44 Liver, Pancreas and Biliary Tract - Lippincotts

32. Which of the following is normal for a client during the icteric phase of viral hepatitis? 1. Tarry stools. 2. Yellowed sclera. 3. Shortness of breath. 4. Light, frothy urine.

2. Liver inflammation & obstruction block the normal flow of bile. Excess bilirubin turns the skin & sclera yellow, and the urine dark & frothy. Profound anorexia is also common. Tarry stools are indicative of GI bleeding & would NOT be expected in hepatitis. Light- or clay-colored stools may occur in hepatitis owing to bile duct obstruction. SOB would be unexpected.

28. The client with chronic pancreatitis should be monitored closely for the development of which of the following disorders? 1. Cholelithiasis. 2. Hepatitis. 3. Irritable bowel syndrome. 4. Diabetes mellitus.

4. Pts with chronic pancreatitis are likely to develop diabetes as a result of the pancreatic fibrosis that occurs. The pancreas becomes unable to secrete insulin. Cholelithiasis, hepatitis & irritable bowel syndrome are NOT caused by chronic pancreatitis.

THE CLIENT WITH CHOLECYSTITIS 1. A client has undergone a laparoscopic cholecystectomy. Which of the following instructions should the nurse include in the discharge teaching? 1. Empty the bile bag daily. 2. If you become nauseated, breathe deeply into a paper bag. 3. Keep adhesive dressings in place for 6 weeks. 4. Report bile-colored drainage from any incision.

4. There should be no bile-colored drainage coming from any of the incisions postoperatively. A laparoscopic cholecystectomy does not involve a bile bag. Breathing deeply into a paper bag will prevent a person from passing out due to hyperventilation. it does not alleviate nausea. If the adhesive dressings have not already fallen off, they are removed by the surgeon in 7-10 days, not 6 weeks.

36. When planning care for a client with viral hepatitis, the nurse should review laboratory reports for which of the following abnormal laboratory values? 1. Prolonged prothrombin time. 2. Decreased blood glucose level. 3. Elevated serum potassium level. 4. Decreased serum calcium level.

1. The prothrombin time may be prolonged because of ↓ absorption of vitamin K & ↓ production of prothrombin by the liver. The pt should be assessed carefully for bleeding tendencies. Blood glucose and serum potassium & calcium levels are NOT affected by hepatitis.

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

2. ↓ Low-fat, ↑ high protein, ↑ high CHO diet is encouraged for a pt with hepatitis to promote liver rejuvenation. Nutrition intake is important because pt may be anorexic & experience weight loss. Activity should be modified & adequate rest obtained to promote hepatocyte. Social isolation should be avoided & education on preventing transmission should be provided.

64. The nurse is preparing a client for a paracentesis. The nurse should: 1. Have the client void immediately before the procedure. 2. Place the client in a side-lying position. 3. Initiate an I.V. line to administer sedatives. 4. Place the client on nothing-by-mouth (NPO) status 6 hours before the procedure.

1. Immediately before a paracentesis, the pt should EMPTY the bladder to prevent perforation The pt will be placed in a high Fowler's position or seated on the side of the bed for the procedure IV sedatives are NOT usually administered The client does NOT need to be NPO.

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

1. Normal serum albumin is administered to ↓ ascites. Hypoalbuminemia, a mechanism underlying ascites formation, results in ↓ colloid osmotic pressure. Administering serum albumin ↑ the plasma colloid osmotic pressure, which causes fluid to flow from the tissue space into the plasma. ↑ UO is the BEST indication that the albumin is having the desired effect. An ↑ serum albumin level & ↑ ease of breathing may indirectly imply that the administration of albumin is effective in relieving the ascites. However, it is NOT as direct as an indicator as ↑ UO is. Anorexia is NOT affected by the administration of albumin.

24. A client is receiving Propantheline bromide (Pro-Banthine) in the management of acute pancreatitis. Which of the following would indicate that the nurse should withhold the medication? 1. Absent bowel sounds. 2. Increased urine output. 3. Diarrhea. 4. Decreased heart rate.

1. Propantheline is an anticholinergic, anti-spasmodic medication that ↓ vagal stimulation & pancreatic secretions. * Ø: It is contraindicated in paralytic ileus, therefore the nurse should be concerned with the absent bowel sounds. Side effects are urinary retention, constipation, and tachycardia.

THE CLIENT WITH PANCREATITIS 15. A client has an amylase level of 450 units/L and lipase level of 659 units/L. The client has mid-epigastric pain with nausea. What assessment helps the nurse to determine severity of the client's condition? 1. Ranson's criteria. 2. Vital signs. 3. Urine output. 4. Glasgow Coma Scale.

