Chapter 47: Caring for Clients with Disorders of the Liver, Gallbladder, or Pancreas

Question: Which of the following conditions is most likely to involve a nursing diagnosis of fluid volume deficit? Answer: Pancreatitis

Explanation: Hypotension is typical and reflects hypovolemia and shock caused by the loss of large amounts of protein-rich fluid into the tissues and peritoneal cavity. The other conditions are less likely to exhibit fluid volume deficit.

Question: What initial measure can the nurse implement to reduce risk of injury for a client with liver disease? Answer: Pad the side rails on the bed

Explanation: Padding the side rails can reduce injury if the client becomes agitated or restless. Restraints would not be an initial measure to implement. Four side rails are considered a restraint, and this would not be an initial measure to implement. Family and friends generally assist in calming a client.

Question: A patient with bleeding esophageal varices has had pharmacologic therapy with Octreotide (Sandostatin) and endoscopic therapy with esophageal varices banding, but the patient has continued to have bleeding. What procedure that will lower portal pressure does the nurse prepare the patient for? Answer: Transjugular intrahepatic portosystemic shunting (TIPS)

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

Questions: A patient with acute pancreatitis puts the call bell on to tell the nurse about an increase in pain. The nurse observes the patient guarding; the abdomen is board-like and no bowel sounds are detected. What is the major concern for this patient? Answer: The patient has developed peritonitis.

Explanation: Abdominal guarding is present. A rigid or board-like abdomen may develop and is generally an ominous sign, usually indicating peritonitis

Question: A client with end-stage liver disease has developed hypervolemia. What nursing interventions would be most appropriate when addressing the client's fluid volume excess? Select all that apply. Answer: 1. Administering diuretics 2. Implementing fluid restrictions 3. Enhancing client positioning

Explanation: Administering diuretics, implementing fluid restrictions, and enhancing client positioning can optimize the management of fluid volume excess. Calcium channel blockers and calorie restriction do not address this problem.

Question: The nurse instructs a client on care at home after a laparoscopic cholecystectomy. Which client statement indicates that teaching has been effective? Answer: I should wash the site with mild soap and water.

Explanation: After a laparoscopic cholecystectomy, the client should be instructed about pain management, activity and exercise, wound care, nutrition, and follow-up care. The client should be directed to wash the puncture site with mild soap and water when caring for the wound. When resuming activity, the client should be instructed to drive after 3 or 4 days, take a shower or bath after 1 or 2 days, and begin light exercise such as walking immediately.

Question: The single modality of pharmacologic therapy for chronic type B viral hepatitis is: Answer: Alpha-interferon

Explanation: Alpha-interferon is a biologic response modifier that is highly effective for treatment of hepatitis B. The other antiviral agents are effective but not the preferred single-agent therapy.

Question: A client has been newly diagnosed with acute pancreatitis and admitted to the acute medical unit. How should the nurse explain the pathophysiology of this client's health problem? Answer: The enzymes that your pancreas produces have damaged the pancreas itself.

Explanation: Although the mechanisms causing pancreatitis are unknown, pancreatitis is commonly described as the autodigestion of the pancreas. Less commonly, toxic substances and microorganisms are implicated as the cause of pancreatitis.

Question: The nurse is caring for a client with a biliary disorder who has an elevated amylase level. If this elevation correlates to dysfunction, which body process does the nurse recognize may be impaired? Answer: Carbohydrate digestion

Explanation: Amylase is a pancreatic enzyme involved in the breakdown and digestion of carbohydrates. Trypsin aids in the digestion of proteins. Lipase aids in the digestion of fats.

Question: A client has been scheduled for an ultrasound of the gallbladder the following morning. What should the nurse do in preparation for this diagnostic study? Answer: Have the client refrain from food and fluids after midnight

Explanation: An ultrasound of the gallbladder is most accurate if the client fasts overnight, so that the gallbladder is distended. Contrast and radioactive agents are not used when performing ultrasonography of the gallbladder, as an ultrasound is based on reflected sound waves.

Question: The nurse is caring for a patient with acute pancreatitis. The patient has an order for an anticholinergic medication. The nurse explains that the patient will be receiving that medication for what reason? Answer: To reduce gastric and pancreatic secretions

Explanation: Anticholinergic medications reduce gastric and pancreatic secretion.

