely contributes to this loss of function? A) Alterations in glucose metabolism B) Retention of bile salts C) Inadequate production of albumin by hepatocytes D) Inability of the liver to use vitamin K

Ans: D Feedback: Decreased production of several clotting factors may be partially due to deficient absorption of vitamin K from the GI tract. This probably is caused by the inability of liver cells to use vitamin K to make prothrombin. This bleeding risk is unrelated to the roles of glucose, bile salts, or albumin.

34. A patient with liver cancer is being discharged home with a biliary drainage system in place. The nurse should teach the patient's family how to safely perform which of the following actions? A) Aspirating bile from the catheter using a syringe B) Removing the catheter when output is 15 mL in 24 hours C) Instilling antibiotics into the catheter D) Assessing the patency of the drainage catheter

Ans: D Feedback: Families should be taught to provide basic catheter care, including assessment of patency. Antibiotics are not instilled into the catheter and aspiration using a syringe is contraindicated. The family would not independently remove the catheter; this would be done by a member of the care team when deemed necessary.

37. A patient with liver cancer is being discharged home with a hepatic artery catheter in place. The nurse should be aware that this catheter will facilitate which of the following? A) Continuous monitoring for portal hypertension B) Administration of immunosuppressive drugs during the first weeks after transplantation C) Real-time monitoring of vascular changes in the hepatic system D) Delivery of a continuous chemotherapeutic dose

Ans: D Feedback: In most cases, the hepatic artery catheter has been inserted surgically and has a prefilled infusion pump that delivers a continuous chemotherapeutic dose until completed. The hepatic artery catheter does not monitor portal hypertension, deliver immunosuppressive drugs, or monitor vascular changes in the hepatic system.

8. A nurse is participating in the emergency care of a patient who has just developed variceal bleeding. What intervention should the nurse anticipate? A) Infusion of intravenous heparin B) IV administration of albumin C) STAT administration of vitamin K by the intramuscular route D) IV administration of octreotide (Sandostatin)

Ans: D Feedback: Octreotide (Sandostatin)—a synthetic analog of the hormone somatostatin—is effective in decreasing bleeding from esophageal varices, and lacks the vasoconstrictive effects of vasopressin. Because of this safety and efficacy profile, octreotide is considered the preferred treatment regimen for immediate control of variceal bleeding. Vitamin K and albumin are not administered and heparin would exacerbate, not alleviate, bleeding.

18. A nurse is performing an admission assessment for an 81-year-old patient who generally enjoys good health. When considering normal, age-related changes to hepatic function, the nurse should anticipate what finding? A) Similar liver size and texture as in younger adults B) A nonpalpable liver C) A slightly enlarged liver with palpably hard edges D) A slightly decreased size of the liver

Ans: D Feedback: The most common age-related change in the liver is a decrease in size and weight. The liver is usually still palpable, however, and is not expected to have hardened edges.

23. A nurse is amending a patient's plan of care in light of the fact that the patient has recently developed ascites. What should the nurse include in this patient's care plan? A) Mobilization with assistance at least 4 times daily B) Administration of beta-adrenergic blockers as ordered C) Vitamin B12 injections as ordered D) Administration of diuretics as ordered

Ans: D Feedback: Use of diuretics along with sodium restriction is successful in 90% of patients with ascites. Beta-blockers are not used to treat ascites and bed rest is often more beneficial than increased mobility. Vitamin B12 injections are not necessary.

The nurse is caring for a patient with cirrhosis of the liver and observes that the patient is having hand-flapping tremors. What does the nurse document this finding as? a) Fetor hepaticus b) Constructional apraxia c) Ataxia d) Asterixis

Asterixis Asterixis, an involuntary flapping of the hands, may be seen in stage II encephalopathy (Fig. 49-13).

Potential Complications Cirrhosis

Bleeding and hemorrhage Hepatic encephalopathy Fluid volume excess

NCLEX review question The patient with suspected pancreatic cancer is having many diagnostic studies done. Which one can be used to establish the diagnosis of pancreatic adenocarcinoma and for monitoring the response to treatment?

Cancer-associated antigen 19-9 Rationale: The cancer-associated antigen 19-9 (CA 19-9) is the tumor marker used for the diagnosis of pancreatic adenocarcinoma and for monitoring the response to treatment. Although a spiral CT scan may be the initial study done and provides information on metastasis and vascular involvement, this test and the PET/CT scan or abdominal ultrasound do not provide additional information.

What are the nursing interventions for a biopsy

Check coagulation studies ensuring they were obtained

A client is admitted for suspected GI disease. Assessment data reveal muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendency. The nurse suspects the client has: a)peptic ulcer disease. b)cirrhosis. c)cholelithiasis. d)appendicitis.

Cirrhosis Muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendencies are all symptoms of cirrhosis. The client may also have mild fever, edema, abdominal pain, and an enlarged liver. Clients with peptic ulcer disease complain of a dull, gnawing epigastric pain that's relieved by eating. Appendicitis is characterized by a periumbilical pain that moves to the right lower quadrant and rebound tenderness. Cholelithiasis is characterized by severe abdominal pain that presents several hours after a large meal.

When assessing a client with cirrhosis of the liver, which of the following stool characteristics is the client likely to report? a) Yellow-green b) Clay-colored or whitish c) Blood tinged d) Black and tarry

Clay-colored or whitish Many clients report passing clay-colored or whitish stools as a result of no bile in the gastrointestinal tract. The other stool colors would not be absolute indicators of cirrhosis of the liver but may indicate other GI tract disorders.

When assessing a client with cirrhosis of the liver, which of the following stool characteristics is the client likely to report? a) Clay-colored or whitish b) Yellow-green c) Black and tarry d) Blood tinged

Clay-colored or whitish Many clients report passing clay-colored or whitish stools as a result of no bile in the gastrointestinal tract. The other stool colors would not be absolute indicators of cirrhosis of the liver but may indicate other GI tract disorders.

A nurse is caring for a client with cholelithiasis. Which sign indicates obstructive jaundice? a) Reduced hematocrit b) Elevated urobilinogen in the urine c) Straw-colored urine d) Clay-colored stools

Clay-colored stools Obstructive jaundice develops when a stone obstructs the flow of bile in the common bile duct. When the flow of bile to the duodenum is blocked, the lack of bile pigments results in a clay-colored stool. In obstructive jaundice, urine tends to be dark amber (not straw-colored) as a result of soluble bilirubin in the urine. Hematocrit levels aren't affected by obstructive jaundice. Because obstructive jaundice prevents bilirubin from reaching the intestine (where it's converted to urobilinogen), the urine contains no urobilinogen.

NCLEX review question The patient with right upper quadrant abdominal pain has an abdominal ultrasound that reveals cholelithiasis. What should the nurse expect to do for this patient?

Control abdominal pain Rationale: Patients with cholelithiasis can have severe pain, so controlling pain is important until the problem can be treated. NPO status may be needed if the patient will have surgery but will not be used for all patients with cholelithiasis. Enteral feedings should not be needed, and avoiding dietary cholesterol is not used to treat cholelithiasis.

Which of the following would be the most important nursing assessment in a patient diagnosed with ascites? a) Assessment of oral cavity for foul-smelling breath b) Daily weight and measurement of abdominal girth c) Palpation of abdomen for a fluid shift d) Auscultation of abdomen

Daily weight and measurement of abdominal girth Daily measurement and recording of abdominal girth and body weight are essential to assess the progression of ascites and its response to treatment.

A preoperative client scheduled to have an open cholecystectomy says to the nurse, "The doctor said that after surgery, I will have a tube in my nose that goes into my stomach. Why do I need that?" What most common reason for a client having a nasogastric tube in place after abdominal surgery should the nurse include in a response? a) Lavage b) Gavage c) Instillation d) Decompression

Decompression Negative pressure exerted through a tube inserted in the stomach removes secretions and gaseous substances from the stomach, preventing abdominal distention, nausea, and vomiting. This is not the most common purpose of a nasogastric tube after surgery; instillations in a nasogastric tube after surgery are done when necessary to promote patency. This is contraindicated after abdominal surgery until peristalsis returns. This is not the most common purpose of a nasogastric tube after surgery; lavage after surgery may be done to promote hemostasis in the presence of gastric bleeding.

NCLEX review question The health care provider orders lactulose for a patient with hepatic encephalopathy. The nurse will monitor for effectiveness of this medication for this patient by assessing what?

Decreased ammonia levels Rationale: Hepatic encephalopathy is a complication of liver disease and is associated with elevated serum ammonia levels. Lactulose traps ammonia in the intestinal tract. Its laxative effect then expels the ammonia from the colon, resulting in decreased serum ammonia levels and correction of hepatic encephalopathy.

Which of the following is an age-related change of the hepatobiliary system? a) Decreased prevalence of gallstones b) Decreased blood flow c) Increased drug clearance capability d) Liver enlargement

Decreased blood flow Explanation: Age-related changes of the hepatobiliary system include decreased blood flow, decreased drug clearance capability, increased presence of gall stones, and a steady decrease in size and weight of the liver.

Nutrition with ESLD with cirrhosis and Hep B

Diet High in Carbs Protein Intake Low Sodium NO RAW SELFISH RESTRICT SODIUM

Assessment/S/SX Hepatic encephalopathy; coma

EEG Changes in LOC, assess neurological status frequently- earliest s/sx Changes in mood, sleep pattern, difficult to awake Potential seizures Fetor hepaticus Monitor fluid, electrolyte, and ammonia levels

What test should the nurse prepare the client for that will locate stones that have collected in the common bile duct? a) Cholecystectomy b) Endoscopic retrograde cholangiopancreatography (ERCP) c) Colonoscopy d) Abdominal x-ray

Endoscopic retrograde cholangiopancreatography (ERCP) ERCP locates stones that have collected in the common bile duct. A colonoscopy will not locate gallstones but only allows visualization of the large intestine. Abdominal x-ray is not a reliable locator of gallstones. A cholecystectomy is the surgical removal of the gallbladder.

