Exam 4 AH1 Ch61

A client is diagnosed with hepatitis B. Which information does the nurse include in the teaching plan as a priority? a. "Avoid drinking any alcohol until the doctor says you can." b. "You will need aggressive control of your serum lipids." c. "Once your lab work returns to normal, you can donate blood again." d. "Wash your hands well after handling meat and shellfish."

ANS: A Alcohol has a hepatotoxic effect, and clients with any liver disease should not drink it. Serum lipids need control in clients with fatty liver. Once a client has hepatitis B, he or she should not donate blood or organs. Handling contaminated shellfish is a cause of hepatitis A infection.

The nurse monitors for which clinical manifestation in a client with a decreased fecal urobilinogen concentration? a. Clay-colored stools b. Petechiae c. Asterixis d. Melena

ANS: A When fecal urobilinogen levels are decreased as a result of biliary cirrhosis, the stools become lighter or clay-colored.

The nurse correlates which data in the client's history as a predisposing factor for Laënnec's cirrhosis? a. Gallstones b. Alcohol abuse c. Viral hepatitis d. Heart disease

ANS: B Laënnec's cirrhosis, also known as alcoholic cirrhosis, is caused by the toxic effect of alcohol on the liver. The nurse should ask the client about a history of alcohol use. The other factors are not related to this type of cirrhosis.

A client has been diagnosed with hepatitis A. The nurse evaluates that teaching regarding the disease is understood when the client makes which statement? a. "Some medications have been known to induce hepatitis A." b. "I may have been exposed when we ate shrimp last weekend." c. "I may have been infected through a recent blood transfusion." d. "My infection with Epstein-Barr virus can co-infect me with hepatitis A."

ANS: B The route of acquisition of hepatitis A infection is through close personal contact or ingestion of contaminated water or shellfish. The other statements are not accurate.

The nurse monitors for which serologic marker in the client who is a carrier of chronic hepatitis B? a. Anti-hepatitis C virus (HCV) antibodies b. Anti-hepatitis B (HBs) antibodies c. Hepatitis B surface antigen (HBsAg) antibodies d. Hepatitis A virus (HAV) antibodies

ANS: C Persistent presence of the serologic marker HBsAg after 6 months indicates a carrier state or chronic hepatitis. The other markers are not indicative of a carrier state.

A client just returned to the nursing unit after having a trans-jugular intrahepatic portal-systemic shunt (TIPS) procedure. Which clinical finding does the nurse expect to observe in this client? a. Decreased level of consciousness b. Decreased urinary volume c. Increased blood pressure d. Increased abdominal girth

ANS: C With TIPS placement, ascitic fluid is routed into the venous system, resulting in vascular volume expansion. An increase in blood pressure is reflective of increased circulating volume. The client should not have the other findings.

Which laboratory findings does the nurse recognize as potentially causing complications of liver disease? a. Elevated aspartate transaminase (AST) and lactate dehydrogenase (LDH) levels b. Elevated prothrombin time and international normalized ratio (INR) c. Decreased serum albumin and serum globulin levels d. Decreased serum alkaline phosphatase and alanine aminotransferase (ALT) levels

ANS: B Elevated prothrombin time and INR are indications of clotting disturbances and alert the nurse to the increased possibility of hemorrhage. The other values do not necessarily place the client at increased risk for complications.

The nurse is assessing health fair participants for risks for hepatitis. The nurse recognizes which client as being at greatest risk for developing hepatitis B? a. College student who has had several sexual partners b. Woman who takes acetaminophen daily for headaches c. Businessman who travels frequently d. Older woman who has eaten raw shellfish

ANS: A Hepatitis B can be spread through sexual contact, needle sharing, needle sticks, blood transfusions, hemodialysis, acupuncture, and the maternal-fetal route. A person with multiple sexual partners has more opportunities to contract the infection.

