리피컷 간췌장

"A client with cirrhosis is receiving lactulose. During the assessment, the nurse notes increased confusion and asterixis. The nurse should: 1.Assess for gastrointestinal (GI) bleeding. 2.Hold the lactulose. 3.Increase protein in the diet. 4.Monitor serum bilirubin levels."

1 "Clients with cirrhosis can develop hepatic encephalopathy caused by increased ammonia levels. Asterixis, a flapping tremor, is a characteristic symptom of increased ammonia levels. Bacterial action on increased protein in the bowel will increase ammonia levels and cause the encephalopathy to worsen. GI bleeding and protein consumed in the diet increase protein in the intestine and can elevate ammonia levels. Lactulose is given to reduce ammonia formation in the intestine and should not be held since neurological symptoms are worsening. Bilirubin is associated with jaundice."

"Which of the following dietary instructions would be appropriate for the nurse to give a client who is recovering from acute pancreatitis? 1.Avoid crash dieting. 2.Restrict carbohydrate intake. 3.Eat six small meals a day. 4.Decrease sodium in the diet."

1 "Crash dieting or bingeing may cause an acute attack of pancreatitis and should be avoided. Carbohydrate intake should be increased because carbohydrates are less stimulating to the pancreas. There is no need to maintain a dietary pattern of six meals a day; the client can eat whenever desired. There is no need to place the client on a sodium-restricted diet because pancreatitis does not promote fluid retention."

"A client with cholecystitis continues to have severe right upper quadrant pain. The nurse obtains the following vital signs: temperature 38.4°C; pulse 114; respirations 22; blood pressure 142/90. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse recommends to the primary care provider for the client to receive: 1.Hydromorphone IV. 2.Diltiazem PO. 3.Meperidine IM. 4.Promethazine IM."

1 "Hydromorphone should be considered for pain management. It should be administered intravenously for rapid action to address the severe pain the client is experiencing. Intramuscular injections are painful and slower acting. Since meperidine's toxic metabolite can cause seizures, it is no longer the treatment choice for pain. Diltiazem, a calcium channel blocker, is not indicated. Elevation of heart rate and blood pressure is likely due to pain and fever. Promethazine is used to treat nausea."

"The client with cirrhosis receives 100 mL of 25% serum albumin IV. Which finding would best indicate that the albumin is having its desired effect? 1.Increased urine output. 2.Increased serum albumin level. 3.Decreased anorexia. 4.Increased ease of breathing."

1 "Normal serum albumin is administered to reduce ascites. Hypoalbuminemia, a mechanism underlying ascites formation, results in decreased colloid osmotic pressure. Administering serum albumin increases the plasma colloid osmotic pressure, which causes fluid to flow from the tissue space into the plasma. Increased urine output is the best indication that the albumin is having the desired effect. An increased serum albumin level and increased ease of breathing may indirectly imply that the administration of albumin is effective in relieving the ascites. However, it is not as direct an indicator as increased urine output. Anorexia is not affected by the administration of albumin."

"A client is receiving Propantheline bromide in the management of acute pancreatitis. Which of the following would indicate that the nurse should discuss withholding the medication with the physician? 1.Absent bowel sounds. 2.Increased urine output. 3.Diarrhea. 4.Decreased heart rate."

1 "Propantheline is an anticholinergic, antispasmodic medication that decreases vagal stimulation and pancreatic secretions. It is contraindicated in paralytic ileus; therefore, the nurse should be concerned with the absent bowel sounds. Side effects are urinary retention, constipation, and tachycardia."

"The nurse is teaching a client with viral hepatitis about preventing transmission of the disease. The nurse should focus teaching on: 1.Proper food handling. 2.Insulin syringe disposal. 3.Alpha-interferon. 4.Use of condoms."

1 "The main route of transmission for hepatitis A is the oral-fecal route, rarely parenteral. Good handwashing before eating or preparing food (AF1). Percutaneous transmission is seen with hepatitis B, C, and D. Alpha-interferon is used for treatment of chronic hepatitis B and C."