What test should the nurse prepare the client for that will locate stones that have collected in the common bile duct? a) Colonoscopy b) Endoscopic retrograde cholangiopancreatography (ERCP) c) Cholecystectomy d) Abdominal x-ray

Endoscopic retrograde cholangiopancreatography (ERCP) ERCP locates stones that have collected in the common bile duct. A colonoscopy will not locate gallstones but only allows visualization of the large intestine. Abdominal x-ray is not a reliable locator of gallstones. A cholecystectomy is the surgical removal of the gallbladder.

What is the mode of transmission of enteral forms of hepatitis?

Fecal-oral

The mode of transmission of hepatitis A virus (HAV) includes which of the following? a) Semen b) Fecal-oral c) Saliva d) Blood

Fecal-oral The mode of transmission of hepatitis A virus (HAV) occurs through fecal-oral route, primarily through person to person contact and/or ingestion of fecal contaminated food or water. Hepatitis B virus (HBV) is transmitted primarily through blood. HBV can be found in blood, saliva, semen, and can be transmitted through mucous membranes and breaks in the skin.

The mode of transmission of hepatitis A virus (HAV) includes which of the following? a) Semen b) Blood c) Fecal-oral d) Saliva

Fecal-oral The mode of transmission of hepatitis A virus (HAV) occurs through fecal-oral route, primarily through person to person contact and/or ingestion of fecal contaminated food or water. Hepatitis B virus (HBV) is transmitted primarily through blood. HBV can be found in blood, saliva, semen, and can be transmitted through mucous membranes and breaks in the skin.

The mode of transmission of hepatitis A virus (HAV) includes which of the following? a) Fecal-oral b) Blood c) Semen d) Saliva

Fecal-oral Explanation: The mode of transmission of hepatitis A virus (HAV) occurs through fecal-oral route, primarily through person to person contact and/or ingestion of fecal contaminated food or water. Hepatitis B virus (HBV) is transmitted primarily through blood. HBV can be found in blood, saliva, semen, and can be transmitted through mucous membranes and breaks in the skin.

Asterixis

Flapping tremors of the hands. Deterioration of writing, drawing simple shapes.

Ascites

Fluid in Peritoneal Cavity Due To: `Portal hypertension resulting in increased capillary pressure and obstruction of venous blood flow `Vasodilatation of circulation in the spleen `Changes in the ability to metabolize aldosterone, increasing fluid retention `Decreased synthesis of albumin, decreasing serum osmotic pressure `Movement of albumin into the peritoneal cavity

Which type of deficiency results in macrocytic anemia? a) Folic acid b) Vitamin A c) Vitamin K d) Vitamin C

Folic acid Folic acid deficiency results in macrocytic anemia. Vitamin C deficiency results in hemorrhagic lesions of scurvy. Vitamin A deficiency results in night blindness and eye and skin changes. Vitamin K deficiency results in hypoprothrombinemia, which is characterized by spontaneous bleeding and ecchymosis

Which type of deficiency results in macrocytic anemia? a) Vitamin K b) Vitamin C c) Vitamin A d) Folic acid

Folic acid Folic acid deficiency results in macrocytic anemia. Vitamin C deficiency results in hemorrhagic lesions of scurvy. Vitamin A deficiency results in night blindness and eye and skin changes. Vitamin K deficiency results in hypoprothrombinemia, which is characterized by spontaneous bleeding and ecchymosis.

Which type of deficiency results in macrocytic anemia? a) Folic acid b) Vitamin A c) Vitamin C d) Vitamin K

Folic acid Explanation: Folic acid deficiency results in macrocytic anemia. Vitamin C deficiency results in hemorrhagic lesions of scurvy. Vitamin A deficiency results in night blindness and eye and skin changes. Vitamin K deficiency results in hypoprothrombinemia, which is characterized by spontaneous bleeding and ecchymosis.

Which of the following would be the least important assessment in a patient diagnosed with ascites? a) Foul-smelling breath b) Palpation of abdomen for a fluid shift c) Measurement of abdominal girth d) Weight

Foul-smelling breath Foul-smelling breath would not be considered an important assessment for this patient. Measurement of abdominal girth, weight, and palpation of the abdomen for a fluid shift are all important assessment parameters for the patient diagnosed with ascites.

Which of the following would be the least important assessment in a patient diagnosed with ascites? a) Palpation of abdomen for a fluid shift b) Measurement of abdominal girth c) Weight d) Foul-smelling breath

Foul-smelling breath Foul-smelling breath would not be considered an important assessment for this patient. Measurement of abdominal girth, weight, and palpation of the abdomen for a fluid shift are all important assessment parameters for the patient diagnosed with ascites.

Which of the following would be the least important assessment in a patient diagnosed with ascites? a) Palpation of abdomen for a fluid shift b) Measurement of abdominal girth c) Foul-smelling breath d) Weight

Foul-smelling breath Explanation: Foul-smelling breath would not be considered an important assessment for this patient. Measurement of abdominal girth, weight, and palpation of the abdomen for a fluid shift are all important assessment parameters for the patient diagnosed with ascites.

Nursing Interventions

Frequent Neuro checks Mental status I&O, weight VS q4h Monitor for s/sx of infection

What is the #1 cause of pancreatitis?

Gallbladder disease (alcohol abuse is #2)

How is additional glucose in the liver synthesized

Gluconeogenesis

Functions of the Liver:Metabolic Functions

Glucose metabolism Ammonia conversion Protein metabolism Fat metabolism Vitamin and iron storage Bile formation Billirubin excretion Drug metabolism

Glycogen is converted back into glucose

Glycogenesis

Nursing Process: The Care of the Patient with Cirrhosis of the Liver—Planning

Goals: increased participation in activities improvement of nutritional status improvement of skin integrity decreased potential for injury improvement of mental status, and absence of complications.

Which type of jaundice is the result of increased destruction of red blood cells? a) Nonobstructive b) Hepatocellular c) Obstructive d) Hemolytic

Hemolytic Hemolytic jaundice is the result of an increased destruction of the red blood cells. Hepatocellular jaundice is caused by the inability of damaged liver cells to clear normal amounts of bilirubin from the blood. Obstructive jaundice resulting from extrahepatic obstruction may be caused by occlusion of the bile duct form a gall stone, inflammatory process, a tumor, or pressure from an enlarged organ. Nonobstructive jaundice occurs with hepatitis.

The nurse identifies which of the following types of jaundice in an adult experiencing a transfusion reaction? a) Hepatocellular b) Nonobstructive c) Obstructive d) Hemolytic

Hemolytic Hemolytic jaundice occurs because, although the liver is functioning normally, it cannot excrete the bilirubin as quickly as it is formed. This type of jaundice is encountered in patients with hemolytic transfusion reactions and other hemolytic disorders. Obstructive jaundice is the result of liver disease. Nonobstructive jaundice occurs with hepatitis. Hepatocellular jaundice is the result of liver disease.

A patient has an elevated serum ammonia level and is exhibiting mental status changes. The nurse should suspect which of the following conditions? a) Asterixis b) Cirrhosis c) Hepatic encephalopathy d) Portal hypertension

Hepatic encephalopathy Hepatic encephalopathy is a central nervous system dysfunction resulting from liver disease. It is frequently associated with elevated ammonia levels that produce changes in mental status, altered level of consciousness, and coma. Portal hypertension is an elevated pressure in the portal circulation resulting from obstruction of venous flow into and through the liver. Asterixis is an involuntary flapping movement of the hands associated with metabolic liver dysfunction.

A patient has an elevated serum ammonia level and is exhibiting mental status changes. The nurse should suspect which of the following conditions? a) Hepatic encephalopathy b) Portal hypertension c) Asterixis d) Cirrhosis

Hepatic encephalopathy Hepatic encephalopathy is a central nervous system dysfunction resulting from liver disease. It is frequently associated with elevated ammonia levels that produce changes in mental status, altered level of consciousness, and coma. Portal hypertension is an elevated pressure in the portal circulation resulting from obstruction of venous flow into and through the liver. Asterixis is an involuntary flapping movement of the hands associated with metabolic liver dysfunction.

A client and spouse are visiting the clinic. The client recently experienced a seizure and says she has been having difficulty writing. Before the seizure, the client says that for several weeks she was sleeping late into the day but having restlessness and insomnia at night. The client's husband says that he has noticed the client has been moody and slightly confused. Which of the following problems is most consistent with the client's clinical manifestations? a) Esophageal varices b) Hepatic encephalopathy c) Portal hypertension d) Hepatitis C

Hepatic encephalopathy The earliest symptoms of hepatic encephalopathy include minor mental changes and motor disturbances. The client appears slightly confused and unkempt and has alterations in mood and sleep patterns. The client tends to sleep during the day and have restlessness and insomnia at night. As hepatic encephalopathy progresses, the client may become difficult to awaken and completely disoriented with respect to time and place. With further progression, the client lapses into frank coma and may have seizures. Simple tasks, such as handwriting, become difficult.

NCLEX review question The condition of a patient who has cirrhosis of the liver has deteriorated. Which diagnostic study would help determine if the patient has developed liver cancer?