Question: A student accepted into a nursing program must begin receiving the hepatitis B series of injections. The student asks when the next two injections should be administered. What is the best response by the instructor? Answer: You must have the second one in 1 month and the third in 6 months.

Explanation: Both forms of the hepatitis B vaccine are administered intramuscularly in three doses; the second and third doses are given 1 and 6 months, respectively, after the first dose.

Question: Ammonia, the major etiologic factor in the development of encephalopathy, inhibits neurotransmission. Increased levels of ammonia are damaging to the body. The largest source of ammonia is from: Answer: The digestion of dietary and blood proteins.

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

Question: A nurse is caring for a client with hepatic encephalopathy. The nurse's assessment reveals that the client exhibits episodes of confusion, is difficult to arouse from sleep and has rigid extremities. Based on these clinical findings, the nurse should document what stage of hepatic encephalopathy? Answer: Stage 3

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

Question: A physician orders spironolactone (Aldactone), 50 mg by mouth four times daily, for a client with fluid retention caused by cirrhosis. Which finding indicates that the drug is producing a therapeutic effect? Answer: Loss of 2.2 lb (1 kg) in 24 hours

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

Question: A client with acute pancreatitis has been started on total parenteral nutrition (TPN). Which action should the nurse perform after administration of the TPN? Answer: Measure blood glucose concentration every 4 to 6 hours

Explanation: Enteral or parenteral nutrition may be prescribed. In addition to administering enteral or parenteral nutrition, the nurse monitors the serum glucose concentration every 4 to 6 hours.

Question: Which is the most common cause of esophageal varices? Answer: Portal hypertension

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

Question: A client with liver cancer is being discharged home with a biliary drainage system in place. The nurse should teach the client's family how to safely perform which of the following actions? Answer: Assessing the patency of the drainage catheter

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

Question: Which condition in a client with pancreatitis makes it necessary for the nurse to check fluid intake and output, check hourly urine output, and monitor electrolyte levels? Answer: Frequent vomiting, leading to loss of fluid volume

Explanation: Fluid and electrolyte disturbances are common complications because of nausea, vomiting, movement of fluid from the vascular compartment to the peritoneal cavity, diaphoresis, fever, and the use of gastric suction. The nurse assesses the client's fluid and electrolyte status by noting skin turgor and moistness of mucous membranes. The nurse weighs the client daily and carefully measures fluid intake and output, including urine output, nasogastric secretions, and diarrhea.

Question: When the nurse is caring for a patient with acute pancreatitis, what intervention can be provided in order to prevent atelectasis and prevent pooling of respiratory secretions? Answer: Frequent changes of positions

Explanation: Frequent changes of position are necessary to prevent atelectasis and pooling of respiratory secretions.

Question: A group of nurses attended an inservice on the prevention of occupationally acquired diseases that affect health care providers. What action has the greatest potential to reduce a nurse's risk of acquiring hepatitis C (HCV ) in the workplace? Answer: Disposing of sharps appropriately and not recapping needles

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

Question: Which type of jaundice seen in adults is the result of increased destruction of red blood cells? Answer: Hemolytic

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

Question: A client has an elevated serum ammonia concentration and is exhibiting changes in mental status. The nurse should suspect which condition? Answer: Hepatic encephalopathy

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

Question: The nurse is providing care to a patient with gross ascites who is maintaining a position of comfort in the high semi-Fowler's position. What is the nurse's priority assessment of this patient? Answer: Respiratory assessment related to increased thoracic pressure

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

Question: A nurse is caring for a client with a blocked bile duct from a tumor. What manifestation of obstructive jaundice should the nurse anticipate? Answer: Orange and foamy urine

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

Question: A student nurse is caring for a client who has a diagnosis of acute pancreatitis and who is receiving parenteral nutrition. The student should prioritize which of the following assessments? Answer: Blood glucose levels

Explanation: In addition to administering enteral or parenteral nutrition, the nurse monitors serum glucose levels every 4 to 6 hours. Output should be monitored but in most cases it is not more important than serum glucose levels. A client on parenteral nutrition would have no oral intake to monitor. Blood sugar levels are more likely to be unstable than indicators of renal function.