4.A client's stools are light gray in color. The nurse should assess the client further for which of the following? Select all that apply. 1.Intolerance to fatty foods. 2.Fever. 3.Jaundice. 4.Respiratory distress. 5.Pain at McBurney's point. 6.Peptic ulcer disease."

123 "Bile is created in the liver, stored in the gallbladder, and released into the duodenum, giving stool its brown color. A bile duct obstruction can cause pale-colored stools. Other symptoms associated with cholelithiasis are right upper quadrant tenderness, fever from inflammation or infection, jaundice from elevated serum bilirubin levels, and nausea or right upper quadrant pain after a fatty meal. Pain at McBurney's point lies between the umbilicus and right iliac crest and is associated with appendicitis. A bleeding ulcer produces black, tarry stools. Respiratory distress is not a symptom of cholelithiasis."

"A nurse is developing a care plan for a client with hepatic encephalopathy. Which of the following are goals for the care for this client? Select all that apply. 1.Preventing constipation. 2.Administering lactulose to reduce blood ammonia levels. 3.Monitoring coordination while walking. 4.Checking the pupil reaction. 5.Providing food and fluids high in carbohydrate. 6.Encouraging physical activity."

12345 "Constipation leads to increased ammonia production. Lactulose is a hyperosmotic laxative that reduces blood ammonia by acidifying the colon contents, which retards diffusion of nonionic ammonia from the colon to the blood while promoting its migration from the blood to the colon. Hepatic encephalopathy is considered a toxic or metabolic condition that causes cerebral edema; it affects a person's coordination and pupil reaction to light and accommodation. Food and fluids high in carbohydrates should be given because the liver is not synthesizing and storing glucose. Because exercise produces ammonia as a byproduct of metabolism, physical activity should be limited, not encouraged."

"After a client who has had a laparoscopic cholecystectomy receives discharge instructions, which of the following client statements would indicate that the teaching has been successful? Select all that apply. 1."I can resume my normal diet when I want." 2."I need to avoid driving for about 4 weeks." 3."I may experience some pain in my right shoulder." 4."I should spend 2 to 3 days in bed before resuming activity." 5."I can take a shower 2 days later."

135 "Following a laparoscopic cholecystectomy, the client can resume a normal diet as tolerated. The client may experience right shoulder pain from the gas that was used to inflate the abdomen during surgery. The puncture site should be cleansed daily with mild soap and water; if a band aid was applied after surgery it can be patted dry or removed and replaced. Driving can usually be resumed in 3 to 4 days following surgery, and there is no need for the client to maintain bed rest in the days following surgery. Light exercise such as walking can be resumed immediately."

"When providing care for a client hospitalized with acute pancreatitis who has acute abdominal pain, which of the following nursing interventions would be most appropriate for this client? Select all that apply. 1.Placing the client in a side-lying position. 2.Administering morphine sulfate for pain as needed. 3.Maintaining the client on a high-calorie, high-protein diet. 4.Monitoring the client's respiratory status. 5.Obtaining daily weights."

145 "The client with acute pancreatitis usually experiences acute abdominal pain. Placing the client in a side-lying position relieves the tension on the abdominal area and promotes comfort. A semi-Fowler's position is also appropriate. The nurse should also monitor the client's respiratory status because clients with pancreatitis are prone to develop respiratory complications. Daily weights are obtained to monitor the client's nutritional and fluid volume status. While the client will likely need opioid analgesics to treat the pain, morphine sulfate is not appropriate as it stimulates spasm of the sphincter of Oddi, thus increasing the client's discomfort. During the acute phase of the illness while the client is experiencing pain, the pancreas is rested by withholding food and drink. When the diet is reintroduced, it is a high-carbohydrate, low-fat, bland diet."

"A 40-year-old client is admitted to the hospital with a diagnosis of acute cholecystitis. The nurse should contact the physician to question which of the following prescriptions? 1.IV fluid therapy of normal saline solution to be infused at 100 mL/h until further prescriptions. 2.Administer morphine sulfate 10 mg IM every 4 hours as needed for severe abdominal pain. 3.Nothing by mouth (NPO) until further prescriptions. 4.Insert a nasogastric tube and connect to low intermittent suction.