Hepatic structure ultrasound Rationale: Hepatic structure ultrasound, CT, and MRI are used to screen and diagnose liver cancer. Serum α-fetoprotein level may be elevated with liver cancer or other liver problems. Ventilation/perfusion scans do not diagnose liver cancer. Abdominal girth measurement would not differentiate between cirrhosis and liver cancer.

Timothy is a client being treated for hepatitis in the infectious disease office where you practice nursing. He has a history of IV drug use. He presents today with jaundice and arthralgias. Timothy most likely has which type of hepatitis? a) Hepatitis A b) Hepatitis E c) Hepatitis B d) Hepatitis C

Hepatitis B Mode of transmission is from infected blood or plasma, needles, syringes, surgical or dental equipment contaminated with infected blood; also sexually transmitted through vaginal secretions and semen of carriers or those actively infected. Mode of transmission is similar to HBV, although less severe and without jaundice. The client's presentation is most similar to hepatitis B. Mode of transmission is the oral route from feces and saliva of infected persons. The client's presentation is most similar to hepatitis B. Mode of transmission is similar to HAV. The client's presentation is most similar to hepatitis B.

A nurse is preparing a presentation for a local community group about hepatitis. Which of the following would the nurse include? a) Infection with hepatitis G is similar to hepatitis A. b) Hepatitis B is transmitted primarily by the oral-fecal route. c) Hepatitis C increases a person's risk for liver cancer. d) Hepatitis A is frequently spread by sexual contact.

Hepatitis C increases a person's risk for liver cancer. Infection with hepatitis C increases the risk of a person developing hepatic (liver) cancer. Hepatitis A is transmitted primarily by the oral-fecal route; hepatitis B is frequently spread by sexual contact and infected blood. Hepatitis E is similar to hepatitis A whereas hepatitis G is similar to hepatitis C.

A nurse is preparing a presentation for a local community group about hepatitis. Which of the following would the nurse include? a) Hepatitis C increases a person's risk for liver cancer. b) Infection with hepatitis G is similar to hepatitis A. c) Hepatitis A is frequently spread by sexual contact. d) Hepatitis B is transmitted primarily by the oral-fecal route.

Hepatitis C increases a person's risk for liver cancer. Explanation: Infection with hepatitis C increases the risk of a person developing hepatic (liver) cancer. Hepatitis A is transmitted primarily by the oral-fecal route; hepatitis B is frequently spread by sexual contact and infected blood. Hepatitis E is similar to hepatitis A whereas hepatitis G is similar to hepatitis C.

A nurse is preparing a presentation for a local community group about hepatitis. Which of the following would the nurse include? a)Infection with hepatitis G is similar to hepatitis A. b)Hepatitis C increases a person's risk for liver cancer. c)Hepatitis A is frequently spread by sexual contact. d)Hepatitis B is transmitted primarily by the oral-fecal route.

Hepatitis C increases a person's risk for liver cancer. Infection with hepatitis C increases the risk of a person developing hepatic (liver) cancer. Hepatitis A is transmitted primarily by the oral-fecal route; hepatitis B is frequently spread by sexual contact and infected blood. Hepatitis E is similar to hepatitis A whereas hepatitis G is similar to hepatitis C.

Hepatitis D and E

Hepatitis D= *-Only persons with hepatitis B are at risk for hepatitis D. -Transmission is through blood and sexual contact. -Symptoms and treatment are similar to hepatitis B but more likely to develop fulminant liver failure and chronic active hepatitis and cirrhosis. Hepatitis E= -Transmitted by fecal-oral route, -Incubation period 15-65 days, -Resembles hepatitis A and is self-limited with an abrupt onset. No chronic form.

NCLEX review question A patient who has hepatitis B surface antigen (HBsAg) in the serum is being discharged with pain medication after knee surgery. Which medication order should the nurse question because it is most likely to cause hepatic complications?

Hydrocodone with acetaminophen (Vicodin) Rationale: The analgesic with acetaminophen should be questioned because this patient is a chronic carrier of hepatitis B and is likely to have impaired liver function. Acetaminophen is not suitable for this patient because it is converted to a toxic metabolite in the liver after absorption, increasing the risk of hepatocellular damage.

Patients diagnosed with esophageal varices are at risk for hemorrhagic shock. Which of the following is a sign of potential hypovolemia? a) Bradycardia b) Hypotension c) Polyuria d) Warm moist skin

Hypotension Signs of potential hypovolemia include cool, clammy skin, tachycardia, decreased blood pressure, and decreased urine output.

Patients diagnosed with esophageal varices are at risk for hemorrhagic shock. Which of the following is a sign of potential hypovolemia? a) Bradycardia b) Warm moist skin c) Hypotension d) Polyuria

Hypotension Explanation: Signs of potential hypovolemia include cool, clammy skin, tachycardia, decreased blood pressure, and decreased urine output.

Imbalanced Nutrition Cirrhosis

I&O Encourage patient to eat Small frequent meals may be better tolerated. Consider patient preferences Supplemental vitamins and minerals, especially B complex, provide water-soluble forms of fat-soluble vitamins if patient has steatorrhea . High-calorie diet, sodium restriction for ascites. Protein is modified to patient needs Protein is restricted if patient is at risk for encephalopathy.

NCLEX review question When planning care for a patient with cirrhosis, the nurse will give highest priority to which nursing diagnosis?

Ineffective breathing pattern related to pressure on diaphragm and reduced lung volume Rationale: Although all of these nursing diagnoses are appropriate and important in the care of a patient with cirrhosis, airway and breathing are always the highest priorities.

Liver Transplant Post Op what is the pt at risk for

Infection Post Op all functions of the pt are assessed

NCLEX review question The patient with sudden pain in the left upper quadrant radiating to the back and vomiting was diagnosed with acute pancreatitis. What intervention(s) should the nurse expect to include in the patient's plan of care?

Insert an NG and maintain NPO status to allow pancreas to rest Rationale: Initial treatment with acute pancreatitis will include an NG tube if there is vomiting and being NPO to decrease pancreatic enzyme stimulation and allow the pancreas to rest and heal. Fluid will be administered to treat or prevent shock. The pain will be treated with IV morphine because of the NPO status. Enteral feedings will only be used for the patient with severe acute pancreatitis in whom oral intake is not resumed. Antibiotic therapy is only needed with acute necrotizing pancreatitis and signs of infection.

What is almost always present in Hepatitis E?

Jaundice

Manifestations of Hepatic Dysfunction

Jaundice Portal hypertension, ascities, and varicies Hepatic encephalopathy or coma Nutritional deficiencies

The nurse is administering medications to a patient that has elevated ammonia due to cirrhosis of the liver. What medication will the nurse give to detoxify ammonium and to act as an osmotic agent? a) Spironolactone (Aldactone) b) Cholestyramine (Questran) c) Kanamycin (Kantrex) d) Lactulose (Cephulac)

Lactulose (Cephulac) Lactulose (Cephulac) is administered to detoxify ammonium and to act as an osmotic agent, drawing water into the bowel, which causes diarrhea in some clients. Potassium-sparing diuretics such as spironolactone (Aldactone) are used to treat ascites. Cholestyramine (Questran) is a bile acid sequestrant and reduces pruritus. Kanamycin (Kantrex) decreases intestinal bacteria and decreases ammonia but does not act as an osmotic agent.

The surgical treatment of choice for the patient with symptomatic gallbladder disease is a

Laparoscopic cholecystectomy Rationale: Laparoscopic cholecystectomy is the surgical treatment of choice for patients with symptomatic cholelithiasis. The procedure is minimally invasive (puncture sites only), and the patient experiences minimal postoperative pain and is discharged on the day of surgery or on the day after. Most patients are able to resume normal activities and return to work within 1 week

Early in the stages of hepatic cirrhosis how is the liver

Large and the cells are loaded with fat

Review of Anatomy and Physiology of the Liver

Largest gland of the body. Located upper right abdomen. Purpose: A very vascular organ that receives blood from GI tract via the portal vein and from the hepatic artery

NCLEX pre-test question The nurse is caring for a 55-year-old man patient with acute pancreatitis resulting from gallstones. Which clinical manifestation would the nurse expect the patient to exhibit?

Left upper abdominal pain Rationale: Abdominal pain (usually in the left upper quadrant) is the predominant manifestation of acute pancreatitis. Other manifestations of acute pancreatitis include nausea and vomiting, low-grade fever, leukocytosis, hypotension, tachycardia, and jaundice. Abdominal tenderness with muscle guarding is common. Bowel sounds may be decreased or absent. Ileus may occur and causes marked abdominal distention. Areas of cyanosis or greenish to yellow-brown discoloration of the abdominal wall may occur. Other areas of ecchymoses are the flanks (Grey Turner's spots or sign, a bluish flank discoloration) and the periumbilical area (Cullen's sign, a bluish periumbilical discoloration).

A client is being prepared to undergo laboratory and diagnostic testing to confirm the diagnosis of cirrhosis. Which test would the nurse expect to be used to provide definitive confirmation of the disorder? a) Magnetic resonance imaging b) Liver biopsy c) Coagulation studies d) Radioisotope liver scan

Liver biopsy A liver biopsy which reveals hepatic fibrosis is the most conclusive diagnostic procedure. Coagulation studies provide information about liver function but do not definitively confirm the diagnosis of cirrhosis. Magnetic resonance imaging and radioisotope liver scan help to support the diagnosis but do not confirm it. These tests provide information about the liver's enlarged size, nodular configuration, and distorted blood flow.

