Med Surg Ch 44

B The presence of surface antibody to HBV (anti-HBs) is a marker of a positive response to the vaccine. The other laboratory values indicate current infection with HBV.

2. The nurse determines that administration of hepatitis B vaccine to a patient has been effective when a specimen of the patient's blood reveals a. HBsAg. b. anti-HBs. c. anti-HBc IgG. d. anti-HBc IgM.

D Hepatitis A is transmitted through the oral-fecal route, and antibody to HAV IgM appears during the acute phase of hepatitis A. The patient would not have antigen for hepatitis B or antibody for hepatitis D. Anti-HAV IgG would indicate past infection and lifelong immunity.

1. A patient contracts hepatitis from contaminated food. During the acute (icteric) phase of the patient's illness, the nurse would expect serologic testing to reveal a. antibody to hepatitis D (anti-HDV). b. hepatitis B surface antigen (HBsAg). c. anti-hepatitis A virus immunoglobulin G (anti-HAV IgG). d. anti-hepatitis A virus immunoglobulin M (anti-HAV IgM).

B Spironolactone is a potassium-sparing diuretic and will help to increase the patient's potassium level. The nurse does not need to talk with the doctor before giving the spironolactone, although the health care provider should be notified about the low potassium value. The furosemide will further decrease the patient's potassium level and should be held until the nurse talks with the health care provider.

10. A patient with cirrhosis who has scheduled doses of spironolactone (Aldactone) and furosemide (Lasix) has a serum potassium level of 3.2 mEq/L (3.2 mmol/L). Which action should the nurse take? a. Give both drugs as scheduled. b. Administer the spironolactone. c. Administer the furosemide and withhold the spironolactone. d. Withhold both drugs until talking with the health care provider.

B Extending the arms allows the nurse to check for asterixis, a classic sign of hepatic encephalopathy. The other tests also might be done as part of the neurologic assessment but would not be diagnostic for hepatic encephalopathy.

11. To evaluate the effectiveness of treatment for a patient who has hepatic encephalopathy, which action should the nurse take? a. Request that the patient stand on one foot. b. Ask the patient to extend both arms to the front. c. Instruct the patient to perform the Valsalva maneuver. d. Have the patient walk a few steps with the eyes closed.

A The purpose for lactulose in the patient with cirrhosis is to lower ammonia levels and prevent encephalopathy. Although lactulose may be used to treat constipation, that is not the purpose for this patient. Lactulose will not decrease nausea and vomiting or lower bilirubin levels.

12. A patient who has advanced cirrhosis is receiving lactulose (Cephulac). Which finding by the nurse indicates that the medication is effective? a. The patient is alert and oriented. b. The patient denies nausea or anorexia. c. The patient's bilirubin level decreases. d. The patient has at least one stool daily.

A The most common complication of balloon tamponade is aspiration pneumonia. In addition, if the gastric balloon ruptures, the esophageal balloon may slip upward and occlude the airway. Coughing increases the pressure on the varices and increases the risk for bleeding. Balloon position is verified after insertion and does not require further verification. The esophageal balloon is deflated every 8 to 12 hours to avoid necrosis, but if the gastric balloon is deflated, the esophageal balloon may occlude the airway.

13. Which nursing action will be included in the plan of care for a patient who is being treated for bleeding esophageal varices with balloon tamponade? a. Monitor the patient for shortness of breath. b. Encourage the patient to cough every 4 hours. c. Deflate the gastric balloon every 8 to 12 hours. d. Verify the position of the balloon every 6 hours.

B The blood in the gastrointestinal (GI) tract will be absorbed as protein and may result in an increase in ammonia level because the liver cannot metabolize protein well. The prothrombin time, bilirubin, and potassium levels also should be monitored, but these will not be affected by the bleeding episode.

14. A patient with severe cirrhosis has an episode of bleeding esophageal varices. To detect possible complications of the bleeding episode, it is most important for the nurse to monitor a. bilirubin levels. b. ammonia levels. c. potassium levels. d. prothrombin time.

C The pressure-relieving mattress will decrease the risk for skin breakdown for this patient. Adequate dietary protein intake is necessary in patients with ascites to improve oncotic pressure. Repositioning the patient every 4 hours will not be adequate to maintain skin integrity. Passive range of motion will not take pressure off areas like the sacrum that are vulnerable to breakdown.