A client is receiving lactulose (Heptalac). Which laboratory value leads the nurse to intervene? a. Serum potassium, 2.6 mEq/L b. Serum sodium, 132 mEq/L c. Serum glucose, 108 mg/dL d. Blood urea nitrogen, 16 mg/dL

ANS: A Lactulose can cause the client to have several loose stools daily. The nurse should monitor for hypokalemia and dehydration. This client's potassium level is low, indicating hypokalemia. The serum sodium level is slightly low, but hyponatremia is not a complication of lactulose therapy. The blood glucose is slightly high, but this is unrelated. Blood urea nitrogen (BUN) is normal

A client who had a liver transplant a month ago is admitted with fever and tachycardia. Which medication does the nurse prepare to administer to this client? a. Ceftriaxone (Rocephin) b. Cyclosporine (Sandimmune) c. Azithromycin (Zithromax) d. Ribavirin (Copegus)

ANS: B This client is showing signs of transplant rejection, which is treated with immune suppressive drugs, such as cyclosporine. Ceftriaxone and azithromycin are antibiotics. Ribavirin is used to treat hepatitis C.

A client is admitted with jaundice and suspected hepatitis B. Which intervention does the nurse add to the client's care plan? a. Encourage rest during this period. b. Assist the client with ambulation. c. Place the client on a clear liquid diet. d. Administer PRN prochlorperazine maleate (Compazine).

ANS: A During the icteric phase, the client is encouraged to rest. Rest reduces the metabolic demands of the liver and promotes hepatic cell regeneration. The client may or may not need assistance with ambulation. The diet should be high in carbohydrates and calories for energy; clear liquids may be needed if the client is nauseated. The client may or may not need antiemetics.

The infection control nurse wants to decrease the number of health care professionals who contract viral hepatitis at work. Which actions does the nurse initiate? (Select all that apply.) a. Strengthen policies related to consistent use of Standard Precautions. b. Mandate hepatitis vaccination for workers in high-risk areas. c. Implement a needleless system for IV therapy. d. Reduce the number of "sharps" needed for client care where possible. e. Provide postexposure prophylaxis in a timely manner.

ANS: A, C, D, E Nurses should always use Standard Precautions for client care, and policies should reflect this. Needleless systems and reduction of sharps can help prevent hepatitis. Postexposure prophylaxis should be provided immediately. All health care workers should receive the hepatitis vaccinations that are available.

A client with an esophagogastric tube suddenly experiences acute respiratory distress. Which is the nurse's first action? a. Call the health care provider. b. Cut the balloon ports and remove the tube. c. Place the client upright and apply oxygen. d. Reduce the balloon pressure slightly.

ANS: B When respiratory compromise is noted in a client with an esophagogastric tube, the nurse should immediately cut both ports with a pair of scissors that is kept at the bedside and remove the tube. The nurse would not call the health care provider until the client was out of immediate danger. Once the tube has been removed, the nurse can reposition the client and apply oxygen

The nursing care plan specifies obtaining abdominal girth measurements each shift. The nurse takes the measurement, but when compared with the previous measurement, the new finding is several millimeters off. Which action by the nurse is best? a. Document the finding in the client's chart. b. Look to see when the client last had a dose of diuretic. c. Ensure that the client's abdomen and flanks are marked with pen. d. Obtain the measurement while the client sits upright.

ANS: C Abdominal girth is measured at the end of exhalation, at the level of the umbilicus, while the client lies flat. To ensure that measurements are taken in the same place each time, the nurse should mark the client's abdomen and flanks with pen. Findings do need to be documented, but this is not the best action when such inconsistency is noted between measurements. Use of a diuretic might decrease ascites, but the best action remains ensuring that measurements are taken in a consistent manner.

A client has cirrhosis and has developed ascites and edema. Which laboratory value does the nurse correlate with this condition? a. Blood glucose, 120 mg/dL b. Serum sodium, 135 mEq/L c. Serum albumin, 2.1 g/dL d. Blood urea nitrogen, 18 mg/dL

ANS: C Ascites occurs as a result of the inability of the liver to synthesize albumin. Loss of albumin leads to edema. This client's albumin level is low, which correlates with the condition. Sodium and blood urea nitrogen (BUN) levels are normal. The glucose level is slightly high, but this is not directly related to edema.

The nurse is assessing a client with mild liver disease. Which assessment does the nurse perform to detect the presence of ascites in this client? a. Measure lower extremities to assess for edema. b. Inspect and palpate the abdomen for distention. c. Palpate the abdomen in assessing for a fluid wave. d. Percuss the liver while listening for dullness.