A physician orders spironolactone (Aldactone), 50 mg by mouth four times daily, for a client with fluid retention caused by cirrhosis. Which finding indicates that the drug is producing a therapeutic effect? a) Blood pH of 7.25 b) Serum sodium level of 135 mEq/L c) Loss of 2.2 lb (1 kg) in 24 hours d) Serum potassium level of 3.5 mEq/L

Loss of 2.2 lb (1 kg) in 24 hours Daily weight measurement is the most accurate indicator of fluid status; a loss of 2.2 lb (1 kg) indicates loss of 1 L of fluid. Because spironolactone is a diuretic, weight loss is the best indicator of its effectiveness. This client's serum potassium and sodium levels are normal. A blood pH of 7.25 indicates acidosis, an adverse reaction to spironolactone

A physician orders spironolactone (Aldactone), 50 mg by mouth four times daily, for a client with fluid retention caused by cirrhosis. Which finding indicates that the drug is producing a therapeutic effect? a) Blood pH of 7.25 b) Loss of 2.2 lb (1 kg) in 24 hours c) Serum sodium level of 135 mEq/L d) Serum potassium level of 3.5 mEq/L

Loss of 2.2 lb (1 kg) in 24 hours Daily weight measurement is the most accurate indicator of fluid status; a loss of 2.2 lb (1 kg) indicates loss of 1 L of fluid. Because spironolactone is a diuretic, weight loss is the best indicator of its effectiveness. This client's serum potassium and sodium levels are normal. A blood pH of 7.25 indicates acidosis, an adverse reaction to spironolactone.

A physician orders spironolactone (Aldactone), 50 mg by mouth four times daily, for a client with fluid retention caused by cirrhosis. Which finding indicates that the drug is producing a therapeutic effect? a) Serum sodium level of 135 mEq/L b) Blood pH of 7.25 c) Serum potassium level of 3.5 mEq/L d) Loss of 2.2 lb (1 kg) in 24 hours

Loss of 2.2 lb (1 kg) in 24 hours Explanation: Daily weight measurement is the most accurate indicator of fluid status; a loss of 2.2 lb (1 kg) indicates loss of 1 L of fluid. Because spironolactone is a diuretic, weight loss is the best indicator of its effectiveness. This client's serum potassium and sodium levels are normal. A blood pH of 7.25 indicates acidosis, an adverse reaction to spironolactone.

A patient with cirrhosis has a massive hemorrhage from esophageal varices. Balloon tamponade therapy is used temporarily to control hemorrhage and stabilize the patient. In planning care, the nurse gives the highest priority to which of the following goals? a) Maintaining the airway b) Relieving the patient's anxiety c) Controlling bleeding d) Maintaining fluid volume

Maintaining the airway Esophageal varices are almost always caused by portal hypertension, which results from obstruction of the portal circulation within the damaged liver. Maintaining the airway is the highest priority because oxygenation is essential for life. The airway is compromised by possible displacement of the tube and the inflated balloon into the oropharynx, which can cause life-threatening obstruction of the airway and asphyxiation.

A patient with cirrhosis has a massive hemorrhage from esophageal varices. Balloon tamponade therapy is used temporarily to control hemorrhage and stabilize the patient. In planning care, the nurse gives the highest priority to which of the following goals? a) Relieving the patient's anxiety b) Maintaining fluid volume c) Maintaining the airway d) Controlling bleeding

Maintaining the airway Esophageal varices are almost always caused by portal hypertension, which results from obstruction of the portal circulation within the damaged liver. Maintaining the airway is the highest priority because oxygenation is essential for life. The airway is compromised by possible displacement of the tube and the inflated balloon into the oropharynx, which can cause life-threatening obstruction of the airway and asphyxiation.

When performing a physical examination on a client with cirrhosis, a nurse notices that the client's abdomen is enlarged. Which of the following interventions should the nurse consider? a) Measure abdominal girth according to a set routine. b) Report the condition to the physician immediately. c) Provide the client with nonprescription laxatives. d) Ask the client about food intake.

Measure abdominal girth according to a set routine. If the abdomen appears enlarged, the nurse measures it according to a set routine. The nurse reports any change in mental status or signs of gastrointestinal bleeding immediately. It is not essential for the client to take laxatives unless prescribed. The client's food intake does not affect the size of the abdomen in case of cirrhosis.

The nurse explains to a patient with an episode of acute pancreatitis that the most effective means of relieving pain by suppressing pancreatic secretions is the use of:

NPO status Rationale: Pain from acute pancreatitis is aggravated by eating; NPO status will help to alleviate the pain by decreasing pancreatic secretions

Other Liver Disorders

Nonviral hepatitis= -Caused by: =Chloroform, phosphorus, gold compounds -Toxic hepatitis =Resembles viral hep =Anorexia, N/V, jaundice, liver enlargement =Recovery unlikely if the exposure is prolonged -Drug-induced hepatitis =Most common cause of liver failure =Cause- sensitivity to a medication =Abrupt onset- fever, chills, rash, pruritis, anorexia, nausea, enlarged liver, dark urine -Fulminant hepatic failure- severe liver failure in healthy individual

A client is scheduled to have a laparoscopic cholecystectomy as an outpatient. The client asks the nurse when he will be able to resume normal activities. What information should the nurse provide? a)Normal activities may be resumed in 1 month. b)Normal activities may be resumed in 2 weeks. c)Normal activities may be resumed in 1 week. d)Normal activities may be resumed the day after surgery.

Normal activities may be resumed in 1 week. A prolonged recovery period usually is unnecessary. Most clients resume normal activities within 1 week.

Portal Hypertension

Obstructed blood flow through the liver results in increased pressure throughout the portal venous system Results in: Ascities Esophageal varicies

A client is admitted to the hospital with acute hemorrhage from esophageal varices. What medication should the nurse anticipate administering that will reduce pressure in the portal venous system and control esophageal bleeding? a) Vasopressin (Pitressin) b) Vitamin K c) Epinephrine d) Octreotide (Sandostatin)

Octreotide (Sandostatin) Acute hemorrhage from esophageal varices is lifethreatening. Resuscitative measures include administration of IV fluids and blood products. IV octreotide (Sandostatin) is started as soon as possible. Sandostatin is preferred because of fewer side effects. Octreotide reduces pressure in the portal venous system and is preferred to the previously used agents, vasopressin (Pitressin) or terlipressin. Vitamin K promotes blood coagulation in bleeding conditions, resulting from liver disease.

A patient has undergone a liver biopsy. Which of the following postprocedure positions is appropriate? a) On the right side b) Trendelenburg c) High Fowler's d) On the left side

On the right side Explanation: In this position, the liver capsule at the site of penetration is compressed against the chest wall, and the escape of blood or bile through the perforation made for the biopsy is impeded. Positioning the patient on his left side is not indicated. Positioning the patient in the Trendelenburg position may be indicated if the patient is in shock, but is not the position designed for the patient after liver biopsy. High Fowler's position is not indicated for the patient after liver biopsy.

To reduce risk of injury for a patient with liver disease, what initial measure can the nurse implement? a) Raise all four side rails on the bed b) Prevent visitors, so as not to agitate the patient c) Pad the side rails on the bed d) Apply soft wrist restraints

Pad the side rails on the bed Padding the side rails can reduce injury if the patient becomes agitated or restless. Restraints would not be an initial measure to implement. Four side rails are considered a restraint and this would not be an initial measure to implement. Family and friends most generally assist in calming a patient.

A nurse is gathering equipment and preparing to assist with a sterile bedside procedure to withdraw fluid from a patient's abdomen. The procedure tray contains the following equipment: trocar, syringe, needles, and drainage tube. The patient is placed in a high Fowler's position and a BP cuff is secured around the arm in preparation for which of the following procedures? a) Liver biopsy b) Dialysis c) Paracentesis d) Abdominal ultrasound

Paracentesis Paracentesis is the removal of fluid (ascites) from the peritoneal cavity through a puncture or a small surgical incision through the abdominal wall under sterile conditions. Paracentesis may be used to withdraw ascitic fluid if the fluid accumulation is causing cardiorespiratory compromise.

A nurse is gathering equipment and preparing to assist with a sterile bedside procedure to withdraw fluid from a patient's abdomen. The procedure tray contains the following equipment: trocar, syringe, needles, and drainage tube. The patient is placed in a high Fowler's position and a BP cuff is secured around the arm in preparation for which of the following procedures? a)Abdominal ultrasound b)Paracentesis c)Liver biopsy d)Dialysis

Paracentesis Paracentesis is the removal of fluid (ascites) from the peritoneal cavity through a puncture or a small surgical incision through the abdominal wall under sterile conditions. Paracentesis may be used to withdraw ascitic fluid if the fluid accumulation is causing cardiorespiratory compromise.

Louisa Collins, a 52-year-old high school science teacher, is your client on the medical-surgical floor at the hospital where you practice nursing. She is undergoing diagnostics to determine what is causing her liver disorder. As you discuss her condition, Louisa asks questions pertaining to liver physiology and cellular function. Which liver cells perform most of the liver's metabolic functions? a) Parenchymal cells b) Canaliculi cells c) Kupffer cells d) Islets of Langerhans

Parenchymal cells

Louisa Collins, a 52-year-old high school science teacher, is your client on the medical-surgical floor at the hospital where you practice nursing. She is undergoing diagnostics to determine what is causing her liver disorder. As you discuss her condition, Louisa asks questions pertaining to liver physiology and cellular function. Which liver cells perform most of the liver's metabolic functions? a) Parenchymal cells b) Canaliculi cells c) Kupffer cells d) Islets of Langerhans

Parenchymal cells The cellular constituents of the liver include the hepatic parenchymal cells (hepatocytes), which perform most of the liver's metabolic functions. The parenchymal cells perform most of the liver's metabolic functions.