15. Which nursing action will be included in the plan of care for a patient with cirrhosis who has ascites and 4+ edema of the feet and legs? a. Restrict dietary protein intake. b. Reposition the patient every 4 hours. c. Use a pressure-relieving mattress. d. Perform passive range of motion qid.

C TIPS is used to lower pressure in the portal venous system and decrease the risk of bleeding from esophageal varices. Indirect bilirubin level and serum albumin levels are not affected by shunting procedures. TIPS will increase the risk for hepatic encephalopathy.

16. After a patient has had a transjugular intrahepatic portosystemic shunt (TIPS) placement, which finding indicates that the procedure has been effective? a. Lower indirect bilirubin level b. Increase in serum albumin level c. Decrease in episodes of variceal bleeding d. Improvement in alertness and orientation

C The patient should empty the bladder to decrease the risk of bladder perforation during the procedure. The patient would be positioned in Fowler's position and would not be able to lie flat without compromising breathing. Since no sedation is required for paracentesis, the patient does not need to be NPO.

17. The health care provider plans a paracentesis for a patient with ascites caused by liver cancer. To prepare the patient for the procedure, the nurse a. places the patient on NPO status. b. assists the patient to lie flat in bed. c. asks the patient to empty the bladder. d. positions the patient on the right side.

C Infection risk is high in the first few months after liver transplant and fever is frequently the only sign of infection. The other patient data indicate the need for further assessment or nursing actions, but do not indicate a need for urgent action.

18. When assessing a patient who had a liver transplant a week previously, the nurse obtains the following data. Which finding is most important to communicate to the health care provider? a. Dry lips and oral mucosa b. Crackles at both lung bases c. Temperature 100.8° F (38.2° C) d. No bowel movement for 4 days

C Amylase is elevated in acute pancreatitis. Although changes in the other values may occur, they would not be as useful in evaluating whether the prescribed therapies have been effective.

19. Which of these laboratory test results will be most important for the nurse to monitor when evaluating the effects of therapy for a patient who has acute pancreatitis? a. Calcium b. Bilirubin c. Amylase d. Potassium

D Muscle twitching and finger numbness indicate hypocalcemia, which may lead to tetany unless calcium gluconate is administered. Although the other findings also should be reported to the health care provider, they do not indicate complications that require rapid action.

20. Which assessment finding in a patient with acute pancreatitis would the nurse need to report most quickly to the health care provider? a. Nausea and vomiting b. Hypotonic bowel sounds c. Abdominal tenderness and guarding d. Muscle twitching and finger numbness

A Alcohol use is one of the most common risk factors for pancreatitis in the United States. Cigarette smoking, diabetes, and high-protein diets are not risk factors.

21. When obtaining a health history from a patient with acute pancreatitis, the nurse asks the patient specifically about a history of a. alcohol use. b. diabetes mellitus. c. high-protein diet. d. cigarette smoking.

B Pancreatic enzymes are used to help with digestion of nutrients and should be taken with every meal.

22. When educating a patient with chronic pancreatitis about the prescribed pancrelipase (Viokase), the nurse will teach the patient to take the medication a. at bedtime. b. with every meal. c. upon arising in the morning. d. as soon as abdominal pain occurs.

A After a laparoscopic cholecystectomy, the patient will have Band-Aids in place over the incisions. Patients are discharged the same (or next) day and have few restrictions on activities of daily living. Drainage from the incisions would be abnormal, and the patient should be instructed to call the health care provider if this occurs. A low-fat diet may be recommended for a few weeks after surgery but will not be a life-long requirement.

23. After providing discharge instructions to a patient following a laparoscopic cholecystectomy, the nurse recognizes that teaching has been effective when the patient states, a. "I can remove the bandages on my incisions tomorrow and take a shower." b. "I can expect some yellow-green drainage from the incision for a few days." c. "I should plan to limit my activities and not return to work for 4 to 6 weeks." d. "I will always need to maintain a low-fat diet since I no longer have a gallbladder."

A The asterixis indicates that the patient has hepatic encephalopathy, and hepatic coma may occur. The spider angiomas and right upper quadrant abdominal pain are not unusual for the patient with cirrhosis and do not require a change in treatment. The ascites and weight gain do indicate the need for treatment but not as urgently as the changes in neurologic status.