ANS: C Mild ascites may be difficult to detect and can be assessed by percussion. Shifting dullness and a fluid wave alert the nurse to the presence of ascites. The other findings are inconsistent with ascites.

Which statement made by a client traveling to a nonindustrialized country indicates the need for further teaching regarding the prevention of viral hepatitis? a. "I will drink bottled water while I'm gone." b. "I will not share my drinking glass." c. "I should eat plenty of fresh fruits and vegetables." d. "I will use careful handwashing."

ANS: C The client should be advised to avoid fresh, raw fruits and vegetables because they can be contaminated by tap water. Drinking bottled water, not sharing glasses (or eating utensils), and careful handwashing are all good ways to prevent illness.

The nurse recognizes which client as being at greatest risk for the development of carcinoma of the liver? a. Middle-aged client with a history of diabetes mellitus b. Young adult client with a history of blunt liver trauma c. Older adult client with a history of cirrhosis d. Older adult client with malnutrition

ANS: C The risk of contracting a primary carcinoma of the liver is higher in clients with cirrhosis from any cause. The other factors do not increase a person's risk for developing liver cancer.

The client with end-stage cirrhosis presents with GI bleeding, combativeness, and confusion. The nurse anticipates an order to administer which medication? a. Omeprazole (Prilosec) b. Somatostatin (Octreotide) c. Propranolol (Inderal) d. Lactulose (Heptalac)

ANS: D Lactulose helps rid the body of ammonia. Excess ammonia leads to encephalopathy, which this client is manifesting. Omeprazole is a proton pump inhibitor used for reflux and ulcer disease. Somatostatin is given to treat bleeding from esophageal varices. Inderal is given to prevent bleeding from esophageal varices.

A client is hemorrhaging from bleeding esophageal varices and has an esophagogastric tube. Which nursing intervention is the priority? a. Keep the client sedated to prevent tube dislodgement. b. Maintain balloon pressure at between 15 and 20 mm Hg. c. Irrigate the gastric lumen with normal saline. d. Maintain the client's airway.

ANS: D Maintaining airway patency is the primary nursing intervention for this client. The nurse suctions oral secretions to prevent aspiration and occlusion of the airway. The client usually is intubated and mechanically ventilated during this procedure. The other interventions are not a priority over airway.

A client is in the emergency department after a motor vehicle crash. In assessing the client, which clinical sign alerts the nurse to the presence of possible liver trauma? a. Abdominal pain referred to the right shoulder b. Left upper quadrant abdominal pain and swelling c. Abdominal pain referred to the spine and legs d. Abdominal pain with accompanying rebound tenderness

ANS: A One of the key features of liver trauma is abdominal pain that is increased on deep breathing and is referred to the right shoulder. The liver is on the right, not the left, side of the body. Liver injury does not produce pain that radiates to the spine and down the legs. Rebound tenderness can indicate peritonitis.

A client had a paracentesis 1 hour ago. Which assessment finding requires action by the nurse? a. Urine output of 20 mL/hr b. Systolic blood pressure increase of 10 mm Hg c. Respiratory rate drop from 18 to 14 d. A 3-pound drop in weight

ANS: A Rapid removal of ascitic fluid causes decreased abdominal pressure, which can contribute to hypovolemia. This can be manifested by a decrease in urine output to below 30 mL/hr. The nurse would expect the client's weight to drop as fluid is removed. A decrease in respiratory rate indicates that breathing has been made easier by the procedure. A slight increase in systolic blood pressure is insignificant.

A client is refusing to take lactulose (Heptalac) because of diarrhea. Which is the nurse's best response to this client? a. "Diarrhea is expected; that's how your body gets rid of ammonia." b. "You may take Kaopectate liquid daily for loose stools." c. "Do not take any more of the medication until your stools firm up." d. "We will need to send a stool specimen to the laboratory."

ANS: A The purpose of administering lactulose to this client is to help ammonia leave the circulatory system through the colon. Lactulose draws water into the bowel with its high osmotic gradient, thereby producing a laxative effect and subsequently evacuating ammonia from the bowel. The client must understand that this is an expected and therapeutic effect for him or her to remain compliant. The other statements are inaccurate.