The most common cause of esophageal varices includes which of the following? a) Portal hypertension b) Jaundice c) Ascites d) Asterixis

Portal hypertension Esophageal varices are almost always caused by portal hypertension, which results from obstruction of the portal circulation within the damaged liver. Jaundice occurs when the bilirubin concentration in the blood is abnormally elevated. Ascites results from circulatory changes within the diseased liver. Asterixis is an involuntary flapping movement of the hands associated with metabolic liver dysfunction.

The most common cause of esophageal varices includes which of the following? a) Ascites b) Portal hypertension c) Asterixis d) Jaundice

Portal hypertension Explanation: Esophageal varices are almost always caused by portal hypertension, which results from obstruction of the portal circulation within the damaged liver. Jaundice occurs when the bilirubin concentration in the blood is abnormally elevated. Ascites results from circulatory changes within the diseased liver. Asterixis is an involuntary flapping movement of the hands associated with metabolic liver dysfunction.

Nursing Care of the Patient Undergoing a Liver Transplantation

Preoperative nursing interventions= -Acceptable candidate -Waiting list (United Network for Organ Sharing) -Emotional support -Pt must be accessible at all times -Many die awaiting livers -Tx of ascites, malnutrition, F&E imbalance Postoperative nursing interventions= -Strict sterile techniques AAT's -Immunosuppressive meds -Monitor: VS, U.O, Billary drainage, blood gasses, cardiac output, O2 Sat, clotting factors, glucose -HRF atelectasis caused by injury and manipulation of the diaphragm -Monitor vent settings Patient teaching= -Follow up appts and labs 2x/week -Eye exams- HRF glaucoma with corticosteroid use -Prophylactic antibiotics before dental visits

An elderly homeless client with a lengthy history of alcohol addiction is visiting the health clinic where you work. He has worsening jaundice. After diagnostic testing is complete, the physician returns a diagnosis of cirrhosis. The nurse begins client education about this condition. What would the nurse emphasize as the principal goal of cirrhosis therapy? a) Restoring fat-soluble vitamin absorption b) Curing the illness c) Preserving liver function d) Increasing alcohol toleration

Preserving liver function The principal aim of therapy is to prevent further deterioration by abolishing underlying causes and preserving what liver function remains. The principal aim of therapy is to prevent further deterioration.

Management Hep A

Prevention: -Good hand washing, safe water, and proper sewage disposal -Vaccine -Immunoglobulin for contacts to provide passive immunity Bed rest during acute stage Nutritional support see 39-8

Cancer of the Liver

Primary liver tumors= -Few cancers originate in the liver -Usually associated with hepatitis B and C -Hepatocellular carcinoma (HCC) Liver metastasis Manifestations: -Pain, a dull continuous ache in RUQ, epigastrium, or back -Weight loss, loss of strength, anorexia, anemia may occur -Jaundice if bile ducts occluded, ascites if obstructed portal veins

The nurse is caring for a client with cirrhosis. Which assessment findings indicate that the client has deficient vitamin K absorption caused by this hepatic disease? a) Gynecomastia and testicular atrophy b) Ascites and orthopnea c) Purpura and petechiae d) Dyspnea and fatigue

Purpura and petechiae A hepatic disorder, such as cirrhosis, may disrupt the liver's normal use of vitamin K to produce prothrombin (a clotting factor). Consequently, the nurse should monitor the client for signs of bleeding, including purpura and petechiae. Dyspnea and fatigue suggest anemia. Ascites and orthopnea are unrelated to vitamin K absorption. Gynecomastia and testicular atrophy result from decreased estrogen metabolism by the diseased liver.

The nurse is caring for a client with cirrhosis. Which assessment findings indicate that the client has deficient vitamin K absorption caused by this hepatic disease? a) Gynecomastia and testicular atrophy b) Dyspnea and fatigue c) Ascites and orthopnea d) Purpura and petechiae

Purpura and petechiae A hepatic disorder, such as cirrhosis, may disrupt the liver's normal use of vitamin K to produce prothrombin (a clotting factor). Consequently, the nurse should monitor the client for signs of bleeding, including purpura and petechiae. Dyspnea and fatigue suggest anemia. Ascites and orthopnea are unrelated to vitamin K absorption. Gynecomastia and testicular atrophy result from decreased estrogen metabolism by the diseased liver.

The nurse is caring for a client with cirrhosis. Which assessment findings indicate that the client has deficient vitamin K absorption caused by this hepatic disease? a) Dyspnea and fatigue b) Gynecomastia and testicular atrophy c) Purpura and petechiae d) Ascites and orthopnea

Purpura and petechiae Explanation: A hepatic disorder, such as cirrhosis, may disrupt the liver's normal use of vitamin K to produce prothrombin (a clotting factor). Consequently, the nurse should monitor the client for signs of bleeding, including purpura and petechiae. Dyspnea and fatigue suggest anemia. Ascites and orthopnea are unrelated to vitamin K absorption. Gynecomastia and testicular atrophy result from decreased estrogen metabolism by the diseased liver.

Connie, a 60-year-old retired financial planner, is recently diagnosed with carcinoma of the pancreas. She has just met with her surgeon and feels overwhelmed by all the information she was given. She tells you that she is having the head of the pancreas removed; additionally, the surgeon is also removing the duodenum and stomach and redirecting the flow of secretions from the stomach, gallbladder, and pancreas into the middle section of the small intestine. What procedure is Connie having performed? a) Distal pancreatectomy b) Total pancreatectomy c) Cholecystojejunostomy d) Radical pancreatoduodenectomy

Radical pancreatoduodenectomy This surgical procedure involves removing the head of the pancreas, resecting the duodenum and stomach, and redirecting the flow of secretions from the stomach, gallbladder, and pancreas into the jejunum. This surgical procedure is a rerouting of the pancreatic and biliary drainage systems, which may be done to relieve obstructive jaundice. This measure is considered palliative only. A pancreatectomy is the surgical removal of the pancreas. A pancreatectomy may be total, in which case the entire organ is removed, usually along with the spleen, gallbladder, common bile duct, and portions of the small intestine and stomach. A distal pancreatectomy is a surgical procedure to remove the bottom half of the pancreas.

Which of the following liver function studies is used to show the size of the liver and hepatic blood flow and obstruction? a) Radioisotope liver scan b) Magnetic resonance imaging (MRI) c) Electroencephalogram (EEG) d) Angiography

Radioisotope liver scan A radioisotope liver scan assesses liver size and hepatic blood flow and obstruction. An MRI is used to identify normal structures and abnormalities of the liver and biliary tree. Angiography is used to visualize hepatic circulation and detect the presence and nature of hepatic masses. An EEG is used to detect abnormalities that occur with hepatic coma.

A client with cirrhosis has portal hypertension, which is causing esophageal varices. What is the goal of the interventions that the nurse will provide? a) Cure the cirrhosis. b) Reduce fluid accumulation and venous pressure. c) Treat the esophageal varices. d) Promote optimal neurologic function.

Reduce fluid accumulation and venous pressure. Methods of treating portal hypertension aim to reduce fluid accumulation and venous pressure. There is no cure for cirrhosis; treating the esophageal varices is only a small portion of the overall objective. Promoting optimal neurologic function will not reduce portal hypertension.

Paracentesis

Removal of fluid from (ascites) the peritoneal cavity through a puncture or a small surgical incision through the abd wall under the sterile conditions.

The nurse is providing care to a patient with gross ascites who is maintaining a position of comfort in the high semi-Fowler's position. What is the nurse's priority assessment of this patient? a) Urinary output related to increased sodium retention b) Peripheral vascular assessment related to immobility c) Skin assessment related to increase in bile salts d) Respiratory assessment related to increased thoracic pressure

Respiratory assessment related to increased thoracic pressure If a patient with ascites from liver dysfunction is hospitalized, nursing measures include assessment and documentation of intake and output (I&O;), abdominal girth, and daily weight to assess fluid status. The nurse also closely monitors the respiratory status because large volumes of ascites can compress the thoracic cavity and inhibit adequate lung expansion. The nurse monitors serum ammonia, creatinine, and electrolyte levels to assess electrolyte balance, response to therapy, and indications of encephalopathy.

The nurse is providing care to a patient with gross ascites who is maintaining a position of comfort in the high semi-Fowler's position. What is the nurse's priority assessment of this patient? a) Peripheral vascular assessment related to immobility b) Respiratory assessment related to increased thoracic pressure c) Urinary output related to increased sodium retention d) Skin assessment related to increase in bile salts

Respiratory assessment related to increased thoracic pressure If a patient with ascites from liver dysfunction is hospitalized, nursing measures include assessment and documentation of intake and output (I&O;), abdominal girth, and daily weight to assess fluid status. The nurse also closely monitors the respiratory status because large volumes of ascites can compress the thoracic cavity and inhibit adequate lung expansion. The nurse monitors serum ammonia, creatinine, and electrolyte levels to assess electrolyte balance, response to therapy, and indications of encephalopathy.

Activity Intolerance Cirrhosis

Rest and supportive measures Positioning for respiratory efficiency Oxygen Planned mild exercise and rest periods Address nutritional status to improve strength Measures to prevent hazards of immobility

Where is the liver located?

Right Upper Portion

After undergoing a liver biopsy, a client should be placed in which position? a) Right lateral decubitus position b) Semi-Fowler's position c) Supine position d) Prone position

Right lateral decubitus position After a liver biopsy, the client is placed on the right side (right lateral decubitus position) to exert pressure on the liver and prevent bleeding. Semi-Fowler's position and the supine and prone positions wouldn't achieve this goal.