24. Which data obtained by the nurse during the assessment of a patient with cirrhosis will be of most concern? a. The patient's hands flap back and forth when the arms are extended. b. The patient has ascites and a 2-kg weight gain from the previous day. c. The patient's skin has multiple spider-shaped blood vessels on the abdomen. d. The patient complains of right upper-quadrant pain with abdominal palpation.

B Since the purpose of -blocker therapy for patients with esophageal varices is to decrease the risk for bleeding from esophageal varices, the best indicator of the effectiveness for propranolol is the lack of blood in the stools. Although propranolol is used to treat hypertension, angina, and tachycardia, the purpose for use in this patient is to decrease the risk for bleeding from esophageal varices.

25. A patient with cirrhosis and esophageal varices has a new prescription for propranolol (Inderal). Which assessment finding is the best indicator that the medication has been effective? a. The apical pulse rate is 68 beats/minute. b. Stools test negative for occult blood. c. The patient denies complaints of chest pain. d. Blood pressure is less than 140/90 mm Hg.

D The therapeutic action of H2 receptor blockers in patients with esophageal varices is to prevent irritation and bleeding from the varices caused by reflux of acid gastric contents. Although ranitidine does decrease the risk for peptic ulcers, reduce nausea, and help prevent aspiration pneumonia, these are not the primary purpose for H2 receptor blockade in this patient.

26. A patient who was admitted with acute bleeding from esophageal varices asks the nurse the purpose for the ordered ranitidine (Zantac). Which response by the nurse is most appropriate? a. The medication will reduce the risk for aspiration. b. The medication will decrease nausea and anorexia. c. The medication will inhibit the development of gastric ulcers. d. The medication will prevent irritation to the esophageal varices.

C The patient with acute pancreatitis is at risk for hypocalcemia, and the assessment data indicate a positive Trousseau's sign. The health care provider should be notified after the nurse checks the patient's calcium level. There is no indication that the patient needs to have the BP rechecked or that there is any arm pain.

27. When taking the BP of a patient with severe acute pancreatitis, the nurse notices carpal spasm of the patient's hand. Which action should the nurse take next? a. Ask the patient about any arm pain. b. Retake the patient's blood pressure. c. Check the calcium level on the chart. d. Notify the health care provider immediately.

D NG suction and NPO status will decrease the release of pancreatic enzymes into the pancreas and decrease pain. Although bowel sounds may be hypotonic with acute pancreatitis, the presence of bowel sounds does not indicate that treatment with NG suction and NPO status have been effective. Electrolyte levels will be abnormal with NG suction and must be replaced by appropriate IV infusion. Although Grey Turner sign will eventually resolve, it would not be appropriate to wait for this occur to determine whether treatment was effective.

28. A patient with acute pancreatitis has a nasogastric (NG) tube to suction and is NPO. Which information obtained by the nurse indicates that these therapies have been effective? a. Bowel sounds are present. b. Grey Turner sign resolves. c. Electrolyte levels are normal. d. Abdominal pain is decreased.

D A palpable abdominal mass may indicate the presence of a pancreatic abscess, which will require rapid surgical drainage to prevent sepsis. Absent bowel sounds, abdominal tenderness, and left upper quadrant pain are common in acute pancreatitis and do not require rapid action to prevent further complications.

29. When the nurse is caring for a patient with acute pancreatitis, which assessment finding is of most concern? a. Absent bowel sounds b. Abdominal tenderness c. Left upper quadrant pain d. Palpable abdominal mass

D Maintaining adequate nutritional intake is important for regeneration of hepatocytes. Interferon and antivirals may be used for chronic hepatitis B, but they are not prescribed for acute hepatitis B infection. Rest is recommended.

4. When a patient is diagnosed with acute hepatitis B, the nurse will plan to teach the patient about a. ways to increase exercise and activity level. b. self-administration of α-interferon (Intron A). c. side effects of nucleoside and nucleotide analogs. d. measures that will be helpful in improving appetite.

A Genotyping of HCV has an important role in managing treatment and is done before drug therapy is initiated. Since most patients with acute HCV infection convert to the chronic state, the nurse should not teach the patient that the HCV will resolve in a few months. Immune globulin or vaccine is not available for HCV. Ribavirin is used for chronic HCV infection.

