Chapter 45 GI - Gallbladder, Liver, Biliary Tract and Exocrine Pancreatic Disorders

The nurse is caring for a patient who underwent liver transplantation. Which preventive measures should the nurse instruct to prevent common respiratory complications in the patient? Select all that apply.

"You should cough." "You should take deep breaths." "You should use the incentive spirometer. Common respiratory problems that occur after a liver transplantation in a patient include pneumonia, atelectasis (collapsed lung), and pleural effusions. To avoid these problems, the patient is asked to follow a few measures such as coughing, incentive spirometry, and deep breathing to prevent respiratory complications. Sneezing and slow breathing do not relieve the patient from respiratory complications.

A patient with cholelithiasis is complaining of severe abdominal pain. Which pain medication, if ordered by the provider, would the nurse question?

Morphine. Morphine can cause an increased tone in the sphincter of Oddi and slows flow of bile into the duodenum, which can lead to an increase in symptoms. Ketorolac and meperidine are good options for pain control. Dicyclomine decreases spasming of the sphincter of Oddi and decreases pain.

A patient in liver failure exhibits transient confusion and lethargy. The nurse anticipates the patient's ammonia level to be which number?

100 mcg/dL Liver failure leads to an increased ammonia level that causes hepatic encephalopathy. The normal ammonia level is 10 to 80 mcg/dL.

A nurse who is providing education to a patient newly diagnosed with liver cirrhosis discusses appropriate pain control at home. Which over-the-counter medication, if listed by the patient, indicates a need for further education on appropriate pain medication choices?

Acetaminophen (Tylenol). Acetaminophen (Tylenol) is hepatotoxic and should not be used in a patient with liver disease. Aspirin, ibuprofen, and naproxen should all be used with caution in a patient with liver disease.

While assessing the diagnostic reports of an adult patient, the nurse finds the aspartate aminotransferase (AST) levels to be 45 units/L. Which condition does the nurse suspect in this patient?

Acute hemolytic anemia. AST is a liver enzyme whose normal range in adults is 0 to 35 units/L. In this patient, the AST level is 45 units/L. An increase in AST levels indicates acute hemolytic anemia. Hyperparathyroidism can be suspected if the patient has elevated levels of alkaline phosphatase. Cancer of the pancreas can be suspected if the patient has elevated levels of gamma-glutamyl transpeptidase GGT). Metastatic tumor in the bones is suspected if the patient has elevated levels of alkaline phosphatase.

The primary health care provider prescribes pancrelipase (Pancrease) to a patient with pancreatic insufficiency. Which factor does the nurse assess before administering the drug?

Assess renal function and urinary output. Pancrelipase (Pancrease) is a drug derived from pork; the nurse should therefore check whether the patient is allergic to pork. Skin integrity severity is assessed when the patient is administered cholestyramine (Questran). Electrolytes and serum creatinine levels have to be assessed in the patient after the administration of spironolactone (Aldactone). Renal function is monitored after the administration of neomycin (Mycifradin) and the urinary output is monitored after the administration of vasopressin (Pitressin).

A nurse is caring for a patient 8 hours after a laparoscopic cholecystectomy. The patient, who was fully ambulatory before the procedure, requests to get up to go the bathroom. What action is most therapeutic for the patient?

Assist the patient to the bathroom. Patients should ambulate by the first night postoperatively; therefore the nurse should assist the patient to the bathroom. The patient is not on bed rest, so a bedpan is not necessary. A Foley catheter is not recommended for this patient. The patient should use a bedside commode if unable to ambulate safely to the bathroom.

Which instruction should the nurse give a patient who is recovering from an acute episode of hepatic encephalopathy?

Avoid a diet rich in proteins. Ammonia is produced after the digestion of proteins. In patients with hepatic encephalopathy, ammonia cannot be eliminated from the body; protein intake is restricted in these patients. A protein-rich diet causes an excess accumulation of ammonia in the body and is contraindicated in patients with hepatic encephalopathy. A diet rich in minerals is not contraindicated, and minerals are essential for metabolic activities of the body. Vitamins are also required in moderate levels and are not contraindicated in patients with hepatic encephalopathy. Carbohydrates are not contraindicated in patients with hepatic encephalopathy. They are an essential source of glucose and can be taken moderately.

A nurse is caring for a patient with cirrhosis. The nurse knows that the patient is unable to absorb vitamin K because of the cirrhotic liver, which puts the patient at an increased risk for which complication?

Bleeding. Vitamin K is an important component of the clotting cascade; a deficiency in vitamin K increases the risk of bleeding. The patient's risk of falls, pneumonia, and myocardial infarction are not increased as a result of decreased vitamin K.

A patient arrives in the emergency department complaining of severe abdominal pain in the right upper quadrant that began 2 hours ago, immediately after a large meal of fatty food. The patient's heart rate and respiratory rates are elevated, and he is diaphoretic. The patient also reports new-onset clay-colored stools and dark amber urine. The nurse anticipates which diagnosis?

Cholecystitis Sudden onset upper quadrant abdominal pain after a fatty meal is most likely cholecystitis caused by cholelithiasis. This patient is not likely to have hepatitis, pancreatitis, or irritable bowel syndrome.