Question: A nurse on a solid organ transplant unit is planning the care of a client who will soon be admitted upon immediate recovery following liver transplantation. What aspect of nursing care is the nurse's priority? Answer: Implementation of infection-control measures

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

Question: The family of a client in the ICU diagnosed with acute pancreatitis asks the nurse why the client has been moved to an air bed. What would be the nurse's best response? Answer: The bed automatically moves, so she's less likely to develop pressure sores while she's in bed.

Explanation: It is important to turn the client every 2 hours; use of specialty beds may be indicated to prevent skin breakdown. The rationale for a specialty bed is not related to repositioning, comfort, or ease of movement.

Question: Which of the following is commonly associated with acute episodes of pancreatitis? Answer: Long-term use of alcohol

Explanation: Long-term use of alcohol is commonly associated with acute episodes of pancreatitis, but the patient usually has had undiagnosed chronic pancreatitis before the first episode of acute pancreatitis. Less common causes of pancreatitis include bacterial or viral infection.

Question: A nurse is caring for a client with cirrhosis secondary to heavy alcohol use. The nurse's most recent assessment reveals subtle changes in the client's cognition and behavior. What is the nurse's most appropriate response? Answer: Report this finding to the primary provider due to the possibility of hepatic encephalopathy

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

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

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

Question: A nurse is caring for a client with cholelithiasis. Which sign indicates obstructive jaundice? Answer: Clay-colored stools

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

Question: A client with chronic pancreatitis had a pancreaticojejunostomy created 3 months ago for relief of pain and to restore drainage of pancreatic secretions. The client has come to the office for a routine postsurgical appointment. The client is frustrated that the pain has not decreased. What is the most appropriate initial response by the nurse? Answer: Pain relief occurs by 6 months in most clients who undergo this procedure, but some people experience a recurrence of their pain.

Explanation: Pain relief from a pancreaticojejunostomy often occurs by 6 months in more than 85% of the clients who undergo this procedure, but pain returns in a substantial number of clients as the disease progresses. This client had surgery 3 months ago; the client has 3 months before optimal benefits of the procedure may be experienced. There is no obvious indication for gallbladder removal and nonadherence is not the most likely factor underlying the pain.

Question: The physician has written the following orders for a new client admitted with pancreatitis: bed rest, nothing by mouth (NPO), and administration of total parenteral nutrition (TPN) . Which does the nurse attribute as the reason for NPO status? Answer: To avoid inflammation of the pancreas

Explanation: Pancreatic secretion is increased by food and fluid intake and may cause inflammation of the pancreas.

Question: A nurse educator is teaching a group of recent nursing graduates about their occupational risks for contracting hepatitis B. What preventative measures should the educator promote? Select all that apply. Answer: Immunization, Use of standard precautions

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

Question: A client comes to the ED with severe abdominal pain, nausea, and vomiting. The physician plans to rule out acute pancreatitis. The nurse would expect the diagnosis to be confirmed by an elevated result on which laboratory test? Answer: Serum amylase

Explanation: Serum amylase and lipase concentrations are used to make the diagnosis of acute pancreatitis. Serum amylase and lipase concentrations are elevated within 24 hours of the onset of symptoms. Serum amylase usually returns to normal within 48 to 72 hours, but the serum lipase concentration may remain elevated for a longer period, often days longer than amylase. Urinary amylase concentrations also become elevated and remain elevated longer than serum amylase concentrations.

Question: Diagnostic testing has revealed that a client's hepatocellular carcinoma (HCC) is limited to one lobe. The nurse should anticipate that this client's plan of care will focus on what intervention? Answer: Lobectomy

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

Question: What is the recommended dietary treatment for a client with chronic cholecystitis? Answer: low-fat diet

Explanation: The bile secreted from the gallbladder helps the body absorb and break down dietary fats. If the gallbladder is not functioning properly, then it will not secrete enough bile to help digest the dietary fat. This can lead to further complications; therefore, a diet low in fat can be used to prevent complications.

Question: A client who has undergone liver transplantation is ready to be discharged home. Which outcome of health education should the nurse prioritize? Answer: The client will take immunosuppressive agents as required

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

Question: When caring for the patient with acute pancreatitis, the nurse must consider pain relief measures. What nursing interventions could the nurse provide? (Select all that apply.) Answer: 1. Administering parenteral opioid analgesics as ordered 2. Withholding oral feedings to limit the release of secretin 3. Encouraging bed rest to decrease the metabolic rate

Explanation: The current recommendation for pain management is the use of opioids, with assessment for their effectiveness and altering therapy if pain is not controlled or increased (Marx, 2009). Nonpharmacologic interventions such as proper positioning (not prone), music, distraction, and imagery may be effective in reducing pain when used along with medications. In addition, oral feedings are withheld to decrease the secretion of secretin.