3. A patient in the outpatient clinic is diagnosed with acute hepatitis C (HCV) infection. Which action by the nurse is appropriate? a. Schedule the patient for HCV genotype testing. b. Administer immune globulin and the HCV vaccine. c. Instruct the patient on ribavirin (Rebetol) treatment. d. Teach that the infection will resolve in a few months.

C Some medications can increase the risk for NAFLD and these should be eliminated. NAFLD is not associated with hepatitis, weight loss is usually indicated, and variceal bleeding would not be a concern in a patient with asymptomatic NAFLD.

30. Which nursing action will be included in the plan of care for a patient who has recently been diagnosed with asymptomatic nonalcoholic fatty liver disease (NAFLD)? a. Teach symptoms of variceal bleeding. b. Discuss the need to increase caloric intake. c. Review the patient's current medication list. d. Draw blood for hepatitis serology testing.

B Pegylated α-interferon is administered weekly. The other medications are appropriate for a patient with chronic hepatitis C infection.

31. The nurse is caring for a patient with chronic hepatitis C infection who has these medications prescribed. Which medication requires further discussion with the health care provider prior to administration? a. ribavirin (Rebetol, Copegus) 600 mg PO bid b. pegylated α-interferon (PEG-Intron, Pegasys) SQ daily c. diphenhydramine (Benadryl) 25 mg PO every 4 hours PRN itching d. dimenhydrinate (Dramamine) 50 mg PO every 6 hours PRN nausea

C This patient's history and fever suggest spontaneous bacterial peritonitis, which would require rapid assessment and interventions such as antibiotic therapy. The clinical manifestations for the other patients are consistent with their diagnoses and do not indicate complications are occurring.

32. During change-of-shift report, the nurse learns about the following four patients. Which patient requires the most rapid assessment? a. 50-year-old with chronic pancreatitis who has gnawing abdominal pain b. 48-year-old who has compensated cirrhosis and is complaining of anorexia c. 45-year-old with cirrhosis and severe ascites who has an oral temperature of 102° F (38.8° C) d. 56-year-old who is recovering from a laparoscopic cholecystectomy and has severe shoulder pain

B The highest priority outcome is to maintain nutrition because adequate nutrition is needed for hepatocyte regeneration. Finding a home for the patient and identifying the source of the infection would be appropriate activities, but they do not have as high a priority as ensuring adequate nutrition. Although the patient's activity level will be gradually increased, rest is indicated during the acute phase of hepatitis.

33. A homeless patient with severe anorexia and fatigue is admitted to the hospital with viral hepatitis. Which patient goal has the highest priority when the nurse is developing the plan of care? a. Increase activity level. b. Maintain adequate nutrition. c. Establish a stable home environment. d. Identify the source of exposure to hepatitis.

C The nurse's first action should be to determine the patient's hemodynamic status by assessing vital signs. Drawing blood for coagulation studies and inserting an IV catheter also are appropriate. However, the vital signs may indicate the need for more urgent actions. Since aspiration is a concern for this patient, the nurse will need to assess the patient's vital signs and neurologic status before placing the patient in the supine position.

34. A patient with cirrhosis who has been vomiting blood is admitted to the emergency department. Which action should the nurse take first? a. Insert a large-gauge IV catheter. b. Draw blood for coagulation studies. c. Check BP, heart rate, and respirations. d. Place the patient in the supine position.

C Respiratory failure can occur as a complication of acute pancreatitis, and maintenance of adequate respiratory function is the priority goal. The other outcomes also would be appropriate for the patient.

35. In planning care for a patient with acute severe pancreatitis, the nurse assigns the highest priority to the patient outcome of a. expressing satisfaction with pain control. b. developing no ongoing pancreatic problems. c. maintenance of normal respiratory function. d. having adequate fluid and electrolyte balance.

D Effective pain management will be necessary in order for the patient to improve nutrition, be receptive to education, or manage anxiety or depression.

36. Which nursing action is a priority when the nurse is caring for a patient with pancreatic cancer? a. Offer high-calorie, high-protein dietary choices. b. Offer psychologic support for anxiety or depression. c. Educate about the need to avoid scratching pruritic areas. d. Administer prescribed opioids to relieve pain as needed.

B The clay-colored stools indicate biliary obstruction, which requires rapid intervention to resolve. The other data are not unusual for a patient with this diagnosis, although the nurse also would report the other assessment information to the health care provider.