The nurse is caring for a patient who is undergoing treatment for acute pancreatitis. Which drug does the nurse expect the primary health care provider to prescribe to prevent stress ulcers in the patient?

Cimetidine (Tagamet). The patient with pancreatitis has reduced gastric pH, which may result in stress ulcers. To prevent this condition, the primary health care provider should prescribe an antacid to elevate the gastric pH. Antacids such as cimetidine (Tagamet) are expected to be prescribed. Ribavirin (Rebetol) is used in the treatment of chronic hepatitis C infections. Propranolol (Inderal) reduces the risk of bleeding from the non-bled esophageal varices in patients. Propantheline (Pro-Banthine) helps to decrease pancreatic activity in patients with pancreatitis.

A patient suffering from severe viral hepatitis is advised a liver function test by the primary health care provider. Which finding would the nurse expect in the patient's diagnostic report?

Decreased serum albumin levels. Hepatitis is characterized by inflammation of the liver, resulting in impairment of the liver function. The liver is associated with the production of albumin, but due to the impairment of its function, the albumin levels are dropped. Decreased albumin levels are observed in the liver diagnostic reports of a hepatitis patient. Impaired liver function is also associated with increased bilirubin levels, which may further lead to jaundice. The alkaline phosphatase levels are increased due to blockage of their flow from the biliary tract and do not indicate hepatitis. Levels of aspartate aminotransferase are elevated if any organ has disease or injury.

A patient with late-stage cirrhosis is experiencing nausea and vomiting. The nurse anticipates the provider to prescribe which medication to alleviate the nausea and vomiting?

Diphenhydramine (Benadryl). Diphenhydramine (Benadryl) or dimenhydrinate (Dramamine) may be prescribed for nausea and vomiting in the patient with cirrhosis. Vistaril, Atarax, and Compazine are contraindicated in patients with severe liver damage.

What is the preferred diagnostic test for visualizing the biliary tree in a patient with jaundice?

Gallbladder ultrasound. The preferred diagnostic test for visualizing the biliary tree in a patient with jaundice is a gallbladder ultrasound. Oral cholecystography (OCG) is a method of visualizing the biliary tree, but it is ineffective in the patient with jaundice. Intravenous cholangiography (IVC) is a method of visualizing the biliary tree, but it is ineffective in the patient with jaundice. Cholecystogram is another term for OCG.

A nurse who is preparing to care for a patient diagnosed with cholecystitis knows the patient most likely also has which condition?

Gallstones Gallstones are the cause of cholecystitis in 90% of cases. Hypercholesterolemia may contribute to the formation of gallstones, but this is not always the case. Cirrhosis and alcoholism are not the primary cause of cholecystitis.

A nurse is assisting with a paracentesis for a patient with ascites caused by cirrhosis. What should the nurse do first?

Have the patient empty his bladder. The patient should empty the bladder before the paracentesis to prevent puncture of the bladder. Then, the patient should be positioned sitting on the side of the bed or in high Fowler position. While the fluid is being removed, the nurse should monitor the patient for signs of syncope. After the procedure, the nurse should observe the dressing site for bleeding and drainage.

What is the most common form of hepatitis today, which has an incubation period of 10 to 40 days?

Hepatitis A. Hepatitis A is the most common form of hepatitis today. Formerly named infectious hepatitis, it is a short-incubation virus (10 to 40 days). Hepatitis B is a long-incubation virus (28 to 160 days). Persons at risk for hepatitis B include health care workers, persons with high-risk lifestyles (drug users, tattoo recipients, homosexual men, and prostitutes), infants born to mothers who are hepatitis B surface antigen (HBsAg) positive, hemodialysis patients, and persons sharing a household with a person infected with hepatitis B. Hepatitis C has an incubation period of 2 weeks to 6 months, commonly 6 to 9 weeks. Hepatitis D, also known as the delta virus, has an incubation period of 2 to 10 weeks. It causes hepatitis as a coinfection with hepatitis B and may progress to cirrhosis and chronic hepatitis.

A nurse is administering lactulose to a patient with hepatic encephalopathy caused by liver cirrhosis. The patient's wife requests to know why her husband is being given this medication, as he is not constipated. The nurse replies that lactulose decreases ammonia levels through which mechanism?

Lactulose decreases bacterial production of ammonia. Lactulose acidifies the bowel, which decreases production of ammonia by the bacteria in the bowel. The bacteria in the bowel do not metabolize the ammonia. Neomycin, not lactulose, reduces the number of ammonia-producing bacteria in the colon.

A patient with late-stage liver cirrhosis arrives in the clinic with several complaints. Which symptom concerns the nurse the most because it puts the patient at risk for a potentially life-threatening complication?

Non-productive cough. The patient with cirrhosis is at risk for esophageal varices, which can rupture when the patient coughs and cause hemorrhage. Diarrhea, pruritus, and increased abdominal girth are all expected symptoms of a patient with cirrhosis.

A patient undergoing a paracentesis to remove ascitic fluid complains of dizziness and lightheadedness. What should the nurse do first?