1. The elevated amylase and lipase & symptoms suggest acute pancreatitis. Ranson's criteria is a clinical predictor scale used to assess the severity of acute pancreatitis & prognosis. VS are used to evaluate hemodynamic stability. UO is monitored for assessment of fluid volume status. Glasgow Coma Scale (GCS) is a neuro scale to assess the LOC.

33. The nurse is planning a home visit for a client with hepatitis. In order to prevent transmission the nurse should focus teaching on: 1. Proper food handling. 2. Insulin syringe disposal. 3. Alpha-interferon. 4. Use of condoms.

1. The main route of transmission for hepatitis A is the oral-fecal route, rarely parenteral. Good hand-washing before eating or preparing food Percutaneous transmission is seen with hepatitis B, C, & D. Alpha-interferon is used for TX of chronic hepatitis B & C.

11. The nurse prepares to administer promethazine (Phenergan) 35 mg I.M. as ordered p.r.n. for a client with cholecystitis complaining of nausea. The ampule label reads that the medication is available in 25 mg/mL. How many milliliters should the nurse administer? ________mL.

1.4 mL

18. A client with acute pancreatitis has a blood pressure of 88/40, heart rate of 128 beats per minute, respirations of 28 per minute, and Grey Turner's sign. What action should the nurse perform first? 1. Assess the urine output. 2. Place an intravenous line. 3. Position on the left side. 4. Insert a nasogastric tube.

2. Grey Turner's sign is a bluish discoloration in the flank area caused by retroperitoneal bleeding. The VS are showing hemodynamic instability. IV access should be obtained to provide immediate volume replacement. The UO will provide information on the fluid status. A nasogastric tube is indicated for pts with uncontrolled nausea & vomiting or gastric distension. Repositioning the pt may be considered for pain management once the pt's VS are stable.

26. Pancreatic enzyme replacements are ordered for the client with chronic pancreatitis. When should the nurse instruct the client to take them to obtain the most therapeutic effect? 1. Three times daily between meals. 2. With each meal and snack. 3. In the morning and at bedtime. 4. Every 4 hours, at specified times.

2. In chronic pancreatitis, destruction of pancreatic tissue requires pancreatic enzyme replacement. Pancreatic enzymes are prescribed to facilitate the digestion of proteins & fats, and should be taken in conjunction with every meal & snack. Specified hours or limited times for administration are ineffective because the enzymes must be taken in conjunction with food ingestion.

7. At 8 a.m., the nurse reviews the amount of T-tube drainage for a client who underwent an open cholecystectomy yesterday. After reviewing the output record (see chart), the nurse should: Output Record of Date T-tube 12 pm - 50 mL, 4 pm - 60 mL, 8 pm - 60 mL, 1 2 am - 70 mL, 4 am - 70 mL, 8 am - 10 mL 1. Report the 24-hour drainage amount at 12 noon. 2. Clamp the T-tube. 3. Evaluate the tube for patency. 4. Irrigate the T-tube.

3. The T-tube should drain approximately 300-500 mL in the first 24 hrs & after 3-4 days the amount should ↓ to <200 mL in 24 hrs. With the sudden ↓ in drainage at 8 a.m., the nurse should IMMEDIATELY assess the tube for obstruction of flow that can be caused by kinks in the tube or the pt lying on the tube. Drainage color must also be assessed for signs of bleeding. The tube should not be irrigated or clamped without an order.

48. The nurse is assessing a client who is in the early stages of cirrhosis of the liver. Which focused assessment is appropriate? 1. Peripheral edema. 2. Ascites. 3. Anorexia. 4. Jaundice.

3. Early clinical manifestations of cirrhosis are subtle & usually include GI symptoms, such as: - anorexia - nausea - vomiting - changes in bowel patterns These changes are caused by the liver's altered ability to metabolize CHO, proteins & fats. Peripheral edema, ascites & jaundice are later signs of liver failure & portal hypertension.

21. The nurse should monitor the client with acute pancreatitis for which of the following complications? 1. Heart failure. 2. Duodenal ulcer. 3. Cirrhosis. 4. Pneumonia.

4. The client with acute pancreatitis is prone to complications associated with the respiratory system. Pneumonia, atelectasis, and pleural effusion are examples of respiratory complications that can develop as a result of pancreatic enzyme exudate. Pancreatitis does NOT cause heart failure, ulcer formation, or cirrhosis.

39. The nurse assesses that the client with hepatitis is experiencing fatigue, weakness, and a general feeling of malaise. The client tires rapidly during morning care. Based on this information, which of the following would be an appropriate nursing diagnosis? 1. Impaired physical mobility related to malaise. 2. Self-care deficit related to fatigue. 3. Ineffective coping related to long-term illness. 4. Activity intolerance related to fatigue.