In what location would the nurse palpate for the liver? a) Right upper quadrant b) Left upper quadrant c) Left lower quadrant d) Right lower quadrant

Right upper quadrant The liver may be palpable in the right upper quadrant. A palpable liver presents as a firm, sharp ridge with a smooth surface.

what position should the patient be in for a liver biopsy and what should they do

Rt side of the patients upper abd should be exposed Instrust pt to inhale and exhale deeply several times, finally to exhale, and to hold breath at the end of expiration. This is when the needle is inserted.

Liver Function Studies

Serum aminotransferases: AST, ALT, GGT, GGTP, LDH Serum protein studies: Altered levels in chronic hepatitis, edema, ascities, cirrhosis, obstructive jaundice, viral hepatitis Pigment studies: direct and indirect serum billirubin, urine billirubin, and urine billirubin and urobilinogen Prothrombin time Serum alkaline phosphatase: -Made in bones, liver, kidneys, intestines- excreted through he liver -Alterations indicate billiary tract obst. Serum ammonia Cholesterol

A patient with hepatic cirrhosis questions the nurse about the possible use of an herbal supplement—milk thistle—to help heal the liver. Which of the following would be the most appropriate response from the nurse? a) Silymarin from milk thistle has anti-inflammatory and antioxidant properties that may have beneficial effects, especially in hepatitis.However, you should always notify your primary care provider of any herbal remedies being used so drug interactions can be evaluated. b) You can use milk thistle instead of the medications you have been prescribed. c) Herbal supplements are approved by the FDA, so there should be no problem with their usage if you check with your primary care provider. d) You should not use herbal supplements in conjunction with medical treatment.

Silymarin from milk thistle has anti-inflammatory and antioxidant properties that may have beneficial effects, especially in hepatitis.However, you should always notify your primary care provider of any herbal remedies being used so drug interactions can be evaluated. Many patients who have end-stage liver disease (ESLD) with cirrhosis use the herb milk thistle (Silybum marianum) to treat jaundice and other symptoms. This herb has been used for centuries because of its healing and regenerative properties for liver disease. Silymarin from milk thistle has anti-inflammatory and antioxidant properties that may have beneficial effects, especially in hepatitis. The natural compound SAM-e (s-adenosylmethionine) may improve outcomes in liver disease by improving liver function, possibly through enhancing antioxidant function. Herbal supplements are used in conjunction with medical treatment and medications. Herbal supplements are not approved by the FDA. Their usage should be discussed with the primary care provider to evaluate their effectiveness and interactions with other treatment regimens.

The nurse is concerned about potassium loss when a diuretic is prescribed for a patient with ascites and edema. What diuretic may be ordered that spares potassium and prevents hypokalemia? a) Bumetanide (Bumex) b) Furosemide (Lasix) c) Acetazolamide (Diamox) d) Spironolactone (Aldactone)

Spironolactone (Aldactone) Potassium-sparing diuretic agents such as spironolactone or triamterene (Dyrenium) may be indicated to decrease ascites, if present; these diuretics are preferred because they minimize the fluid and electrolyte changes commonly seen with other agents.

The nurse is concerned about potassium loss when a diuretic is prescribed for a patient with ascites and edema. What diuretic may be ordered that spares potassium and prevents hypokalemia? a)Bumetanide (Bumex) b)Furosemide (Lasix) c)Acetazolamide (Diamox) d)Spironolactone (Aldactone)

Spironolactone (Aldactone) Potassium-sparing diuretic agents such as spironolactone or triamterene (Dyrenium) may be indicated to decrease ascites, if present; these diuretics are preferred because they minimize the fluid and electrolyte changes commonly seen with other agents.

Which of the following medications would the nurse expect the physician to order for a client with cirrhosis who develops portal hypertension? a) Kanamycin (Kantrex) b) Cyclosporine (Sandimmune) c) Spironolactone (Aldactone) d) Lactulose (Cephulac)

Spironolactone (Aldactone) Explanation: For portal hypertension, a diuretic usually an aldosterone antagonist such as spironolactone (Aldactone) is ordered. Kanamycin (Kantrex) would be used to treat hepatic encephalopathy to destroy intestinal microorganisms and decrease ammonia production. Lactulose would be used to reduce serum ammonia concentration in a client with hepatic encephalopathy. Cyclosporine (Sandimmune) would be used to prevent graft rejection after a transplant.

Why should total parental nutrition (TPN) be used cautiously in clients with pancreatitis? a) Such clients can digest high-fat foods. b) Such clients are at risk for gallbladder contraction. c) Such clients cannot tolerate high-glucose concentration. d) Such clients are at risk for hepatic encephalopathy.

Such clients cannot tolerate high-glucose concentration. Total parental nutrition (TPN) is used carefully in clients with pancreatitis because some clients cannot tolerate a high-glucose concentration even with insulin coverage. Intake of coffee increases the risk for gallbladder contraction, whereas intake of high protein increases risk for hepatic encephalopathy in clients with cirrhosis. Patients with pancreatitis should not be given high-fat foods because they are difficult to digest.

NCLEX review question The patient with a history of lung cancer and hepatitis C has developed liver failure and is considering liver transplantation. After the comprehensive evaluation, the nurse knows that which factor discovered may be a contraindication for liver transplantation?

The chest x-ray showed another lung cancer lesion. Rationale: Contraindications for liver transplant include severe extrahepatic disease, advanced hepatocellular carcinoma or other cancer, ongoing drug and/or alcohol abuse, and the inability to comprehend or comply with the rigorous post-transplant course.

A nurse is caring for a client with cirrhosis. The nurse assesses the client at noon and discovers that the client is difficult to arouse and has an elevated serum ammonia level. The nurse should suspect which situation? a) The client didn't take his morning dose of lactulose (Cephulac). b) The client's hepatic function is decreasing. c) The client is avoiding the nurse. d) The client is relaxed and not in pain.

The client's hepatic function is decreasing. The decreased level of consciousness caused by an increased serum ammonia level indicates hepatic dysfunction. If the client didn't take his morning dose of lactulose, he wouldn't have elevated ammonia levels and decreased level of consciousness this soon. These assessment findings don't indicate that the client is relaxed or avoiding the nurse.

Ammonia, the major etiologic factor in the development of encephalopathy, inhibits neurotransmission. Increased levels of ammonia are damaging to the body. The largest source of ammonia is from: a) The digestion of dietary and blood proteins. b) Excess potassium loss subsequent to prolonged use of diuretics. c) Excessive diuresis and dehydration. d) Severe infections and high fevers.

The digestion of dietary and blood proteins. Circumstances that increase serum ammonia levels tend to aggravate or precipitate hepatic encephalopathy. The largest source of ammonia is the enzymatic and bacterial digestion of dietary and blood proteins in the GI tract. Ammonia from these sources increases as a result of GI bleeding (ie, bleeding esophageal varices, chronic GI bleeding), a high-protein diet, bacterial infection, or uremia.

Because the liver is responsible for the storage of glycogen and the synthesis of protein and clotting factors

These substances need to be monitored and replaced in the immediate post op

A patient with bleeding esophageal varices has had pharmacologic therapy with Octreotide (Sandostatin) and endoscopic therapy with esophageal varices banding, but the patient has continued to have bleeding. What procedure that will lower portal pressure does the nurse prepare the patient for? a) Vasopressin (Pitressin) b) Transjugular intrahepatic portosystemic shunting (TIPS) c) Balloon tamponade d) Sclerotherapy

Transjugular intrahepatic portosystemic shunting (TIPS) A TIPS procedure (see Fig. 49-8) is indicated for the treatment of an acute episode of uncontrolled variceal bleeding refractory to pharmacologic or endoscopic therapy. In 10% to 20% of patients for whom urgent band ligation or sclerotherapy and medications are not successful in eradicating bleeding, a TIPS procedure can effectively control acute variceal hemorrhage by rapidly lowering portal pressure.

Medical Management

Treat underlying cause Lactulose IV glucose Vitamins Protein restriction Reduction of ammonia from GI tract by gastric suction, enemas, oral antibiotics. Discontinue sedatives analgesics and tranquilizers. Monitor for and promptly treat complications and infections.

Surgical Management of Liver Cancer

Treatment of choice for HCC if confined to one lobe and liver function is adequate. Liver has regenerative capacity. Types of surgery= Lobectomy Cyrosurgery Liver transplant

Treatment of Bleeding Varices

Treatment of shock: -Oxygen -IV fluids & electrolytes -Blood and blood products Meds: -Vasopressin, somatostatin, octretide -Nitroglycerin may be used in combination with vasopressin to reduce coronary vasoconstriction -Propranolol and nadolol to decrease portal pressure; used in combination with other treatment

Immediately after liver biopsy what should the patient be instructed to do.

Turn on to the rt side; place a pillow under the costal margin and caution the pt to remain in this postion AVOID coughing and deep breathing!

Hepatic Cirrhosis

Types: -Alcoholic =Scar tissue surrounds the liver. Caused by chronic alcohol abuse. Most common type -Postnecrotic =Broad bands of scar tissue. Caused by acute viral hepatitis -Billiary =Scarring around the bile ducts become occluded with bile and pus. Less common =Liver enlargement, portal obstruction and ascites, gastrointestinal varices, edema, vitamin deficiency and anemia, mental deterioration

Which of the following liver function studies is used to show the size of abdominal organs and the presence of masses? a) Angiography b) Ultrasonography c) Electroencephalogram d) Magnetic resonance imaging

Ultrasonography Explanation: A ultrasonography will show the size of the abdominal organs and the presence of masses. Magnetic resonance imaging is used to detect hepatic neoplasms. An angiography is used to visualize hepatic circulation and detect the presence and nature of hepatic masses. An electroencephalogram is used to detect abnormalities that occur with hepatic coma.