Obtain the patient's vital signs The patient is likely experiencing syncope because the fluid was removed too quickly. The nurse should first determine the patient's blood pressure and pulse. It may be necessary to decrease the flow of fluid, but the nurse should first determine the cause of the patient's symptoms. It would not be appropriate to increase the flow of fluid or remove the catheter immediately.

A patient with cirrhosis of the liver is admitted to the hospital for moderate respiratory distress as a result of ascites. The nurse knows to prepare the patient for which procedure?

Paracentesis Paracnetesis is a procedure in which fluid is withdrawn from the abdominal cavity. This buildup of fluid is likely the cause of the patient's respiratory distress. A thoracentesis drains fluid from the chest cavity and is not applicable to this patient. Although the patient may need an esophagoscopy with barium esophagography to determine if the patient has esophageal varices, these are not the best option at this time.

The nurse is caring for a patient who has developed non-bleeding esophageal varices. Which drug does the nurse expect the primary health care provider to prescribe to ensure safety of the patient?

Propranolol (Inderal). Esophageal varices are characterized by enlarged and edematous veins at the lower end of the esophagus. The patient is susceptible to hemorrhage; however, a few patients may not bleed. As this patient has no bleeding, a prophylactic treatment with nonselective beta blockers such as propranolol (Inderal) reduces the risk of bleeding and bleeding-related deaths. Cimetidine (Tagamet) is an antacid and is used to prevent gastric stress ulcers. Vasopressin (Pitressin) is administered intravenously to stop hemorrhage and is not administered in the patient who has not bled. Nitroglycerin (Nitro-Bid) is used for therapeutic management of ruptured esophageal varices.

The nurse is caring for a patient with hepatic encephalopathy who is administered lactulose (Chronulac). Which biochemical level does the nurse monitor in the serum, to ensure the patient's safety?

Serum ammonia. The drug lactulose (Chronulac) retards ammonia absorption by acidifying the colonic contents. The nurse should therefore monitor serum ammonia levels after the administration of lactulose (Chronulac). The nurse should monitor serum sodium levels after administering vasopressin (Pitressin), as it is an anti-diuretic. Serum creatinine levels should be monitored in the patient after the administration of spironolactone (Aldactone). Spironolactone (Aldactone) retains potassium when administered to a patient with liver cirrhosis; the nurse should therefore monitor serum potassium levels.

A patient admitted to the hospital with cirrhosis of the liver suddenly starts vomiting blood. What is the priority action that the nurse should take in this situation?

Stabilize the patient and manage airway. Individuals with cirrhosis of liver are at risk of bleeding from esophageal and gastric varices. Hematemesis in the patient with cirrhosis of the liver is likely to because variceal bleeding. In this case, the nurse should first stabilize the patient and manage the airway. Once the patient is stable, other steps in treatment can be initiated, such as assessing further and administering medications, checking signs of cirrhosis or preparing for further treatment.

A nurse is preparing a patient for a needle liver biopsy. The nurse correctly positions the patient in which manner?

Supine. The patient should lie supine with the right arm elevated over the head. Prone, lithotomy, and Trendelenburg positions would not be appropriate for this test.

The nurse is caring for a patient who underwent a cholecystectomy. On assessment, the primary health care provider (PHP) suspects that the patient has retained bile ductal stones. Which diagnostic test does the nurse expect the PHP to prescribe to detect the stones?

T-tube cholangiography test. A T-tube cholangiography is performed to detect retained bile ductal stones postoperatively in the patient who had a cholecystectomy. A urine amylase test is particularly useful in detecting pancreatitis late in the course of the disease. The serum amylase test can aid in quickly diagnosing pancreatitis in its early stages. The oral cholecystography provides a roentgenographic visualization of the gallbladder.

A patient expresses concern about getting pregnant while the partner is on ribavirin (Rebetol) therapy for chronic hepatitis C. What should the nurse advise the patient?

The person should avoid getting pregnant now. Any woman who is on ribavirin (Rebetol) or whose male partner is on ribavirin should avoid pregnancy during treatment. Pregnancy can be planned after the treatment is complete. The person can get pregnant with the current partner, but not while on treatment. Avoiding intercourse after conception is not necessary.

A nurse who is providing education to a patient with cirrhosis knows the importance of preventing bleeding. Which instruction would be most important to prevent bleeding?

Use a soft-bristled toothbrush. To prevent bleeding, the patient should use a soft-bristled toothbrush. The patient should also change position often, follow the therapeutic diet, and avoid use of perfumed lotions and soaps, but these instructions do not help the patient prevent bleeding.

Which vitamin supplements does the primary health care provider prescribe for a patient with ascites? Select all that apply.

Vitamin K Vitamin C Vitamin B9 Patients with severe fluid retention are prescribed spironolactone (Aldactone) to promote dieresis. Vitamin supplements such as vitamin K, vitamin C, and vitamin B9 (folic acid) also induce diuresis in the patient. These vitamin supplements synergize the actions of spironolactone (Aldactone) by promoting diuresis in severe conditions. Vitamin D is associated with the absorption of calcium in the intestines and is not associated with diuresis. Vitamin B12 is associated with formation of blood cells and does not produce any diuretic effect.