4. The most appropriate DX for this pt is Activity intolerance related to fatigue. The major goal of care for the pt with hepatitis is to ↑ activity gradually as tolerated. Periods of alternating rest & activity should be included in the plan of care. There is NO evidence that the pt is physically immobile, unable to provide self-care, or coping ineffectively.

61. The nurse has an order to administer 2 oz of lactulose (Cephulac) to a client who has cirrhosis. How many milliliters of lactulose should the nurse administer? ________mL.

60 mL 1oz=30 mL X2= 60

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

1, 2, 3, 4, 5. - Constipation leads to ↑ ammonia production - Lactulose (Cephulac) is a hyperosmotic laxative that ↓ blood ammonia by acidifying the colon contents, which retards diffusion of nonionic ammonia from the colon to the blood while promoting its migration from the blood to the colon. - Hepatic encephalopathy is considered a toxic or metabolic condition that causes cerebral edema; it affects a person's coordination & pupil reaction to light & accommodation. - Food & fluids ↑ in CHO should be given because the liver is NOT synthesizing & storing glucose. * Ø Exercise produces ammonia as a byproduct of metabolism, physical activity should be limited, NOT encouraged.

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

1, 3, 5. Following a laparoscopic cholecystectomy, the pt can resume a normal diet as tolerated. The client may experience right shoulder pain from the gas that was used to inflate the abdomen during surgery. The puncture site should be cleansed daily with mild soap & water. Driving can usually be resumed in 3-4 days following surgery & there is no need for the pt to maintain bed rest in the days following surgery. Light exercise such as walking can be resumed immediately.

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

2. The pt should be able to verbalize the importance of reporting any bleeding tendencies that could be the result of a prolonged prothrombin time. Ascites is not typically a clinical manifestation of hepatitis; it is assoc. with cirrhosis. * Ø Alcohol use should be eliminated for AT LEAST 1 YR after the DX of hepatitis to allow the liver time to fully recover. There is no need for a pt to be restricted to the home because hepatitis is not spread through casual contact between individuals.

13. Which of the following discharge instructions would be appropriate for a client who has had a laparoscopic cholecystectomy? 1. Avoid showering for 48 hours after surgery. 2. Return to work within 1 week. 3. Leave dressings in place until you see the surgeon at the postoperative visit. 4. Use acetaminophen (Tylenol) to control any fever.

3. After a laparoscopic cholecystectomy, the pt should not remove dressings from the puncture sites but should wait until visiting the surgeon. The pt may shower the day after surgery. A client can return to work within 1 week, but only if approved by the surgeon & no strenuous activity is involved. The pt should report any fever, which could be an indication of a complication.

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

3. Clients with acute necrotizing pancreatitis should remain NPO with early enteral feeding via the jejunum to maintain bowel integrity & immune function. TPN is considered if enteral feedings are contraindicated. Access is also needed for TPN, preferably via a central line. Hemodynamic instability can result from fluid volume loss & bleeding; requires fluid & electrolyte replacement. Fat necrosis occurring with acute pancreatitis can cause hypocalcemia requiring calcium replacement. A Foley catheter provides accurate output assessment to monitor for prerenal acute renal failure that can occur from hypovolemia.

27. The nurse should teach the client with chronic pancreatitis to monitor the effectiveness of pancreatic enzyme replacement therapy by doing which of the following? 1. Monitoring fluid intake. 2. Performing regular glucose fingerstick tests. 3. Observing stools for steatorrhea. 4. Testing urine for ketones.

3. If the dosage & administration of pancreatic enzymes are adequate, the pt's stool will be relatively normal. Any ↑ in odor or fat content would indicate the need for dosage adjustment. Stable body weight would be another indirect indicator. Fluid intake does not affect enzyme replacement therapy. If diabetes has developed, the pt will need to monitor glucose levels. However, glucose & ketone levels are not affected by pancreatic enzyme therapy & would not indicate effectiveness of the therapy.

58. The physician orders oral neomycin (Mycifradin) as well as a neomycin enema for a client with cirrhosis. The expected outcome of this therapy is to: 1. Reduce abdominal pressure. 2. Prevent straining during defecation. 3. Block ammonia formation. 4. Reduce bleeding within the intestine.

3. Neomycin (Mycifradin) is administered to ↓ the bacterial action on protein in the intestines, which results in ammonia production. This ammonia, if not detoxified by the liver, can result in hepatic encephalopathy and coma. The antibiotic does NOT ↓ abdominal pressure, prevent straining during defecation, or ↓ hemorrhaging within the intestine.

30. The nurse is assessing a client with hepatitis and notices that the AST and ALT lab values have increased. Which of the following statements by the client requires further instruction by the nurse? 1. "I require increased periods of rest." 2. "I follow a low-fat, high carbohydrate diet." 3. "I eat dry toast to relieve my nausea." 4. "I take acetaminophen (Tylenol) for arthritis pain."