Question: Clinical manifestations of common bile duct obstruction include all of the following except: Answer: Light-colored urine

Explanation: The excretion of the bile pigments by the kidneys gives the urine a very dark color. The feces, no longer colored with bile pigments, are grayish, like putty, or clay-colored. The symptoms may be acute or chronic. Epigastric distress, such as fullness, abdominal distention, and vague pain in the right upper quadrant of the abdomen, may occur. If it goes untreated jaundice and pruritus can occur.

Question: A client with a history of alcohol abuse comes to the emergency department and complains of abdominal pain. Laboratory studies help confirm a diagnosis of acute pancreatitis. The client's vital signs are stable, but the client's pain is worsening and radiating to his back. Which intervention takes priority for this client? Answer: Administering morphine I.V. as ordered

Explanation: The nurse should address the client's pain issues first by administering morphine I.V. as ordered. Placing the client in a Semi-Fowler's position, maintaining NPO status, and providing mouth care don't take priority over addressing the client's pain issues.

Question: A nurse is caring for a client with hepatic encephalopathy. While making the initial shift assessment, the nurse notes that the client has a flapping tremor of the hands. The nurse should document the presence of what sign of liver disease? Answer: Asterixis

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

Question: The nurse is administering Cephulac (lactulose) to decrease the ammonia level in a patient who has hepatic encephalopathy. What should the nurse carefully monitor for that may indicate a medication overdose? Answer: Watery diarrhea

Explanation: The patient receiving lactulose is monitored closely for the development of watery diarrhea stools, because they indicate a medication overdose. Serum ammonia levels are closely monitored as well.

Question: A client is admitted to the health care facility with abdominal pain, a low-grade fever, abdominal distention, and weight loss. The physician diagnoses acute pancreatitis. What is the primary goal of nursing care for this client? Answer: Relieving abdominal pain

Explanation: The predominant clinical feature of acute pancreatitis is abdominal pain, which usually reaches peak intensity several hours after onset of the illness. Therefore, relieving abdominal pain is the nurse's primary goal. Because acute pancreatitis causes nausea and vomiting, the nurse should try to prevent fluid volume deficit, not overload. The nurse can't help the client achieve adequate nutrition or understand the disease and its treatment until the client is comfortable and no longer in pain.

Question: Total parental nutrition (TPN) should be used cautiously in clients with pancreatitis because such clients: Answer: cannot tolerate high-glucose concentration.

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

Question: Which medication is used to decrease portal pressure, halting bleeding of esophageal varices? Answer: Vasopressin

Explanation: Vasopressin may be the initial therapy for esophageal varices because it produces constriction of the splanchnic arterial bed and decreases portal hypertension. Nitroglycerin has been used to prevent the side effects of vasopressin. Spironolactone and cimetidine do not decrease portal hypertension.

Question:A client with chronic pancreatitis is treated for uncontrolled pain. Which complication does the nurse recognize is most common in the client with chronic pancreatitis? Answer: Weight Loss

Explanation: Weight loss is most common in the client with chronic pancreatitis due to decreased dietary intake secondary to anorexia or fear that eating will precipitate another attack. The other answer choices are not the most common complications related to chronic pancreatitis.

Question: A client with a diagnosis of esophageal varices has undergone endoscopy to gauge the progression of this complication of liver disease. Following the completion of this diagnostic test, what nursing intervention should the nurse perform? Answer: Keep client NPO until the client's gag reflex returns.

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

Question: The nurse is planning care for a client following an incisional cholecystectomy for cholelithiasis. Which intervention is the highest nursing priority for this client? Answer: Assisting the client to turn, cough, and deep breathe every 2 hours

Explanation: Assessment should focus on the client's respiratory status. If a traditional surgical approach is planned, the high abdominal incision required during surgery may interfere with full respiratory excursion. The other nursing actions are also important, but are not as high a priority as ensuring adequate ventilation.