A nurse is contributing to the admission assessment of a patient in the early stages of cirrhosis of the liver. The nurse anticipates the patient to report which symptom(s)? Select all that apply

Vomiting Diarrhea Flatulence Loss of appetite In the early stages of cirrhosis of the liver, the patient experiences nausea and vomiting, abnormal bowel function, flatulence, weakness, and loss of appetite. Severe fatigue and pruritus are among the symptoms experienced in the late stages.

A nurse is contributing to the admission assessment of a patient in the early stages of cirrhosis of the liver. The nurse anticipates the patient to report which symptom(s)? Select all that apply.

Vomiting Diarrhea Loss of appetite In the early stages of cirrhosis of the liver, the patient experiences nausea and vomiting, abnormal bowel function, flatulence, weakness, and loss of appetite. Severe fatigue and pruritus are among the symptoms experienced in the late stages.

A nurse assesses jaundice in a newly admitted patient. What is there an excess amount of in the bloodstream that causes jaundice? Correct 1

Bilirubin Jaundice, a yellow discoloration of body tissues, results when there is an excess amount of bilirubin in the bloodstream. This abnormal assessment finding is recognized when total serum bilirubin exceeds 2.5 mg/dL. AST is elevated in myocardial infarction, hepatitis, liver disorders (cirrhosis, necrosis, tumor, hepatitis), acute pancreatitis, and hemolytic anemia; it does not result in jaundice. Alkaline phosphatase is elevated in biliary tract disorders, hepatic tumors, cirrhosis, primary and metastatic tumors, hyperparathyroidism, and bone disorders (fractures, tumors); it does not result in jaundice. Lactic dehydrogenase is elevated in myocardial infarction, pulmonary infarction, hepatic disease, pancreatitis, and skeletal muscle disease; it does not result in jaundice.

A patient is diagnosed with acute pancreatitis. When providing dietary teaching, what are the points that a nurse should tell the patient? Select all that apply.

Consume a low-fat diet. Avoid consuming alcohol. Consume a high-protein diet. Consuming a low fat diet is essential in case of pancreatitis. Fats should be avoided because they stimulate the secretion of cholecystokinin, which then stimulates the pancreas. Alcohol is an irritant and must be avoided. A diet high in protein content is recommended. Fluid intake should be increased to prevent dehydration. Carbohydrates are less stimulating to the pancreas and are encouraged.

A patient is prescribed propantheline (Pro-Banthine) for spasms in the liver. Which instruction should the nurse provide to ensure drug safety?

"Avoid alcohol intake along with the drug." Drowsiness and confusion are side effects of using propantheline (Pro-Banthine). The patient is advised to avoid the use of CNS depressants or alcohol when the drug is administered. Spironolactone (Aldactone) is administered in the morning to avoid interference with sleep. Vasopressin (Pitressin) should be discontinued if the patient develops chest pain. The patient is administered gemcitabine hydrochloride (Gemzar) with an antiemetic drug to control nausea and vomiting in the patient.

A patient in the clinic has been diagnosed with acute viral hepatitis caused by the hepatitis B virus. The patient requests that the nurse not tell anyone about his infection. What is the best response by the nurse?

"By law, I have to notify the Centers for Disease Control and Prevention (CDC)." The nurse should tell the patient that the law requires all cases of viral hepatitis to be reported to the CDC. Although the nurse cannot tell the patient's partners, the patient should be encouraged to inform the partners so they may seek testing and treatment in a timely fashion.

A patient with cirrhosis of the liver is admitted to the hospital. What hematologic symptoms might be noted in this patient? Select all that apply.

Anemia Leukopenia Thrombocytopenia Hematologic problems include thrombocytopenia, leukopenia, anemia, and coagulation disorders. Anemia caused due to inadequate red blood cell (RBC) production and survival, poor diet, poor absorption of folic acid, and bleeding from varices. Anemia, leukopenia, and thrombocytopenia are also probably caused by the splenomegaly that results from the backup of blood from the portal vein into the spleen (portal hypertension). Over activity of the enlarged spleen, results in increased removal of blood cells from circulation. Leukemia and polycythemia vera are not caused due to cirrhosis.

A nurse assesses jaundice in a newly admitted patient. What is there an excess amount of in the bloodstream that causes jaundice?

Bilirubin. Jaundice, a yellow discoloration of body tissues, results when there is an excess amount of bilirubin in the bloodstream. This abnormal assessment finding is recognized when total serum bilirubin exceeds 2.5 mg/dL. AST is elevated in myocardial infarction, hepatitis, liver disorders (cirrhosis, necrosis, tumor, hepatitis), acute pancreatitis, and hemolytic anemia; it does not result in jaundice. Alkaline phosphatase is elevated in biliary tract disorders, hepatic tumors, cirrhosis, primary and metastatic tumors, hyperparathyroidism, and bone disorders (fractures, tumors); it does not result in jaundice. Lactic dehydrogenase is elevated in myocardial infarction, pulmonary infarction, hepatic disease, pancreatitis, and skeletal muscle disease; it does not result in jaundice.

A patient with cancer of the head of the pancreas is admitted to the hospital. What are the manifestations that a nurse might expect to find in this patient? Select all that apply.