4. Acetaminophen is toxic to the liver & should be avoided in a pt with liver dysfunction. ↑ periods of rest allow for liver regeneration. A low-fat, high carbohydrate diet & dry toast to relieve nausea are appropriate.

9. After a cholecystectomy, the client is to follow a low-fat diet. Which of the following foods would be most appropriate to include in a low-fat diet? 1. Cheese omelet. 2. Peanut butter. 3. Ham salad sandwich. 4. Roast beef.

4. Lean meats, such as: beef, lamb, veal & well-trimmed lean ham & pork, are low in fat. Rice, pasta & vegetables are low in fat when NOT served with butter, cream, or sauces. Fruits are low in fat The amount of fat allowed in a pt's diet after a cholecystectomy will depend on the pt's ability to tolerate fat. Typically, the pt does not require a special diet but is encouraged to Ø excessive fat intake. A cheese omelet & peanut butter have high fat content. Ham salad is high in fat from the fat in salad dressing.

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

1, 2, 3. Bile is created in the liver, stored in the gallbladder & released into the duodenum giving stool its brown color. A bile duct obstruction can cause PALE colored stools. Other symptoms assoc. with cholelithiasis are - right upper quadrant tenderness - fever from inflammation or infection - jaundice from ↑ serum bilirubin levels - nausea and/or RUQ pain after a fatty meal Pain at McBurney's point lies between the umbilicus and right iliac crest and is associated with appendicitis. A bleeding ulcer produces black, tarry stools. Respiratory distress is not a symptom of cholelithiasis.

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

1, 4, 5. The pt with acute pancreatitis usually experiences acute abdominal pain. Placing the pt in a side-lying position relieves the tension on the abdominal area & promotes comfort. A semi Fowler's position is also appropriate. The nurse should also monitor the pt's respiratory status because pts with pancreatitis are prone to develop respiratory complications. Daily weights are obtained to monitor the pt's nutritional & fluid volume status. Ø: While the pt will likely need opioid analgesics to tx the pain, morphine sulfate is NOT appropriate as it stimulates spasm of the sphincter of Oddi, thus ↑ the Pt's discomfort. During the acute phase of the illness while the pt is experiencing pain, the pancreas is RESTED by withholding food & drink. When the diet is reintroduced, it is a: ↑ high-carbohydrate ↓ low-fat / bland diet

52. Which of the following health promotion activities would be appropriate for the nurse to suggest that the client with cirrhosis add to the daily routine at home? 1. Supplement the diet with daily multivitamins. 2. Limit daily alcohol intake. 3. Take a sleeping pill at bedtime. 4. Limit contact with other people whenever possible.

1. General health promotion measures include: - maintaining good nutrition - avoiding infection - abstaining from alcohol Rest & sleep is essential, but an impaired liver may not be able to detoxify sedatives & barbiturates. Such drugs must be used cautiously, if at all, by pts with cirrhosis. The pt does not need to limit contact with others but should exercise caution to stay away from ill people.

50. What diet should be implemented for a client who is in the early stages of cirrhosis? 1. High-calorie, high-carbohydrate. 2. High-protein, low-fat. 3. Low-fat, low-protein. 4. High-carbohydrate, low-sodium.

1. For pts who have Cirrhosis w/o complications, a ↑ high-calorie / ↑ high-CHO diet is preferred to provide an adequate supply of nutrients. In the EARLY stages of cirrhosis, there is no need to restrict fat, protein, or sodium.

20. Which of the following medications would the nurse question for a client with acute pancreatitis? 1. Furosemide (Lasix) 20 mg I.V. push. 2. Imipenem (Primaxin) 500 mg I.V. 3. Morphine Sulfate 2 mg I.V. push. 4. Famotidine (Pepcid) 20 mg I.V. push.

1. Furosemide (Lasix) can cause pancreatitis. Additionally, hypovolemia can develop with acute pancreatitis & Lasix will further delete fluid volume. Imipenem is indicated in the TX of acute pancreatitis with necrosis & infection. Research no longer supports Meperidine (Demerol) over other opiates. Morphine & Dilaudid are opiates of choice in acute pancreatitis to get pain under control. "Famoti-DINE" is a Histamine 2 receptor antagonist used to ↓ acid secretion & prevent stress or peptic ulcers.

23. The nurse notes that a client with acute pancreatitis occasionally experiences muscle twitching and jerking. How should the nurse interpret the significance of these symptoms? 1. The client may be developing hypocalcemia. 2. The client is experiencing a reaction to meperidine (Demerol). 3. The client has a nutritional imbalance. 4. The client needs a muscle relaxant to help him rest.