2 "A nurse should question the prescription for morphine sulfate because it is believed to cause biliary spasm. Thus, the preferred opioid analgesic to treat cholecystitis is meperidine (Demerol). Elderly clients should not be given meperidine because of the risk of acute confusion and seizures in this population. An alternative pain medication will be necessary. IV fluid therapy is used to maintain fluid and electrolyte balance that may result from NPO status and gastric suctioning. NPO status and gastric decompression prevent further gallbladder stimulation."

"The nurse should teach the client with viral hepatitis to: 1.Limit caloric intake and reduce weight. 2.Increase carbohydrates and protein in the diet. 3.Avoid contact with others and sleep in a separate room. 4.Intensify routine exercise and increase strength."

2 "Low-fat, high-protein, high-carbohydrate diet is encouraged for a client with hepatitis to promote liver rejuvenation. Nutrition intake is important because clients may be anorexic and experience weight loss. Activity should be modified and adequate rest obtained to promote recovery. Social isolation should be avoided and education on preventing transmission should be provided; the client does not need to sleep in a separate room."

"The nurse measures the amount of bile drainage from a t-tube and records it by which one of the following methods? 1.Adding it to the client's urine output. 2.Charting it separately on the output record. 3.Adding it to the amount of wound drainage. 4.Subtracting it from the total intake for each day."

2 "T-tube bile drainage is recorded separately on the output record. Adding the t-tube drainage to the urine output or wound drainage makes it difficult to accurately determine the amounts of bile, urine, or drainage. The client's total intake will be incorrect if drainage is subtracted from it."

"Which of the following expected outcomes would be appropriate for a client with viral hepatitis? The client will: 1.Demonstrate a decrease in fluid retention related to ascites. 2.Verbalize the importance of reporting bleeding gums or bloody stools. 3.Limit use of alcohol to two to three drinks per week. 4.Restrict activity to within the home to prevent disease transmission"

2 "The client should be able to verbalize the importance of reporting any bleeding tendencies that could be the result of a prolonged prothrombin time. Ascites is not typically a clinical manifestation of hepatitis; it is associated with cirrhosis. Alcohol use should be eliminated for at least 1 year after the diagnosis of hepatitis to allow the liver time to fully recover. There is no need for a client to be restricted to the home because hepatitis is not spread through casual contact between individuals."

"A client is to be discharged with a prescription for lactulose. The nurse teaches the client and the client's spouse how to administer this medication. Which of the following statements would indicate that the client has understood the information? 1."I'll take it with Maalox." 2."I'll mix it with apple juice." 3."I'll take it with a laxative." 4."I'll mix the crushed tablets in some gelatin."

2 "The taste of lactulose is a problem for some clients. Mixing it with fruit juice, water, or milk can make it more palatable. Lactulose should not be given with antacids, which may inhibit its action. Lactulose should not be taken with a laxative because diarrhea is an adverse effect of the drug. Lactulose comes in the form of syrup for oral or rectal administration."

"A client with jaundice has pruritus and areas of irritation from scratching. What measures can the nurse discuss to prevent skin breakdown? Select all that apply. 1.Avoid lotions containing calamine. 2.Add baking soda to the water in a tub bath. 3.Keep nails short and clean. 4.Rub the skin when it itches with knuckles instead of nails. 5.Massage skin with alcohol. 6.Increase sodium intake in diet."

234 \"Baking soda baths can decrease pruritis. Keeping nails short and rubbing with knuckles can decrease breakdown when scratching cannot be resisted, such as during sleep. Calamine lotions help relieve itching. Alcohol will increase skin dryness. Sodium in the diet will increase edema and weaken skin integrity."

"A client with chronic hepatitis C is experiencing nausea, anorexia, and fatigue. During the health history the client states that he is homosexual, drinks one to two glasses of wine with dinner, is taking St. John's Wort for a "bit of depression," and takes Tylenol for frequent headaches. The nurse should do which of the following? Select all that apply. 1.Instruct the client that the wine with meals can be beneficial for cardiovascular health. 2.Instruct the client to ask the health care provider about taking any other medications as they may interact with medications the client is currently taking. 3.Instruct the client to increase the protein in his diet and eat less frequently. 4.Advise the client of the need for additional testing for HIV. 5.Encourage the client to obtain sufficient rest."