Clay-colored stools Itching and irritation of the skin Extreme pain in the upper abdomen that may radiate to the back. Tumor of the head of the pancreas will obstruct the common bile duct where it passes through the head of the pancreas to join the pancreatic duct and empty at the ampulla of Vater into the duodenum. The stools will be clay-colored when bile is not able to enter the duodenum. Pruritus is also a common symptom in cancer of the pancreas; hence, the patient may complain of itching and irritation of the skin. Severe pain is also present. The pain generally depends on the part affected and severity. Edema and ulcers are not common manifestations of pancreatic cancer.

A nurse is preparing to care for a patient immediately after liver transplant surgery. The nurse anticipates administering which medication to the patient?

Cyclosporine (Sandimmune). Immediately after transplant surgery, the nurse should anticipate administering cyclosporine to help prevent rejection. Acetaminophen is hepatotoxic and should not be administered after a liver transplant. Lactulose and hepatitis B vaccine are not necessary at this point.

Which drug does the nurse expect the primary health care provider to prescribe to reduce nausea in a patient with severe liver dysfunction?

Dimenhydrinate (Dramamine) The metabolism of oral drugs takes place in the liver. Patients with a liver dysfunction cannot clear the drug from their systems, resulting in toxicity. Dimenhydrinate (Dramamine) has an easy first pass metabolism and can be cleared from the system more effectively when compared to other antiemetic drugs. Hydroxyzine pamoate (Vistaril) is an antiemetic, but is contraindicated in patients with liver dysfunction. Hydroxyzine hydrochloride (Atarax) is also an antiemetic, contraindicated in patients with a liver dysfunction. Prochlorperazine maleate (Compazine) is another drug which reduces nausea, but is contraindicated in patients with liver dysfunction.

A nurse is caring for a patient scheduled for a laparoscopic cholecystectomy. In the patient's chart, the nurse finds signed consent forms for a laparoscopic cholecystectomy and an open cholecystectomy. What should the nurse do first?

Do nothing. Both consent forms are necessary in case the surgery plan changes. A consent form for both the laparoscopic and open cholecystectomies should be signed and placed in the patient's chart in case the surgery plan must be changed during the operation. The nurse does not need to call the primary health care provider, cancel the surgery, or discard the open cholecystectomy consent form.

A patient with cirrhosis of the liver is admitted to the hospital. What complications of cirrhosis is the nurse likely to find in the patient? Select all that apply.

Edema of the feet Disorientation and lethargy Blood in the stools or black stools Complications of cirrhosis of the liver include peripheral edema, gastric varices, and hepatic encephalopathy. Peripheral edema presents itself as swelling/edema of the feet. Hepatic encephalopathy presents as disorientation, altered mental status, sleep disturbances, and lethargy. Gastric varices bleed easily. This bleeding can be presented as blood in vomiting or blood in the stool. Cirrhosis does not lead to pain in the chest with a cold sweat, or difficulty in breathing.

A patient has just undergone a liver transplant and is now in the intensive care unit (ICU). What nursing interventions are appropriate for this patient to prevent respiratory complications? Select all that apply.

Encourage the patient to cough. Consider repositioning the patient. Encourage the patient to take deep breaths. The patient who has had a liver transplant requires highly skilled nursing care in an ICU or another specialized unit. To prevent respiratory complications, the patient should be encouraged to use measures such as coughing, repositioning, and deep breathing. The patient can be ambulated later, when the condition is stable. Administering cough suppressants would be counterproductive to recovery.

A patient is prescribed iopanoic acid (Telepaque) to treat a gall bladder infection. Which is the best nursing intervention to ensure the maximum therapeutic activity of the drug?

Ensure the patient is not currently experiencing diarrhea. Iopanoic acid (Telepaque) has an iodine dye as an active ingredient. Iodine dye is used in effectively treating oral cholecystography. The patient with diarrhea has increased elimination from the gastrointestinal tract, consequently resulting in low bioavailability of the drug. The therapeutic efficiency of the drug is therefore greatly reduced in patients with diarrhea. The patient is advised to be placed on NPO status from midnight on the day before the test is performed. If the patient is allergic to iodine, the test is not performed. One tablet is provided every 5 minutes beginning after the evening meal for effective oral cholecystography.

The nurse is caring for a patient with metastatic adenocarcinoma of the pancreas. Which drug does the nurse expect to find in the patient's prescription?

Gemcitabine hydrochloride (Gemzar) Gemcitabine hydrochloride (Gemzar) is used to treat patients with metastatic adenocarcinoma of the pancreas. Vasopressin (Pitressin) is an antidiuretic drug, used to treat bleeding esophageal varices in the patients. Cholestyramine (Questran) is used to relieve pruritus associated with elevated levels of bile acids in the patients. Spironolactone (Aldactone) is used to treat cirrhosis of the liver with ascites.

A patient has recently had a bout of acute pancreatitis. He is asking for something to eat. Which would be most appropriate for this patient? Select all that apply.

Grilled chicken and a baked potato Reduced fat cheese and whole-wheat crackers. The optimal diet for a patient who has recently had pancreatitis is a bland, low-fat, high-protein, high-carbohydrate diet. The reduced fat cheese and whole-wheat crackers and chicken and baked potato best meet these recommendations. Chips and salsa would not be the best choice, because salsa is not considered to be bland. Eggs and bacon would not be a good choice; this meal is neither bland nor low fat. Coffee and Danish pastry would not be the best choice because coffee is a gastric stimulant and the pastry is likely to be high in fat.