1. Hypocalcemia develops in SEVERE cases of acute pancreatitis. The exact cause is unknown. S/SX of hypocalcemia: jerking & muscle twitching, numbness of fingers & lips, and irritability. Meperidine (Demerol) may cause tremors or seizures as an adverse effect, but NOT muscle twitching. Muscle twitching is not caused by a nutritional deficit, nor does it indicate that the pt needs a muscle relaxant.

5. A client who has been scheduled to have a choledocholithotomy expresses anxiety about having surgery. Which nursing intervention would be the most appropriate to achieve the outcome of anxiety reduction? 1. Providing the client with information about what to expect postoperatively. 2. Telling the client it is normal to be afraid. 3. Reassuring the client by telling her that surgery is a common procedure. 4. Stressing the importance of following the physician's instructions after surgery.

1. Providing information can help to answer the pts questions & ↓ anxiety Fear of the unknown can ↑ anxiety Telling the pt not to be afraid, that the procedure is common, or to follow her physician's orders will not necessarily ↓ anxiety.

70. The nurse is taking care of a client who has an I.V. infusion pump. The pump alarm rings. What should the nurse do in order from first to last? 1. Silence the pump alarm. 2. Determine if the infusion pump is plugged into an electrical outlet. 3. Assess the client's access site for infiltration or inflammation. 4. Assess the tubing for hindrances to flow of solution.

1. Silence the pump alarm. 3. Assess the client's access site for infiltration or inflammation. 4. Assess the tubing for hindrances to flow of solution. 2. Determine if the infusion pump is plugged into an electrical outlet. Silencing the alarm will eliminate a stress to the pt & allow the nurse to focus on the task at hand. The nurse should then assess the access site to note if the needle is inserted in the vein or if there is tissue trauma, infiltration, or inflammation. Next, the nurse should check for kinks in the tubing. Finally, the nurse can plug the pump into the wall to allow the battery to become recharged.

68. The nurse's assignment consists of the following four clients. From highest to lowest PRIORITY, in which order should the nurse assess the clients after receiving morning report? 1. The client with cirrhosis who became confused and disoriented during the night. 2. The client with acute pancreatitis who is requesting pain medication. 3. The client who is 1 day postoperative following a cholecystectomy and has a T-tube inserted. 4. The client with hepatitis B who has questions about his discharge instructions.

1. The client with cirrhosis who became confused and disoriented during the night. 2. The client with acute pancreatitis who is requesting pain medication. 3. The client who is 1 day postoperative following a cholecystectomy and has a T-tube inserted. 4. The client with hepatitis B who has questions about his discharge instructions. The nurse should FIRST assess the client with cirrhosis to ensure the pt's safety and to assess the client for the onset of hepatic encephalopathy. The nurse should then assess the client with acute pancreatitis who is requesting pain medication & administer the needed medication. The nurse should next assess the pt who underwent a cholecystectomy and is 1 day postop to make sure that the T-tube is draining & that the pt is performing postop breathing exercises. This pt's safety is NOT at risk & the pt is not indicating that he is in pain, so his care is a lower priority. The nurse can speak last with the pt with hepatitis B who has questions about his discharge instructions because this pt's issues are NOT urgent

35. The nurse is developing a plan of care for the client with viral hepatitis. The nurse should instruct the client to: 1. Obtain adequate bed rest. 2. Increase fluid intake. 3. Take antibiotic therapy as ordered. 4. Drink 8 oz of an electrolyte solution every day.

1. Treatment of hepatitis consists primarily of bed rest with bathroom privileges. Bed rest is maintained during the acute phase to ↓ metabolic demands on the liver, thus ↑ its blood supply & promoting liver cell regeneration. When activity is gradually resumed, the pt should be taught to rest before becoming overly tired. Although adequate fluid intake is important, it is not necessary to force fluids to tx hepatitis. Antibiotics are NOT used to tx hepatitis. Electrolyte imbalances are NOT typical of hepatitis.

51. A client with jaundice has pruritis and states that he has areas of irritation from scratching. What measures can the nurse discuss to prevent skin breakdown? Select all that apply. 1. Avoid lotions containing calamine. 2. Take baking soda baths. 3. Keep nails short and clean. 4. Rub with knuckles instead of nails. 5. Massage skin with alcohol. 6. Increase sodium intake in diet.

2, 3, 4. - Baking soda baths can ↓ pruritis - Keeping nails short & rubbing with knuckles can ↓ breakdown when scratching cannot be resisted, such as during sleep. - Calamine lotions help relieve itching * Ø Alcohol will ↑ skin dryness. Sodium in the diet will ↑ edema & weaken skin integrity.

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

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

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

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

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

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

60. A client's serum ammonia level is elevated, and the physician orders 30 mL of lactulose (Cephulac). Which of the following is an adverse effect of this drug? 1. Increased urine output. 2. Improved level of consciousness. 3. Increased bowel movements. 4. Nausea and vomiting.