37. A patient is admitted to the hospital with acute cholecystitis. Which assessment information will be most important for the nurse to report to the health care provider? a. The patient's urine is bright yellow. b. The patient's stools are clay colored. c. The patient complains of chronic heartburn. d. The patient has an increase in pain after eating.

D Postoperative nursing care after a cholecystectomy focuses on prevention of respiratory complications because the surgical incision is high in the abdomen and impairs coughing and deep breathing. The other nursing actions also are important to implement but are not as high a priority as ensuring adequate ventilation.

38. When caring for a patient following an incisional cholecystectomy for cholelithiasis, the nurse places the highest priority on assisting the patient to a. choose low-fat foods from the menu. b. perform leg exercises hourly while awake. c. ambulate the evening of the operative day. d. turn, cough, and deep breathe every 2 hours.

B Providing oral hygiene is included in the education and scope of practice of nursing assistants. Assessments and assisting patients to choose therapeutic diets are nursing actions that require higher-level nursing education and scope of practice and would be delegated to LPNs/LVNs or RNs.

39. Which of the following nursing actions included in the plan of care for a patient with cirrhosis can the RN delegate to nursing assistive personnel? a. Assessing the patient for jaundice b. Providing oral hygiene before meals c. Palpating the abdomen for distention d. Assisting the patient in choosing the diet

A, B, D The recommendations for hepatitis B exposure include both vaccination and immune globulin administration. In addition, baseline testing for hepatitis B antibodies will be needed. Interferon and oral antivirals are not used for hepatitis B prophylaxis.

40. After an unimmunized individual is exposed to hepatitis B through a needle-stick injury, which actions will the nurse plan to take (select all that apply)? a. Administer hepatitis B vaccine. b. Test for antibodies to hepatitis B. c. Teach about α-interferon therapy. d. Give hepatitis B immune globulin. e. Educate about oral antiviral therapy.

A Therapy with ribavirin and -interferon may cause leukopenia. The other problems are not associated with this drug therapy.

5. When combination therapy of -interferon and ribavirin (Rebetol) is being used to treat chronic hepatitis C, the nurse will plan to monitor for a. leukopenia. b. hypokalemia. c. polycythemia. d. hypoglycemia.

D Any patient with a history of IV drug use should be tested for hepatitis C. Blood transfusions given after 1992, when an antibody test for hepatitis C became available, do not pose a risk for hepatitis C. Hepatitis C is not spread by the oral-fecal route and therefore is not caused by contaminated food or by traveling in underdeveloped countries.

6. Which information given by a patient when the nurse is taking a health history indicates that screening for hepatitis C should be done? a. The patient eats frequent meals in fast-food restaurants. b. The patient recently traveled to an undeveloped country. c. The patient had a blood transfusion after surgery in 1998. d. The patient reports a one-time use of IV drugs 20 years ago.

ANS: C The patient's symptoms, lack of antibodies for hepatitis, and the abrupt onset of symptoms suggest toxic hepatitis, which can be caused by commonly used OTC drugs such as acetaminophen (Tylenol). Travel to a foreign country and a history of IV drug use are risk factors for viral hepatitis. Corticosteroid use does not cause the symptoms listed.

7. A patient is admitted with an abrupt onset of jaundice, nausea, and abnormal liver function studies. Serologic testing is negative for viral causes of hepatitis. Which question by the nurse is most appropriate? a. "Is there any history of IV drug use?" b. "Are you taking corticosteroids for any reason?" c. "Do you use any over-the-counter (OTC) drugs?" d. "Have you recently traveled to a foreign country?"

D The low oncotic pressure caused by hypoalbuminemia is a major pathophysiologic factor in the development of edema. The other parameters also should be monitored, but they are not directly associated with the patient's current symptoms.

8 A patient with cirrhosis has 4+ pitting edema of the feet and legs. The data indicate that it is most important for the nurse to monitor the patient's a. hemoglobin. b. temperature. c. activity level. d. albumin level.

A The disease progression can be stopped or reversed by alcohol abstinence. The other interventions may be used when cirrhosis becomes more severe to decrease symptoms or complications, but the priority for this patient is to stop the progression of the disease.

9. A 32-year-old patient is diagnosed with early alcoholic cirrhosis. Which topic is most important to include in patient teaching? a. Need to abstain from alcohol b. Use of vitamin B supplements c. Maintenance of a nutritious diet d. Treatment with lactulose (Cephulac)