The nurse is caring for a patient with ascites due to cirrhosis of the liver. What position does the nurse understand will activate the renin-angiotensin aldosterone and sympathetic nervous system and decrease responsiveness to diuretic therapy? a) Prone b) Left-lateral Sims' c) Upright d) Supine

Upright In patients with ascites, an upright posture is associated with activation of the renin-angiotensin-aldosterone system and sympathetic nervous system (Porth & Matfin, 2009). This causes reduced renal glomerular filtration and sodium excretion and a decreased response to loop diuretics.

What position is the pt in during paracentesis

Upright positon on edge of bed Or in chair with feet supported on stool

Which of the following is the most effective strategy to prevent hepatitis B infection? a) Vaccine b) Barrier protection during intercourse c) Covering open sores d) Avoid sharing toothbrushes

Vaccine The most effective strategy to prevent hepatitis B infection is through vaccination. Recommendations to prevent transmission of hepatitis B include vaccination of sexual contacts of individuals with chronic hepatitis, use of barrier protection during sexual intercourse, avoidance of sharing toothbrushes, razors with others, and covering open sores or skin lesions.

Which of the following is the most effective strategy to prevent hepatitis B infection? a)Vaccine b)Barrier protection during intercourse c)Avoid sharing toothbrushes d)Covering open sores

Vaccine The most effective strategy to prevent hepatitis B infection is through vaccination. Recommendations to prevent transmission of hepatitis B include vaccination of sexual contacts of individuals with chronic hepatitis, use of barrier protection during sexual intercourse, avoidance of sharing toothbrushes, razors with others, and covering open sores or skin lesions.

Which of the following is the most effective strategy to prevent hepatitis B infection? a) Vaccine b) Barrier protection during intercourse c) Avoid sharing toothbrushes d) Covering open sores

Vaccine Explanation: The most effective strategy to prevent hepatitis B infection is through vaccination. Recommendations to prevent transmission of hepatitis B include vaccination of sexual contacts of individuals with chronic hepatitis, use of barrier protection during sexual intercourse, avoidance of sharing toothbrushes, razors with others, and covering open sores or skin lesions.

A client is actively bleeding from esophageal varices. Which of the following medications would the nurse most expect to be administered to this client? a) Spironolactone (Aldactone) b) Propranolol (Inderal) c) Lactulose (Cephulac) d) Vasopressin (Pitressin)

Vasopressin (Pitressin) In an actively bleeding client, medications are administered initially because they can be obtained and administered quicker than other therapies. Vasopressin (Pitressin) may be the initial mode of therapy in urgent situations, because it produces constriction of the splanchnic arterial bed and decreases portal pressure. Propranolol (Inderal) and nadolol (Corgard), beta-blocking agents that decrease portal pressure, are the most common medications used both to prevent a first bleeding episode in clients with known varices and to prevent rebleeding. Beta-blockers should not be used in acute variceal hemorrhage, but they are effective prophylaxis against such an episode. Spironolactone (Aldactone), an aldosterone-blocking agent, is most often the first-line therapy in clients with ascites from cirrhosis. Lactulose (Cephulac) is administered to reduce serum ammonia levels in clients with hepatic encephalopathy.

Which of the following medications is used to decrease portal pressure, halting bleeding of esophageal varices? a) Vasopressin (Pitressin) b) Spironolactone (Aldactone) c) Cimetidine (Tagamet) d) Nitroglycerin

Vasopressin (Pitressin) Vasopressin may be the initial therapy for esophageal varices, because it constricts the splanchnic arterial bed and decreases portal hypertension. Nitroglycerin has been used to prevent the side effects of vasopressin. Aldactone and Tagamet do not decrease portal hypertension.

A client with severe and chronic liver disease is showing manifestations related to inadequate vitamin intake and metabolism. He reports difficulty driving at night because he cannot see well. Which of the following vitamins is most likely deficient for this client? a) Thiamine b) Riboflavin c) Vitamin K d) Vitamin A

Vitamin A Problems common to clients with severe chronic liver dysfunction result from inadequate intake of sufficient vitamins. Vitamin A deficiency results in night blindness and eye and skin changes. Thiamine deficiency can lead to beriberi, polyneuritis, and Wernicke-Korsakoff psychosis. Riboflavin deficiency results in characteristic skin and mucous membrane lesions. Vitamin K deficiency can cause hypoprothrombinemia, characterized by spontaneous bleeding and ecchymoses.

A client with severe and chronic liver disease is showing manifestations related to inadequate vitamin intake and metabolism. He reports difficulty driving at night because he cannot see well. Which of the following vitamins is most likely deficient for this client? a) Vitamin A b) Thiamine c) Riboflavin d) Vitamin K

Vitamin A Problems common to clients with severe chronic liver dysfunction result from inadequate intake of sufficient vitamins. Vitamin A deficiency results in night blindness and eye and skin changes. Thiamine deficiency can lead to beriberi, polyneuritis, and Wernicke-Korsakoff psychosis. Riboflavin deficiency results in characteristic skin and mucous membrane lesions. Vitamin K deficiency can cause hypoprothrombinemia, characterized by spontaneous bleeding and ecchymoses.

NCLEX review question When caring for a patient with a biliary obstruction, the nurse will anticipate administering which vitamin supplements (select all that apply)?

Vitamin A Vitamin D Vitamin E Vitamin K Rationale: Biliary obstruction prevents bile from entering the small intestine and thus prevents the absorption of fat-soluble vitamins. Vitamins A, D, E, and K are all fat-soluble and thus would need to be supplemented in a patient with biliary obstruction.

A client with carcinoma of the head of the pancreas is scheduled for surgery. Which of the following should a nurse administer to the client before surgery? a) Vitamin B b) Vitamin K c) Oral bile acids d) Potassium

Vitamin K Clients with carcinoma of the head of the pancreas typically require vitamin K before surgery to correct a prothrombin deficiency. Potassium would be given only if the client's serum potassium levels were low. Oral bile acids are not prescribed for a client with carcinoma of the head of the pancreas; they are given to dissolve gallstones. Vitamin B has no implications in the surgery.

A client with carcinoma of the head of the pancreas is scheduled for surgery. Which of the following should a nurse administer to the client before surgery? a) Vitamin K b) Oral bile acids c) Potassium d) Vitamin B

Vitamin K Clients with carcinoma of the head of the pancreas typically require vitamin K before surgery to correct a prothrombin deficiency. Potassium would be given only if the client's serum potassium levels were low. Oral bile acids are not prescribed for a client with carcinoma of the head of the pancreas; they are given to dissolve gallstones. Vitamin B has no implications in the surgery.

A patient with severe chronic liver dysfunction comes to the clinic with bleeding of the gums and blood in the stool. What vitamin deficiency does the nurse suspect the patient may be experiencing? a) Vitamin K deficiency b) Riboflavin deficiency c) Vitamin A deficiency d) Folic acid deficiency

Vitamin K deficiency Vitamin A deficiency results in night blindness and eye and skin changes. Thiamine deficiency leads to beriberi, polyneuritis, and Wernicke-Korsakoff psychosis. Riboflavin deficiency results in characteristic skin and mucous membrane lesions. Pyridoxine deficiency results in skin and mucous membrane lesions and neurologic changes. Vitamin C deficiency results in the hemorrhagic lesions of scurvy. Vitamin K deficiency results in hypoprothrombinemia, characterized by spontaneous bleeding and ecchymoses. Folic acid deficiency results in macrocytic anemia.

Which of the following indicates an overdose of lactulose? a) Hypoactive bowel sounds b) Constipation c) Fecal impaction d) Watery diarrhea

Watery diarrhea The patient receiving lactulose is monitored closely for the development of watery diarrheal stool, which indicates a medication overdose.

Which of the following indicates an overdose of lactulose? a) Watery diarrhea b) Fecal impaction c) Constipation d) Hypoactive bowel sounds

Watery diarrhea The patient receiving lactulose is monitored closely for the development of watery diarrheal stool, which indicates a medication overdose.

Which of the following indicates an overdose of lactulose? a) Constipation b) Watery diarrhea c) Hypoactive bowel sounds d) Fecal impaction

Watery diarrhea Explanation: The patient receiving lactulose is monitored closely for the development of watery diarrheal stool, which indicates a medication overdose.

Jaundice

Yellow- or green-tinged body tissues; sclera and skin due to increased serum billirubin levels =Billirubin elevated =Results from impairment of hepatic intake or impaired excretion 4 Types: 1. Hemolytic 2. Hepatocellular 3. Obstructive 4. Hereditary hyperbilirubinemia Hepatocellular and obstructive jaundice are most associated with liver disease

What is hepatic cirrhosis?

a chronic disease characterized by replacement of normal liver tissue with diffuse fibrosis that disrupts the structure and function of the liver

What is hepatic encephalopathy (or portosystemic encephalopathy)?

a life-threatening complication of liver disease that occurs with profound liver failure

What are the most frequently used tests of liver damage?

alanine aminotransferase (ALT), aspartate transferase (AST), and gamma-glutamyl transferase (GGT) (also called gamma-glutamyl transpeptidase [GGTP]).

A client has just been diagnosed with hepatitis A. On assessment, the nurse expects to note: a) anorexia, nausea, and vomiting. b) eructation and constipation. c) abdominal ascites. d) severe abdominal pain radiating to the shoulder.

anorexia, nausea, and vomiting. Early hallmark signs and symptoms of hepatitis A include anorexia, nausea, vomiting, fatigue, and weakness. Abdominal pain may occur but doesn't radiate to the shoulder. Eructation and constipation are common in gallbladder disease, not hepatitis A. Abdominal ascites is a sign of advanced hepatic disease, not an early sign of hepatitis A.