245 "Clients with chronic hepatitis C should abstain from alcohol as it can speed cirrhosis and end-stage liver disease. Clients should also check with their health care providers before taking any nonprescription or prescription medications, or herbal supplements. It is also important that clients who are infected with HCV be tested for HIV, as clients who have both HIV and HCV have a more rapid progression of liver disease than those who have HCV alone. Clients with HCV and nausea should be instructed to eat four to five times a day to help reduce anorexia and nausea. The client should obtain sufficient rest to manage the fatigue."

"A client has an open cholecystectomy with bile duct exploration. Following surgery, the client has a t-tube. To evaluate the effectiveness of the t-tube, the nurse should: 1.Irrigate the tube with 20 mL of normal saline every 4 hours. 2.Unclamp the t-tube and empty the contents every day. 3.Assess the color and amount of drainage every shift. 4.Monitor the multiple incision sites for bile drainage."

3 "A t-tube is inserted in the common bile duct to maintain patency until edema from the duct exploration subsides. The bile color should be gold to dark green and the amount of drainage should be closely monitored to ensure tube patency. Irrigation is not routinely done, unless prescribed using a smaller volume of fluid. The t-tube is not clamped in the early postop period to allow for continuous drainage. An open cholecystectomy has one right subcostal incision, whereas a laparoscopic cholecystectomy has multiple small incisions."

"A client is admitted with acute necrotizing pancreatitis. Lab results have been obtained, and a peripheral IV has been inserted. Which of the following prescriptions from a health care provider should the nurse question? 1.Infuse a 500-mL normal saline bolus. 2.Calcium gluconate 90 mg in 100 mL NS. 3.Total parenteral nutrition (TPN) at 72 mL/h. 4.Placement of a Foley catheter.

3 "Clients with acute necrotizing pancreatitis should remain nothing by mouth (NPO) with early enteral feeding via the jejunum to maintain bowel integrity and immune function. TPN is considered if enteral feedings are contraindicated. Access is also needed for TPN, preferably via a central line. Hemodynamic instability can result from fluid volume loss and bleeding and requires fluid and electrolyte replacement. Fat necrosis occurring with acute pancreatitis can cause hypocalcemia requiring calcium replacement. A Foley catheter provides accurate output assessment to monitor for prerenal acute renal failure that can occur from hypovolemia."

"The nurse is providing discharge instructions for a client with cirrhosis. Which of the following statements best indicates that the client has understood the teaching? 1."I should eat a high-protein, high-carbohydrate diet to provide energy." 2."It is safer for me to take acetaminophen (Tylenol) for pain instead of aspirin." 3."I should avoid constipation to decrease chances of bleeding." 4."If I get enough rest and follow my diet, it is possible for my cirrhosis to be cured."

3 "Clients with cirrhosis should be instructed to avoid constipation and straining at stool to prevent hemorrhage. The client with cirrhosis has bleeding tendencies because of the liver's inability to produce clotting factors. A low-protein and high-carbohydrate diet is recommended. Clients with cirrhosis should not take acetaminophen (Tylenol), which is potentially hepatotoxic. Aspirin also should be avoided if esophageal varices are present. Cirrhosis is a chronic disease"

"A client with ascites and peripheral edema is at risk for impaired skin integrity. To prevent skin breakdown, the nurse should: 1.Institute range-of-motion (ROM) exercise every 4 hours. 2.Massage the abdomen once a shift." 3.Use an alternating air pressure mattress. 4.Elevate the lower extremities.

3 "Edematous tissue is easily traumatized and must receive meticulous care. An alternating air pressure mattress will help decrease pressure on the edematous tissue. ROM exercises are important to maintain joint function, but they do not necessarily prevent skin breakdown. When abdominal skin is stretched taut due to ascites, it must be cleaned very carefully. The abdomen should not be massaged. Elevation of the lower extremities promotes venous return and decreases swelling."