The nurse reviews laboratory results for a client with cirrhosis and finds the following: hematocrit, 72%; blood urea nitrogen (BUN), 42 mg/dL; and sodium, 166 mEq/L. Which action by the nurse is most appropriate? a. Check the client's blood pressure and pulse. b. Increase the client's oral fluid intake. c. Call the health care provider. d. Document the results in the chart.

ANS: A These values are all elevated, which can occur in hypovolemia. The nurse should assess the client for signs of hypovolemia, including tachycardia and hypotension. The nurse should consult with the provider about the client's fluid status before increasing oral fluids but after obtaining vital signs. Documentation should occur after all assessments have been completed and must include actions taken.

A thin, cachectic-appearing client has hepatic portal-systemic encephalopathy (PSE). The family expresses distress that the client is receiving so little protein in the diet. Which explanation by the nurse is most appropriate? a. "A low-protein diet will help the liver rest and will restore liver function." b. "Less protein in the diet will help with the confusion." c. "Despite looking so thin, protein will not help with weight gain." d. "Less protein is needed to prevent fluid from leaking into the abdomen."

ANS: B A low-protein diet is ordered when serum ammonia levels increase and/or the client shows signs of PSE. A low-protein diet helps reduce excessive breakdown of protein into ammonia by intestinal bacteria. Encephalopathy is caused by excess ammonia. The other statements are not correct.

A client has cirrhosis. Which nursing intervention would be most effective in controlling ascites? a. Monitoring intake and output b. Providing a low-sodium diet c. Increasing oral fluid intake d. Weighing the client daily

ANS: B A low-sodium diet is one means of controlling abdominal fluid collection. Monitoring intake and output does not control fluid accumulation, nor does weighing the client. These interventions merely assess or monitor the situation. Increasing fluid intake would not be helpful.

A client is receiving an infusion of vasopressin (Pitressin) to treat bleeding esophageal varices. Which client complaint indicates to the nurse that a serious adverse effect of the drug may be occurring? a. Acute nausea and vomiting b. A pounding frontal headache c. Vertigo and syncope d. Midsternal chest pain

ANS: D Midsternal chest pain is indicative of acute angina or myocardial infarction, which can be precipitated by vasopressin. The other side effects do not necessarily indicate that a serious side effect has occurred.

A client is bleeding from esophageal varices. The health care provider is arranging sclerotherapy for the client. Before the client goes to interventional radiology, the nurse prepares to administer which medication? a. Terlipressin (Glypressin) b. Enoxaparin (Lovenox) c. Lactulose (Heptalac) d. Spironolactone (Aldactone)

ANS: A Terlipressin is a vasoactive drug that works by reducing portal pressure, which decreases bleeding. These drugs are often given in conjunction with sclerotherapies. Enoxaparin is a low-molecular-weight heparin, which would be contraindicated in a client with bleeding problems. Lactulose helps rid the body of ammonia. Aldactone is a diuretic.

A client admitted with hepatopulmonary syndrome is experiencing dyspnea but does not want oxygen increased because the client's nose keeps bleeding from it. The client becomes agitated when discussing this with the nurse. The client's oxygen saturation is 92%. What intervention by the nurse is best? a. Instruct the client to sit in as upright a position as possible. b. Tell the client that humidity can be added, but that the oxygen must be worn. c. Document the client's refusal in the chart, and call the health care provider. d. Call the health care provider to request an extra dose of the client's diuretic.

ANS: A The client with hepatopulmonary syndrome is often dyspneic. Because the oxygen saturation is not significantly low, the nurse should first allow the client to sit upright to see if that helps. If the client remains dyspneic, or if the oxygen saturation drops further, the nurse should investigate adding humidity to the oxygen and seeing whether the client will tolerate that. The other two options may be beneficial, but they are not the best choices. If the client is comfortable, his or her agitation will decrease; this will improve respiratory status.

A client with hepatitis C is being treated with ribavirin (Copegus). What nursing action takes priority? a. Educating the client on ways to remain complaint with the drug regimen b. Teaching the client that transient muscle aching is a common side effect c. Ensuring that the client returns to the clinic each week for follow-up care d. Showing the client how to take and record a radial pulse for 1 minute

ANS: A Treatment with ribavirin takes up to 48 weeks, making compliance a serious issue. The nurse should work with the client on a strategy to remain compliant for this length of time. The other actions are not warranted.