Question: An adult client has been admitted to the medical unit for the treatment of acute pancreatitis. What nursing action should be included in this client's plan of care? Answer: Measure the client's abdominal girth daily

Explanation: Due to the risk of ascites, the nurse should monitor the client's abdominal girth. There is no specific need to avoid the use of opioids or to monitor for dysphagia, and activity is usually limited.

Question: A nurse who provides care in a community clinic assesses a wide range of individuals. The nurse should identify which client as having the highest risk for chronic pancreatitis? Answer: A 39-year-old man with chronic alcoholism

Explanation: Excessive and prolonged consumption of alcohol accounts for approximately 50% of all cases of chronic pancreatitis.

Question: The nurse identifies which type of jaundice in an adult experiencing a transfusion reaction? Answer: Hemolytic

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

Question: A client has had a laparoscopic cholecystectomy. The client is now reporting right shoulder pain. What should the nurse suggest to relieve the pain? Answer: Application of heat 15 to 20 minutes each hour

Explanation: If pain occurs in the right shoulder or scapular area (from migration of the CO2 used to insufflate the abdominal cavity during the procedure), the nurse may recommend use of a heating pad for 15 to 20 minutes hourly, walking, and sitting up when in bed. Aspirin would constitute a risk for bleeding.

Question: Which term describes the passage of a hollow instrument into a cavity to withdraw fluid? Answer: Paracentesis

Explanation: Paracentesis may be used to withdraw fluid (ascites) if the accumulated fluid is causing cardiorespiratory compromise. Asterixis refers to involuntary flapping movements of the hands associated with metabolic liver dysfunction. Ascites refers to accumulation of serous fluid within the peritoneal cavity. Dialysis refers to a form of filtration to separate crystalloid from colloid substances.

Question: Which is a clinical manifestation of cholelithiasis? Answer: Clay- colored stools

Explanation: The client with gallstones has clay-colored stools and excruciating upper right quadrant pain that radiates to the back or right shoulder. The excretion of bile pigments by the kidneys makes urine very dark. The feces, no longer colored with bile pigments, are grayish (like putty) or clay colored. The client develops a fever and may have a palpable abdominal mass.

Question: A nurse is assessing a postoperative client for hemorrhage. What responses associated with the compensatory stage of shock should be reported to the healthcare provider? Answer: Tachycardia and Tachypnea

Explanation: The compensatory stage is the first stage of shock. During this stage, the sympathetic nervous system (SNS) is activated due to changes in blood volume and blood pressure. The SNS stimulates the cardiovascular system, causing tachycardia, and the respiratory system, causing tachypnea. Thus, tachycardia (not bradycardia) and tachypnea (not bradypnea) occur with the compensatory stage of shock.

Question: A client with liver cirrhosis develops ascites. Which medication will the nurse prepare teaching for this client? Answer: Spironolactone

Explanation: The use of diuretic agents along with sodium restriction is successful in 90% of clients with ascites. Spironolactone, an aldosterone-blocking agent, is most often the first-line therapy in clients with ascites from cirrhosis. When used with other diuretic agents, spironolactone helps prevent potassium loss. Oral diuretic agents such as furosemide may be added but should be used cautiously because long-term use may induce severe hyponatremia (sodium depletion). Acetazolamide and ammonium chloride are contraindicated because of the possibility of precipitating hepatic encephalopathy and coma.

Question: A client has been diagnosed with acute pancreatitis. The nurse is addressing the client's acute pain. What pharmacologic intervention is most likely to be ordered for this client? Answer: IV hydromorphone

Explanation: The pain of acute pancreatitis is often very severe and pain relief may require parenteral opioids such as morphine, fentanyl, or hydromorphone. There is no clinical evidence to support the use of meperidine for pain relief in pancreatitis. Opioids are preferred over NSAIDs.

Question: Total parental nutrition (TPN) should be used cautiously in clients with pancreatitis because such clients: Answer: Cannot tolerate high-glucose concentration

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

Question: A patient is diagnosed with mild acute pancreatitis. What does the nurse understand is characteristic of this disorder? Answer: Edema and inflammation

Explanation: Mild acute pancreatitis is characterized by edema and inflammation confined to the pancreas. Minimal organ dysfunction is present, and return to normal function usually occurs within 6 months.