A patient suffering from cholelithiasis underwent a cholecystectomy. What dietary advice will the nurse give this patient? Select all that apply.

Have a high-fiber diet. Have small but frequent meals. Avoid or keep fats to the minimum. Having a high-fiber diet helps in the smoother passage of stools and prevents constipation. Having small and frequent meals helps digestion and prevents nausea. Fats make it harder to digest, so fat should be avoided. After cholecystectomy, it is essential that the patient take adequate intake of water, around 2500-3000 mL per day. The patient should not have the usual foods; modifications are needed to facilitate easy digestion of food in the absence of the gall bladder.

During an assessment of a patient, the nurse finds asterixis, twitching of the extremities, and notices that the patient is displaying inappropriate behavior and disorientation. Which condition does the nurse suspect in this patient?

Hepatic encephalopathy Hepatic encephalopathy is a type of brain damage caused by liver disease. The patient's signs and symptoms progress from inappropriate behavior, disorientation, asterixis, and twitching of the extremities. Symptoms of ascites include loss of appetite, nausea and vomiting, general weakness, and fatigue. Liver cirrhosis is characterized by dyspepsia, changes in bowel habits, gradual weight loss, ascites, enlarged spleen, malaise, nausea, jaundice, and ecchymoses. Esophageal varices (a complex of longitudinal, tortuous veins at the lower end of the esophagus) enlarge and become edematous as the result of portal hypertension. It may lead to bleeding in the esophagus if not treated, but it is not accompanied by symptoms such as asterixis, twitching of the extremities, inappropriate behavior and disorientation.

The nurse is caring for a patient suffering from ascites is. What are the factors that the nurse knows may lead to ascites development? Select all that apply.

Hyperaldosteronism Portal hypertension Decreased serum colloidal oncotic pressure Hyperaldosteronism or increased secretion of aldosterone causes ascites. Portal hypertension causes an increase in resistance to blood flow in the liver leading to ascites. When there is decreased serum colloidal oncotic pressure, there is impairment of synthesis of albumin and loss of albumin in the peritoneal cavity. It leads to ascites. Diabetes is a metabolic syndrome and does not cause ascites. Increased flow of hepatic lymph, not decreased flow, leads to ascites.

A patient with asthma is using royal jelly for pancreatitis. Which parameter should the nurse monitor to ensure the patient's safety?

Hypersensitivity Royal jelly (bee pollen complex) is used in treating pancreatitis. Hypersensitive reactions should be monitored in asthma patients using royal jelly for pancreatitis. If the patient is allergic to royal jelly, it may lead to asthma attacks, anaphylaxis and even death. Patients with pancreatitis are not at risk of hypotension and royal jelly does not alter blood pressure. Hypoglycemia is not related to pancreatitis. Royal jelly has good glucose supplements and does not diminish glucose content. Neither pancreatitis nor royal jelly is associated with hypokalemia.

A patient is scheduled to undergo T-tube cholangiography. Before administration of contrast dye, what allergy should the nurse check the patient for?

Iodine. Before administration of contrast dye, it is essential that the nurse determine if the patient has any allergy to iodine. Patients with iodine allergies may react to the contrast dye, and this reaction can be life-threatening. There has been no documentation that a strawberry allergy would place the patient at risk for an allergy to contrast dye; however, people who are allergic to strawberries are often allergic to other foods and substances. All allergies should be clearly documented on the appropriate part of the medical record. There has been no documentation that a peanut allergy would place the patient at risk for an allergy to contrast dye; however, people who are allergic to peanuts are often allergic to other foods and substances. There has been no documentation that an allergy to silk tape would place the patient at risk for an allergy to contrast dye. Any such allergy, which would manifest as redness near areas with silk tape, would be uncomfortable for the patient, but not life-threatening.

A patient who underwent a cholecystectomy is now complaining of pain referred to his right shoulder. What are the probable causes of this pain? Select all that apply.

Irritation of the phrenic nerve Carbon dioxide used in surgery The carbon dioxide that is used to inflate the abdomen during surgery may not be released or absorbed by the body and can irritate the phrenic nerve and diaphragm. This is the reason for breathing difficulty and the most common cause of shoulder pain following a cholecystectomy. Other conditions, such as myocardial infarction, pericarditis after surgery, and a gallstone left in the gall bladder, may also cause shoulder pain but are less relevant in this situation.

A patient with intense pruritus asks the nurse what is causing the severe itching. The nurse informs the patient that the itching is caused by which mechanism?

Jaundice, which causes the accumulation of bile salts under the skin. The accumulation of bile salts causes jaundice and pruritus in the patient with liver cirrhosis. The patient's pruritus is not caused by ascites, poor diet, or poor hygiene.

A nurse is caring for a patient with moderate symptoms caused by three gallstones. The nurse knows to prepare the patient for which procedure?

Lithotripsy. Mild to moderate symptoms caused by just a few gallstones are treated by lithotripsy to break up the stones. Open cholecystectomy, endoscopic sphincterectomy, and laparoscopic cholecystectomy are reserved for many gallstones and more serious disease.