DECOMPENSATED cirrhosis -result from failure of the liver to synthesize proteins, clotting factors, and substances of portal hypertension

ascites sparse body hair jaundice white nails weakness gonadal atrophy muscle wasting wt loss continuous fever clubbing purpura bruising epistaxis hypotension

High risk for what from the surgery of liver transplant

atelectasis and altered ventilation So Nurse watches for respiratory status and pneumonia

What may a pt have temporarily to control hemorrhage and stabilize the patient if have esophageal varices

balloon tamponade therapy

What is hepatocellular jaundice?

caused by the inability of damaged liver cells to clear normal amounts of bilirubin from the blood

A client is admitted for suspected GI disease. Assessment data reveal muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendency. The nurse suspects the client has: a) peptic ulcer disease. b) appendicitis. c) cholelithiasis. d) cirrhosis.

cirrhosis. Muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendencies are all symptoms of cirrhosis. The client may also have mild fever, edema, abdominal pain, and an enlarged liver. Clients with peptic ulcer disease complain of a dull, gnawing epigastric pain that's relieved by eating. Appendicitis is characterized by a periumbilical pain that moves to the right lower quadrant and rebound tenderness. Cholelithiasis is characterized by severe abdominal pain that presents several hours after a large meal.

A client is admitted for suspected GI disease. Assessment data reveal muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendency. The nurse suspects the client has: a) appendicitis. b) peptic ulcer disease. c) cholelithiasis. d) cirrhosis.

cirrhosis. Explanation: Muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendencies are all symptoms of cirrhosis. The client may also have mild fever, edema, abdominal pain, and an enlarged liver. Clients with peptic ulcer disease complain of a dull, gnawing epigastric pain that's relieved by eating. Appendicitis is characterized by a periumbilical pain that moves to the right lower quadrant and rebound tenderness. Cholelithiasis is characterized by severe abdominal pain that presents several hours after a large meal.

What tests should be covered before a liver biopsy

coagulation test PT PTT platlet count

Bleeding of Esophageal Varices

extremely dilated sub-mucosal veins in the lower esophagus Patients with cirrhosis should undergo screening endoscopy every 2 years.

In planning care for a patient with metastatic liver cancer, the nurse should include interventions that

focus primarily on symptomatic and comfort measures Rationale: Nursing intervention for a patient with liver cancer focuses on keeping the patient as comfortable as possible. The prognosis for patients with liver cancer is poor. The cancer grows rapidly, and death may occur within 4 to 7 months as a result of hepatic encephalopathy or massive blood loss from gastrointestinal (GI) bleeding.

COMPENSATED cirrhosis -less severe vague symptoms-

intermittent mild fever vascular spiders palmar erythema(reddened palms) unexplain epistaxis ankle edema abd pain firm enlarged liver splenomegaly

The nursing management of the patient with cholecystitis associated with cholelithiasis is based on the knowledge that

laparoscopic cholecystectomy is the treatment of choice in most patients who are symptomatic Rationale: Laparoscopic cholecystectomy is the treatment of choice for symptomatic cholelithiasis.

The patient with advanced cirrhosis asks why his abdomen is so swollen. The nurse's response is based on the knowledge that a. a lack of clotting factors promotes the collection of blood in the abdominal cavity

portal hypertension and hypoalbuminemia cause a fluid shift into the peritoneal space Rationale: Ascites is the accumulation of serous fluid in the peritoneal or abdominal cavity and is a common manifestation of cirrhosis. With portal hypertension, proteins shift from the blood vessels through the larger pores of the sinusoids (capillaries) into the lymph space. When the lymphatic system is unable to carry off the excess proteins and water, those substances leak through the liver capsule into the peritoneal cavity. Osmotic pressure of the proteins pulls additional fluid into the peritoneal cavity. A second mechanism of ascites formation is hypoalbuminemia, which results from the inability of the liver to synthesize albumin. Hypoalbuminemia results in decreased colloidal oncotic pressure. A third mechanism is hyperaldosteronism, which occurs when aldosterone is not metabolized by damaged hepatocytes. The increased level of aldosterone causes increases in sodium reabsorption by the renal tubules. Sodium retention and an increase in antidiuretic hormone levels cause additional water retention.

Late stages of hepatic cirrhosis how is the liver

portal obstruction and ascites are caused by chronis failure of liver function and partly by obstruction of the portal circulation

A patient with hepatitis A is in the acute phase. The nurse plans care for the patient based on the knowledge that

pruritus is a common problem with jaundice in this phase Rationale: The acute phase of jaundice may be icteric or anicteric. Jaundice results when bilirubin diffuses into the tissues. Pruritus sometimes accompanies jaundice. Pruritus is the result of an accumulation of bile salts beneath the skin.

A patient has been told that she has elevated liver enzymes caused by nonalcoholic fatty liver disease (NAFLD). The nursing teaching plan should include

recommending a heart-healthy diet Rationale: Nonalcoholic fatty liver disease (NAFLD) can progress to liver cirrhosis. There is no definitive treatment, and therapy is directed at reduction of risk factors, which include treatment of diabetes, reduction in body weight, and elimination of harmful medications. For patients who are overweight, weight reduction is important. Weight loss improves insulin sensitivity and reduces liver enzyme levels. No specific dietary therapy is recommended. However, a heart-healthy diet as recommended by the American Heart Association is appropriate.

A patient with pancreatic cancer is admitted to the hospital for evaluation of possible treatment options. The patient asks the nurse to explain the Whipple procedure that the surgeon has described. The explanation includes the information that a Whipple procedure involves

removal of part of the pancreas, part of the stomach, the duodenum, and the gallbladder, with joining of the pancreatic duct, the common bile duct, and the stomach into the jejunum Rationale: The classic operation for pancreatic cancer is a radical pancreaticoduodenectomy, or Whipple procedure. This entails resection of the proximal pancreas (i.e., proximal pancreatectomy), the adjoining duodenum (i.e., duodenectomy), the distal portion of the stomach (i.e., partial gastrectomy), and the distal segment of the common bile duct. The pancreatic duct, common bile duct, and stomach are anastomosed to the jejunum.

Teaching in relation to home management after a laparoscopic cholecystectomy should include

reporting any bile-colored drainage or pus from any incision Rationale: The following discharge instructions are taught to the patient and caregiver after a laparoscopic cholecystectomy: First, remove the bandages on the puncture site the day after surgery and shower. Second, notify the surgeon if any of the following signs and symptoms occur: redness, swelling, bile-colored drainage or pus from any incision; and severe abdominal pain, nausea, vomiting, fever, or chills. Third, gradually resume normal activities. Fourth, return to work within 1 week of surgery. Fifth, resume a usual diet, but a low-fat diet is usually better tolerated for several weeks after surgery.

What is obstructive jaundice?

resulting from extrahepatic obstruction may be caused by occlusion of the bile duct from a gallstone, an inflammatory process, a tumor, or pressure from an enlarged organ (e.g., liver, gallbladder)

A client with acute liver failure exhibits confusion, a declining level of consciousness, and slowed respirations. The nurse finds him very difficult to arouse. The diagnostic information which best explains the client's behavior is: a) elevated blood urea nitrogen and creatinine levels and hyperglycemia. b) subnormal clotting factors and platelet count. c) elevated liver enzymes and low serum protein level. d) subnormal serum glucose and elevated serum ammonia levels.

subnormal serum glucose and elevated serum ammonia levels. In acute liver failure, serum ammonia levels increase because the liver can't adequately detoxify the ammonia produced in the GI tract. In addition, serum glucose levels decline because the liver isn't capable of releasing stored glucose. Elevated serum ammonia and subnormal serum glucose levels depress the level of a client's consciousness. Elevated liver enzymes, low serum protein level, subnormal clotting factors and platelet count, elevated blood urea nitrogen and creatine levels, and hyperglycemia aren't as directly related to the client's level of consciousness.

What is portal hypertension?

the increased pressure throughout the portal venous system that results from obstruction of blood flow into and through the damaged liver

A patient with acute hepatitis B is being discharged in 2 days. In the discharge teaching plan the nurse should include instructions to

use a condom during sexual intercourse Rationale: Hepatitis B virus may be transmitted by mucosal exposure to infected blood, blood products, or other body fluids (e.g., semen, vaginal secretions, saliva). Hepatitis B is a sexually transmitted disease that is acquired through unprotected sex with an infected person. Condom use should be taught to patients to prevent transmission of hepatitis B.

A nurse in the surgical ICU just received a client from recovery following a Whipple procedure. Which of the following nursing diagnoses should the nurse consider when caring for this acutely ill client? Select all that apply. a) Alterations in respiratory function b) Acute pain and discomfort c) Potential for infection d) Fluid volume excess

• Alterations in respiratory function • Acute pain and discomfort • Potential for infection Monitor for potential for infection related to invasive procedure and poor physical condition. Monitor for pain related to extensive surgical incision. Monitor for alterations in respiratory function related to extensive surgical incisions, immobility, and prolonged anesthesia. Client is at risk for fluid volume deficit related to hemorrhage and loss of fluids.

A 67-year-old client is returning for a follow-up appointment to the primary care group where you practice nursing. At his last appointment, he received the diagnosis of portal hypertension. What is the primary aim of portal hypertension treatment? Select all that apply. a) Reduce fluid output. b) Reduce fluid accumulation. c) Reduce venous pressure. d) Reduce blood coagulation.

• Reduce venous pressure. • Reduce fluid accumulation. Methods of treating portal hypertension aim to reduce venous pressure and fluid accumulation.