Which statement by a client with alcohol-induced cirrhosis indicates the need for further teaching? a. "I cannot drink any alcohol at all anymore." b. "I need to avoid protein in my diet." c. "I should not take over-the-counter medications." d. "I should eat small, frequent, balanced meals."

ANS: B Based on the degree of liver involvement and decreased function, protein intake may have to be decreased. However, some protein is necessary for the synthesis of albumin and normal healing. The other statements indicate accurate understanding of self-care measures for this client.

The nurse is reviewing a client's history. Which statement by the client indicates a need for health teaching? a. "I drink 1 to 2 glasses of red wine a week." b. "Because of my arthritis, I take a lot of Tylenol." c. "One of my cousins died of liver cancer 10 years ago." d. "I got a hepatitis vaccine before traveling last year."

ANS: B Acetaminophen (Tylenol) can cause liver damage if taken in large amounts. Clients should be taught not to exceed 4000 mg/day of acetaminophen. The nurse should teach the client about this limitation and should explore other drug options with the client to manage his or her arthritis pain. The other statements do not necessarily require health teaching by the nurse.

A client just had a paracentesis. Which nursing intervention is a priority for this client? a. Monitor urine output. b. Maintain bedrest as per protocol. c. Position the client flat in bed. d. Secure the trocar to the abdomen with tape.

ANS: B After a paracentesis, the client should remain on bedrest with the head of the bed elevated. A client with liver dysfunction is at risk for bleeding, and bedrest decreases this risk. Clients with liver dysfunction must have intake and output monitored, but this is not the priority after this procedure. A drain may be placed for short-term therapy in some clients.

A client is admitted with cirrhosis and hepatopulmonary syndrome. Which clinical manifestation does the nurse monitor for progression or resolution of this problem? a. Right upper quadrant pain b. Crackles on auscultation c. Skin and scleral jaundice d. Nausea and vomiting

ANS: B An increase in intra-abdominal pressure from ascites can lead to hepatopulmonary syndrome. This is manifested by dyspnea and crackles on auscultation. The other symptoms are consistent with liver disease but are not specific to respiratory involvement.

The nursing assistant is helping a client who has advanced cirrhosis with a bath and other hygiene. Which action by the assistant requires intervention by the registered nurse? a. Helping the client apply lotion to dry skin areas b. Giving the client a basin of warm water and soap to use c. Providing a soft toothbrush for oral care d. Helping the client keep nails trimmed short

ANS: B Clients with advanced cirrhosis often have pruritus. These clients should use cool, not warm, water on their skin, and should not use excessive amounts of soap. The other actions are appropriate.

The nurse recognizes that fetor hepaticus is consistent with which assessment finding? a. Purpuric lesions on the extremities b. A fruity or musty breath odor c. Warm and bright red palms d. Jaundice of the sclera

ANS: B Fetor hepaticus is a distinctive breath odor that presents with chronic liver disease. The client's breath has a fruity or musty odor. The other statements do not apply to fetor hepaticus.

A client who underwent liver transplantation 2 weeks ago reports a temperature of 101° F (38.3° C) and right flank pain. Which is the nurse's best response? a. "The anti-rejection drugs you are taking made you susceptible to infection." b. "You should go to the hospital immediately to have your new liver checked out." c. "You should take an additional dose of cyclosporine today." d. "Take acetaminophen (Tylenol) every 4 hours until you feel better."

ANS: B Fever, right quadrant or flank pain, and jaundice are signs of liver transplant rejection; the client should be admitted to the hospital as soon as possible for intervention. The other statements are not appropriate.

The nurse is assessing a client for asterixis. Which instruction to the client is most appropriate? a. "Close your eyes and take turns touching your nose with your fingers." b. "Sit on the edge of the bed and hold your legs straight out for 30 seconds." c. "Extend your arm, flex your wrist upward, and extend your fingers." d. "Say 'EEEEE' while I listen to your lungs in the back on both sides."

ANS: C Asterixis, or liver flap, is a tremor in the client's wrists and fingers. The correct technique for assessing the presence of asterixis is to extend the arm, dorsiflex the wrist, and extend the fingers. The other directions are not related to asterixis.