A patient arrives at the clinic with a yellow discoloration of the skin and sclera. The nurse anticipates the primary health care provider will prescribe tests to determine the function of which organ?

Liver Bilirubin, which is normally broken down in the liver, causes jaundice, a yellow discoloration of the skin, when the liver is not functioning properly. Jaundice is not caused by spleen, kidney, or small intestine dysfunction.

The nurse is caring for a patient who reports dull abdominal pain, clay colored stools, dark urine and fever. On assessment, the nurse finds hepatomegaly, jaundice, and anemia in the patient. Which condition does the nurse suspect in the patient?

Liver abscess Liver abscess is the collection of pus in the liver due to bacterial infections. These infections retard the liver's function, and the patient experiences dull abdominal pain. Abnormal functioning of the liver results in increased bilirubin content, indicated by clay-colored stools and dark urine. Hepatomegaly, jaundice, and anemia in the patient confirm the presence of liver abscess. Cholecystitis is characterized by symptoms such as pain in the right upper quadrant epigastric region, anorexia, nausea, vomiting, and flatulency. Liver cirrhosis is characterized by dyspepsia, changes in bowel habits, gradual weight loss, ascites, enlarged spleen, malaise, nausea, jaundice and ecchymoses. Hepatic encephalopathy is characterized by symptoms which progress from inappropriate behavior, disorientation, asterixis, and twitching of the extremities.

A patient with cholecystostomy has an accidental obstruction of bile drainage. Which nursing intervention may reduce the risk for impaired skin integrity? Correct 1

Maintaining patency of the T-tube Maintaining patency of the T-tube is a primary nursing intervention. This promotes the draining of the obstructed bile through the opening of the T-tube. Drainage of the obstructed bile retards if pressure is applied on the T-tube. If the bag is changed after it is fully filled, it may soil the linen, causing discomfort to the patient. The bile bag should be emptied after it is half-filled. Moist dressing may cause infections; the dressing applied should be dry.

A nurse is called to the room of a patient with cirrhosis and esophageal varices. The patient is vomiting and the nurse notes hematemesis. What should the nurse do first?

Place the patient in a side-lying position. A bleeding varix is a medical emergency. An airway must be maintained, so the patient should first be placed in a side-lying position to prevent aspiration. The primary health care provider should then be notified. The nurse should stay with the patient until the vomiting subsides and ensure the patient's airway is maintained. The patient should not be encouraged to continue vomiting.

Which type of liver cirrhosis is caused by viral hepatitis, exposure to hepatotoxins (e.g., industrial chemicals), or infection?

Postnecrotic cirrhosis Postnecrotic cirrhosis is a type of liver cirrhosis caused by viral hepatitis, exposure to hepatotoxins (e.g., industrial chemicals), or infection. In cirrhosis, fibrous scar tissue covers the lobes, restricts blood flow to the liver, and contributes to the destruction of the liver. Alcoholic cirrhosis, most commonly found in the Western world, affects more men than women. It is found in patients with a history of chronic ingestion of alcohol. Laennec cirrhosis is the term formerly used to refer to alcoholic cirrhosis. Primary biliary cirrhosis is found more often in women than men and results from destruction of the bile ducts.

What is the highest priority in managing a patient with a ruptured esophageal varix?

Protecting the airway Although all answers may be important, the highest priority is airway protection. This may be accomplished via endotracheal intubation if necessary. Control of bleeding is essential in managing the patient with a ruptured esophageal varix, because death from hemorrhage may happen as a result of the high pressure and high vascularity of the area. Vasopressin may be administered for this purpose, and a Sengstaken-Blakemore tube may be inserted (balloon inflation helps achieve hemostasis). Performing a portacaval shunt diverts blood from the portal vein to the inferior vena cava. This may be used in an emergency situation to control acute bleeding or in a therapeutic situation when a patient has already bled. Administration of FFP as well as packed red blood cells (RBCs) is important in replacing the blood and volume the patient has lost.

The nurse is caring for a patient with severe liver cirrhosis and imbalanced nutrition. Which nursing intervention would prevent malnutrition in this patient?

Provide oral care before meals. The patient with liver cirrhosis shows less interest in food intake, which may lead to malnutrition. It is required to provide oral care to patients with liver cirrhosis before meals to remove the foul taste in their mouths and improve the taste of food. When digested, proteins produce ammonia, which is not eliminated in patients with severe liver cirrhosis. It is therefore not advised to provide protein-rich food. It is advised to provide small, frequent meals at times the patient can best tolerate them to prevent a feeling of fullness and maintain nutritional status. Antiemetics are to be administered per the prescription, in order to relieve the patient from nausea and vomiting while eating.

A nurse is collaborating with an unlicensed assistive personnel (UAP) to care for a patient with cirrhosis of the liver. The nurse overhears the UAP say, "This patient did this to himself by being an alcoholic. I don't understand why we're trying to save him." What should the nurse do first?

Remind the UAP that cirrhosis is also caused by factors other than alcohol. Cirrhosis of the liver can be caused by alcohol, hepatitis viruses, gallstones, and other causes. The nurse should first remind the UAP of these other causes. It may also be necessary to tell the UAP that each patient deserves the best care regardless of how the patient came to be in his or her condition. Should the UAP compromise the care of the patient, the nurse should report the UAP to the nurse manager. It is not appropriate to remain silent in this situation.