"The nurse is assessing a client with cirrhosis who has developed hepatic encephalopathy. The nurse should notify the physician of a decrease in which serum lab value that is a potential precipitating factor for hepatic encephalopathy? 1.Aldosterone. 2.Creatinine. 3.Potassium. 4.Protein."

3 "Hypokalemia is a precipitating factor in hepatic encephalopathy. A decrease in creatinine results from muscle atrophy; an increase in creatinine would indicate renal insufficiency. With liver dysfunction, increased aldosterone levels are seen. A decrease in serum protein will decrease colloid osmotic pressure and promote edema."

"A client undergoes a laparoscopic cholecystectomy. Which of the following dietary instructions should the nurse give the client immediately after surgery? 1."You cannot eat or drink anything for 24 hours." 2."You may resume your normal diet the day after your surgery." 3."Drink liquids today and eat lightly for a few days." 4."You can progress from a liquid to a bland diet as tolerated."

3 "Immediately after surgery, the client will drink liquids. A light diet can be resumed the day after surgery. There is no need for the client to remain on nothing-by-mouth status after surgery because peristaltic bowel activity should not be affected. The client will probably not be able to tolerate a full meal comfortably the day after surgery. There is no need for the client to stay on a bland diet after a laparoscopic cholecystectomy. The client should, however, avoid excessive fats."

"Interferon alfa-2b (Intron A) has been prescribed to treat a client with chronic hepatitis B. The nurse should assess the client for which of the following adverse effects? 1.Retinopathy. 2.Constipation. 3.Flulike symptoms. 4.Hypoglycemia."

3 "Interferon alfa-2b (Intron A) most commonly causes flulike adverse effects, such as myalgia, arthralgia, headache, nausea, fever, and fatigue. Retinopathy is a potential adverse effect, but not a common one. Diarrhea may develop as an adverse effect. Clients are advised to administer the drug at bedtime and get adequate rest. Medications may be prescribed to treat the symptoms. The drug may also cause hematologic changes; therefore, laboratory tests such as a complete blood count and differential should be conducted monthly during drug therapy. Blood glucose laboratory values should be monitored for the development of hyperglycemia."

A client is admitted to the hospital with a diagnosis of cholecystitis from cholelithiasis. The client has severe abdominal pain and nausea, and has vomited several times. Based on these data, which nursing action would have the highest priority for intervention at this time? 1.Manage anxiety. 2.Restore fluid loss. 3.Manage the pain. 4.Replace nutritional loss.

3 "The priority for nursing care at this time is to decrease the client's severe abdominal pain. The pain, which is frequently accompanied by nausea and vomiting, is caused by biliary spasm. Opioid analgesics are given to relieve the severe pain and spasm of cholecystitis. Relief of pain may decrease nausea and vomiting and thereby decrease the client's likelihood of developing further complications, such as severe fluid loss and inadequate nutrition. There are no data to suggest that the client is anxious."

"The nurse is planning a staff development program on how to care for clients with hepatitis A. Which of the following precautions should the nurse indicate as essential when caring for clients with hepatitis A? 1.Gowning when entering a client's room. 2.Wearing a mask when providing care. 3.Assigning the client to a private room. 4.Wearing gloves when giving direct care."

4 "Contact precautions are recommended for clients with hepatitis A. This includes wearing gloves for direct care. A gown is not required unless substantial contact with the client is anticipated. It is not necessary to wear a mask. The client does not need a private room unless incontinent of stool."

"A client has been admitted to the medical surgical unit following an emergency cholecystectomy. There is a Jackson Pratt drain with a portable suction unit attached. After 4 hours, the drainage unit is full. The nurse should do which of the following? 1.Notify the surgeon. 2.Remove the drain and suction unit. 3.Check the dressing for bleeding. 4.Empty the drainage unit.

4 "ortable suction units should be emptied and drained every shift or when full. It is normal for the unit to fill within the first hours after surgery; the nurse does not need to contact the surgeon. There should not be bleeding on the dressing if the drainage system is emptied when full. The drain should not be removed until prescribed by the physician."