3. Lactulose (Cephulac) ↑ intestinal motility, thereby trapping & expelling ammonia in the feces. An ↑ in the number of bowel movements is expected as an adverse effect. Lactulose does NOT affect UO Any improvements in mental status would be the result of ↑ ammonia elimination, not an adverse effect of the drug. Nausea & vomiting are not common adverse effects of lactulose.

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

3. Pts with cirrhosis should be instructed to Ø avoid constipation & straining at stool to prevent hemorrhage. The pt with cirrhosis has bleeding tendencies because of the liver's inability to produce clotting factors. A ↓ low-protein & ↑ high-CHO diet is recommended PT's with cirrhosis should NOT take acetaminophen (Tylenol), which is potentially hepatotoxic. Aspirin also should be avoided Ø IF esophageal varices & present Cirrhosis is a chronic disease.

MANAGING CARE QUALITY AND SAFETY 67. The nurse is planning a staff development program on how to care for clients with hepatitis A. Which of the following precautions should the nurse indicate as essential when caring for clients with hepatitis A? 1. Gowning when entering a client's room. 2. Wearing a mask when providing care. 3. Assigning the client to a private room. 4. Wearing gloves when giving direct care.

4. Contact precautions are recommended for pt's with hepatitis A This includes wearing gloves for direct care These recommendations are made by the CDC & Prevention A gown is NOT required unless substantial contact with the pt is anticipated It is NOT necessary to wear a mask The pt does NOT need a private room UNLESS: incontinent of stool.

34. A client who is recovering from hepatitis A has fatigue and malaise. The client asks the nurse, "When will my strength return?" Which of the following responses by the nurse is most appropriate? 1. "Your fatigue should be gone by now. We will evaluate you for a secondary infection." 2. "Your fatigue is an adverse effect of your drug therapy. It will disappear when your treatment regimen is complete." 3. "It is important for you to increase your activity level. That will help decrease your fatigue." 4. "It is normal for you to feel fatigued. The fatigue should go away in the next 2 to 4 months."

4. During the convalescent or posticteric stage of hepatitis, fatigue & malaise are the most common complaints. These symptoms usually disappear within 2-4 months. Fatigue & malaise are NOT evidence of a secondary infection. Hepatitis A is not TX by drug therapy. It is important that the pt continue to balance activity with periods of rest.

53. The nurse is reviewing the chart information for a client with increased ascites. The data include: temperature 37.2° C; heart rate 118; shallow respirations 26; blood pressure 128/76; and SpO2 89% on room air. Which action should receive priority by the nurse? 1. Assess heart sounds. 2. Obtain an order for blood cultures. 3. Prepare for a paracentesis. 4. Raise the head of the bed.

4. Elevating the head of the bed will allow for ↑ lung expansion by ↓ the ascites pressing on the diaphragm. The pt requires reassessment A paracentesis is reserved for symptomatic pts with ascites & impaired respiration or abdominal pain NOT responding to other measures such as: sodium restriction & diuretics. There is NO indication for blood cultures Heart sounds are assessed with the routine physical assessment.

31. College freshman are participating in a study abroad program. When teaching them about hepatitis B, the nurse should instruct the students on: 1. Water sanitation. 2. Single dormitory rooms. 3. Vaccination for hepatitis D. 4. Safe sexual practices.

4. Hepatitis B is considered a STD and students should observe safe sex practices. Poor sanitary conditions in underdeveloped countries relate to spread of hepatitis A & E. Focusing on routes of transmission & avoidance of infection can prevent the spread of hepatitis; isolation in single rooms is not required. There is NO vaccine for hepatitis D.

42. The nurse is preparing a community education program about preventing hepatitis B infection. Which of the following would be appropriate to incorporate into the teaching plan? 1. Hepatitis B is relatively uncommon among college students. 2. Frequent ingestion of alcohol can predispose an individual to development of hepatitis B. 3. Good personal hygiene habits are most effective at preventing the spread of hepatitis B. 4. The use of a condom is advised for sexual intercourse.

4. Hepatitis B is spread through exposure to blood or blood products & through high-risk sexual activity. Hepatitis B is considered to be a STD. High-risk sexual activities include sex with multiple partners, unprotected sex with an infected individual, male homosexual activity, and sexual activity with IV drug users. The CDC & Prevention recommends immunization of all newborns & adolescents. College students are at high risk for development of hepatitis B & are encouraged to be immunized. Alcohol intake by itself does not predispose an individual to hepatitis B, but it can lead to high-risk behaviors such as unprotected sex. Good personal hygiene alone will not prevent the transmission of hepatitis B.