A patient who was admitted with acute hepatic encephalopathy is ordering dinner. Which would be the best option for this patient?

Spaghetti with marinara sauce and salad Patients recovering from acute hepatic encephalopathy may require a protein-restricted diet. Spaghetti with marinara sauce and salad is low in protein. Cheeseburgers, grilled chicken, and ham are all protein-rich foods.

Following a laparoscopic cholecystectomy, a patient without pre- or postoperative complications is being discharged from the hospital. What instructions should the nurse include in the discharge teaching? Select all that apply.

Take a shower. Wait 1 week after surgery surgery to return to work. Notify the surgeon of any redness and swelling at the incision site. The patient who undergoes a laparoscopic cholecystectomy without complications may be discharged shortly after surgery. Therefore, it is important to teach the patient about care following discharge. The patient should be informed to take a shower. Normal activities can be resumed the next day, and the patient may return to work within 1 week of surgery. The patient should immediately notify the surgeon if there is redness, swelling, bile-colored drainage, or pus from any incision; severe abdominal pain; nausea; vomiting; and/or fever and chills. If the patient has no complication, the patient does not need to take bed rest for 2 weeks. A normal diet can also be resumed, but a low-fat diet is recommended for several weeks after surgery.

The nurse is caring for a patient with a chronic hepatitis B infection. Which drug does the nurse expect the primary health care provider to prescribe to decrease the viral load?

Telbivudine (Tyzeka) Telbivudine (Tyzeka) is a new drug used to treat a chronic hepatitis B infection. Telbivudine (Tyzeka) has been shown to decrease the viral load more effectively than conventional drugs. Ribavirin (Rebetol) also decreases the viral load, but treats hepatitis C infections. Interferon alfa-2b (Intron A) acts as a static drug and decreases the disease progression in hepatitis C infections. Pegylated interferon alfa-2a (Pegasys) is also used in treating hepatitis C infections by promoting seroconversion.

A patient with cirrhosis of liver has ascites, and is being prepared for a paracentesis. What instructions should the nurse give the patient?

The patient should void urine immediately before paracentesis. The nurse should instruct the patient to void prior to paracentesis to prevent accidental puncture of the bladder. During the procedure, the patient sits on the side of the bed or, is placed in high Fowler's position. There is no need to keep the patient on NPO status (taking nothing by mouth) or to restrict fluid intake.

The primary health care provider prescribed cimetidine (Tagamet) to a patient with acute pancreatitis. What reason does the nurse expect behind the prescription?

To prevent stress ulcers. Pancreatic juice is alkaline in nature, as it has more bicarbonate ions. It maintains the gastric pH; however, in patients with pancreatitis, pancreatic activity is reduced, which may result in stress ulcers. Therefore, antacids such as cimetidine (Tagamet) should be prescribed to prevent stress ulcers. In pancreatitis, the pH of the stomach is reduced and cimetidine (Tagamet) is an antacid which elevates the gastric pH. Secondary infections are not treated using cimetidine (Tagamet), as it is not an antibiotic. Cimetidine (Tagamet) is not associated with altering the pancreatic activity.

What is an imaging technique in which deep structures of the body are visualized by recording reflections or echoes of ultrasonic waves directed into the tissues

Ultrasonography Ultrasonography is an imaging technique in which deep structures of the body are visualized by recording reflections or echoes of ultrasonic waves directed into the tissues. This test is not effective in examining all tissues because ultrasound waves do not pass through structures that contain air, such as the lungs. It requires no contrast medium and has no associated radiation, so it is useful for patients allergic to iodine and pregnant patients. Angiography is a type of blood vessel study using contrast dye. Blood vessels from various parts of the body can be examined using this technique. Before administration of contrast dye, it is essential that the nurse determine if the patient has any allergy to iodine. HIDA scanning, done in the nuclear medicine department, uses a camera to record distribution of a tracer (technetium 99) in the liver, biliary tree, gallbladder, and proximal small intestine. It is considered to be safe, noninvasive, and accurate. Percutaneous biopsy is performed by using a needle inserted through a patient's skin to obtain a tissue sample, such as in a liver biopsy. There is special positioning of the patient, depending on what area of the body is being studied, and it may be done under ultrasound or computed tomography (CT) guidance to direct the physician accurately toward the area to take a biopsy.

A patient with hepatitis A infection is being discharged from the hospital. What is the most important instruction that the nurse should include in the discharge teaching?

Wash hands carefully after bowel movements. The mode of transmission of hepatitis A infection is the fecal-oral route. Therefore, it is very important to maintain personal and environmental hygiene. The nurse should teach the patient and his family members about washing hands after bowel movements, and before eating to prevent outbreaks of hepatitis A viral infection. Not sharing toothbrushes and razors is a concern for the prevention of hepatitis B and C because it is transferred through blood contact. There is no need to isolate the patient with hepatitis A unless he is incontinent or maintains poor personal hygiene. Acetaminophen causes liver damage, and should be avoided in hepatic viral infection.