The nurse is meeting a client post-liver transplantation for the first time and notices a tremor as they shake hands. The client states this has not happened before. Which action by the nurse is most appropriate? a. Conduct a thorough assessment, then notify the surgeon of the findings. b. Review today's laboratory work, including liver function studies. c. Assess the client's vital signs, and offer acetaminophen if the client is febrile. d. Perform an assessment of the client's gross and fine motor skills.

ANS: A The client may be exhibiting asterixis. Any sign of deteriorating neurologic function could indicate that the new liver is not working properly. The surgeon must be notified, but first the nurse should conduct a thorough assessment of the client. Reviewing today's laboratory work is important, but this is not the best option because the client's liver could have deteriorated after the laboratory work was drawn. Clients with any type of liver problem should not take acetaminophen. Assessing the client's fine and gross motor skills is part of an assessment.

A client is scheduled for a paracentesis. Which activity does the nurse delegate to the unlicensed assistive personnel? a. Have the client sign the informed consent form. b. Assist the client to void before the procedure. c. Help the client lie flat in bed, on the right side. d. Get the client into a chair after the procedure.

ANS: B For safety, the client should void just before a paracentesis. The nurse or the provider should have the client sign the consent form. The proper position for a paracentesis is sitting upright in bed or, alternatively, sitting on the side of the bed and leaning over the bedside table. The client will be on bedrest after the procedure

A client has liver cancer. Which statement by the client about treatment options demonstrates an accurate understanding? a. "I guess it's a good thing that surgery is usually so successful." b. "I choose hepatic arterial infusion of chemo to limit side effects." c. "Because I have only local metastases, I am thinking about transplant." d. "This disease is so rare, no wonder no good treatments are available."

ANS: B Hepatic arterial chemotherapy infusion allows chemotherapeutic agents to be delivered directly into the liver tumor, limiting systemic side effects. Surgery is not usually successful because the cancer is frequently widespread when detected. Transplant is considered only for primary liver tumors that have not metastasized. The lack of successful treatments is due not to rarity, but rather to the fact that generally the cancer has already spread when found.

A client is in the emergency department after a motor vehicle crash, and the nurse notices a "steering wheel mark" across the client's chest. Which action by the nurse is most appropriate? a. Ask the client where in the car he or she was during the crash. b. Assess the client by gently palpating the abdomen for tenderness. c. Notify the laboratory to come draw blood for blood type and crossmatch. d. Place the client on the stretcher in reverse Trendelenburg position.

ANS: B The liver is often injured by a steering wheel in a motor vehicle crash. Because the client's chest was marked by the steering wheel, the nurse should perform an abdominal assessment. Assessing the client's position in the crash is not needed because of the steering wheel imprint. The client may or may not need a blood transfusion. The client does not need to be in reverse Trendelenburg position.

A client is admitted with end-stage cirrhosis and severe vomiting. Which problem should the nurse monitor the client most carefully for? a. Intrahepatic bile stasis b. Bleeding esophageal varices c. Decreased excretion of bilirubin d. Accumulation of ascites in the abdomen

ANS: B The portal hypertension that accompanies end-stage cirrhosis predisposes the client to esophageal varices. These varices can rupture from increased pressure in the esophagus caused by coughing or vomiting. Bleeding varices can be life threatening. None of the other assessments take priority over monitoring for bleeding from esophageal varices.

Which laboratory data does the nurse correlate with advanced disease in a client with cirrhosis? a. Elevated serum protein level b. Elevated serum ammonia level c. Decreased serum ammonia level d. Decreased lactate dehydrogenase level

ANS: B The serum ammonia level is elevated in the presence of advanced disease because conversion of ammonia to urea for excretion is decreased. The other laboratory values do not correlate with advanced disease.

A client with severe esophageal varices is scheduled for trans-jugular intrahepatic portal-systemic shunt (TIPS) insertion. The nurse determines that teaching has been effective when the client makes which statement? a. "I will be discharged home after I wake up completely." b. "The procedure may be painful because I get only light sedation." c. "My liver will function normally within 8 hours of placement of the shunt." d. "I will be monitored closely for a while after the procedure is over."

ANS: D This procedure is performed in the radiology department under heavy sedation or general anesthesia. The client will be monitored as would any other postoperative client. The other statements are inaccurate.