46. A client has advanced cirrhosis of the liver. The client's spouse asks the nurse why his abdomen is swollen, making it very difficult for him to fasten his pants. How should the nurse respond to provide the most accurate explanation of the disease process? 1. "He must have been eating too many foods with salt in them. Salt pulls water with it." 2. "The swelling in his ankles must have moved up closer to his heart so the fluid circulates better." 3. "He must have forgotten to take his daily water pill." 4. "Blood is not able to flow readily through the liver now, and the liver cannot make protein to keep fluid inside the blood vessels."

4. Portal hypertension & hypo-albuminemia as a result of cirrhosis causes a fluid shift into the peritoneal space causing ascites. In a cardiac or kidney problem, NOT cirrhosis, sodium can promote edema formation & subsequent ↓ UO Edema does NOT migrate upward toward the heart to enhance its circulation. Although diuretics promote the excretion of excess fluid, occasionally forgetting or omitting a dose will not yield the ascites found in cirrhosis of the liver.

40. What would be the nurse's best response to the client's expressed feelings of isolation as a result of having hepatitis? 1. "Don't worry. It's normal to feel that way." 2. "Your friends are probably afraid of contracting hepatitis from you." 3. "I'm sure you're imagining that!" 4. "Tell me more about your feelings of isolation."

4. The nurse should encourage the pt to further verbalize feelings of isolation. Instead of dismissing these feelings or making assumptions about the cause of isolation, the nurse should allow pts to verbalize their fears & provide education on how to prevent infection transmission.

65. Which of the following interventions should the nurse anticipate incorporating into the client's plan of care when hepatic encephalopathy initially develops? 1. Inserting a nasogastric (NG) tube. 2. Restricting fluids to 1,000 mL/day. 3. Administering I.V. salt-poor albumin. 4. Implementing a low-protein diet.

4. When hepatic encephalopathy develops, measures are taken to ↓ ammonia formation Protein is Ø restricted in the diet An NG tube is NOT inserted initially but may be necessary as the disease progresses Fluid restriction & salt-poor albumin is incorporated into the TX of ascites, but NOT hepatic encephalopathy.

57. A client with a Sengstaken-Blakemore tube has a sudden drop in SpO2 and increase in respiratory rate to 40 breaths/minute. The nurse should do which of the following in order from first to last? 1. Affirm airway obstruction by the tube. 2. Remove the tube. 3. Deflate the tube by cutting with bedside scissors. 4. Apply oxygen via face mask.

1. Affirm airway obstruction by the tube. 3. Deflate the tube by cutting with bedside scis¬sors. 2. Remove the tube. 4. Apply oxygen via face mask. The nurse should first assess the Pt to determine if the tube is obstructing the airway Assessment is done by assessing air flow Once obstruction is established, the tube should be deflated & then quickly removed A set of scissors should ALWAYS be at the bedside to allow for 911 deflation of the balloon. Oxygen via face mask should then be applied once the tube is removed.

16. The client who has been hospitalized with pancreatitis does not drink alcohol because of her religious convictions. She becomes upset when the physician persists in asking her about alcohol intake. The nurse should explain that the reason for these questions is that: 1. There is a strong link between alcohol use and acute pancreatitis. 2. Alcohol intake can interfere with the tests used to diagnose pancreatitis. 3. Alcoholism is a major health problem, and all clients are questioned about alcohol intake. 4. The physician must obtain the pertinent facts, regardless of religious beliefs.

1. Alcoholism is a major cause of acute pancreatitis in the United States. Because some Pt's are reluctant to discuss alcohol use, staff may inquire about it in several ways. Generally, alcohol intake does not interfere with the tests used to DX pancreatitis. Recent ingestion of large amounts of alcohol, however, may cause an ↑ serum amylase level. Large amounts of ethyl & methyl alcohol may produce an ↑ urinary amylase concentration. **All pts are asked about alcohol & drug use on hospital admission, but this information is especially pertinent for pts with pancreatitis. Physicians do need to seek facts, but this can be done while respecting the pt's religious beliefs. Respecting religious beliefs is important in providing holistic client care.

54. Which of the following positions would be appropriate for a client with severe ascites? 1. Fowler's. 2. Side-lying. 3. Reverse Trendelenburg. 4. Sims.

1. Ascites can compromise the action of the diaphragm & ↑ the Pt's risk of respiratory problems. Ascites also greatly ↑'s the risk of skin breakdown. Frequent position changes are important, but the preferred position is Fowler's Placing the Pt in Fowler's position helps facilitate the pt's breathing by relieving pressure on the diaphragm. The other positions do not relieve pressure on the diaphragm.

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

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

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

1. Dilaudid should be considered for pain management. It should be administered IV for rapid action to address the severe pain the pt is experiencing. IM injections are painful & slower acting Since meperidine's toxic metabolite can cause seizures, it is no longer the TX choice for pain. Diltiazem, a calcium channel blocker, is not indicated. ↑ HR & BP are likely due to pain & fever. Phenergan is used to treat nausea.

THE CLIENT WITH VIRAL HEPATITIS 29. The nurse is assessing a client with chronic hepatitis B who is receiving Lamivudine (Epivir). What information is most important to communicate to the physician? 1. The client's daily record indicates a 3 kg weight gain over 2 days. 2. The client is complaining of nausea. 3. The client has a temperature of 99° F orally. 4. The client has fatigue.

1. The fluid weight gain is of concern since the drug should be used with caution with impaired renal function. Dosage adjustment may be needed with renal insufficiency since the drug is excreted in the urine. Nausea, mild temperature elevation, and fatigue are symptoms that should be monitored, but are associated with hepatitis.

59. The nurse monitors a client with cirrhosis for the development of hepatic encephalopathy. Which of the following would be an indication that hepatic encephalopathy is developing? 1. Decreased mental status. 2. Elevated blood pressure. 3. Decreased urine output. 4. Labored respirations.

1. The pt should be monitored closely for changes in mental status. Ammonia has a toxic effect on CNS tissue & produces an altered LOC, marked by: drowsiness & irritability. If this process is unchecked, the pt may lapse into coma. ↑ ammonia levels are NOT detected by changes in BP, UO or respirations.

69. The nurse should institute which of the following measures to prevent transmission of the hepatitis C virus to health care personnel? 1. Administering hepatitis C vaccine to all health care personnel. 2. Decreasing contact with blood and blood-contaminated fluids. 3. Wearing gloves when emptying the bedpan. 4. Wearing a gown and mask when providing direct care.

2. Hepatitis C is usually transmitted through blood exposure or needlesticks. A hepatitis C vaccine is currently under development, but it is NOT available for use. The first line of defense against hepatitis B is the hepatitis B vaccine Hepatitis C is not transmitted through feces or urine Wearing a gown & mask will NOT prevent transmission of the hepatitis C virus if the caregiver comes in contact with infected blood or needles.

17. The nurse monitors the client with pancreatitis for early signs of shock. Which of the following conditions is primarily responsible for making it difficult to manage shock in pancreatitis? 1. Severity of intestinal hemorrhage. 2. Vasodilating effects of kinin peptides. 3. Tendency toward heart failure. 4. Frequent incidence of acute tubular necrosis.

2. Life-threatening shock is a potential complication of pancreatitis. Kinin peptides activated by the trapped trypsin cause vasodilation & ↑ capillary permeability. These effects exacerbate shock & are not easily reversed with pharmacologic agents such as vasopressors. Hemorrhage may occur into the pancreas, but NOT in the intestines. Systemic complications include pulmonary complications, but NOT heart failure or acute tubular necrosis.

49. A client with cirrhosis begins to develop ascites. Spironolactone (Aldactone) is prescribed to treat the ascites. The nurse should monitor the client closely for which of the following drug-related adverse effects? 1. Constipation. 2. Hyperkalemia. 3. Irregular pulse. 4. Dysuria.

2. Spironolactone (Aldactone) is a potassium-sparing diuretic; therefore, pts should be monitored closely for hyperkalemia Other common adverse effects include: - abdominal cramping - diarrhea - dizziness - headache - rash Constipation and dysuria are not common adverse effects of spironolactone. An irregular pulse is not an adverse effect of spironolactone but could develop if serum potassium levels are not closely monitored.

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

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

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

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

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

3. Hypokalemia is a precipitating factor in hepatic encephalopathy. ↓ in creatinine results from muscle atrophy (smaller muscles); so, an ↑ in creatinine would indicate renal insufficiency With liver dysfunction ↑ aldosterone levels are seen. A ↓ in serum protein will ↓ colloid osmotic pressure & promote edema. *No protein = no pressure to keep fluid out of tissues = edema formation.

38. The nurse develops a teaching plan for the client about how to prevent the transmission of hepatitis A. Which of the following discharge instructions is appropriate for the client? 1. Spray the house to eliminate infected insects. 2. Tell family members to try to stay away from the client. 3. Tell family members to wash their hands frequently. 4. Disinfect all clothing and eating utensils.

3. The hepatitis A virus is transmitted via the fecal-oral route. It spreads through contaminated hands, water, and food, especially shellfish growing in contaminated water. Certain animal handlers are at risk for hepatitis A, particularly those handling primates. **Frequent hand washing is probably the single MOST important preventive action. Insects do not transmit hepatitis A. Family members DO NOT need to stay away from the pt with hepatitis. It is not necessary to disinfect food & clothing.

3. A client is admitted to the hospital with a diagnosis of cholecystitis from cholelithiasis. The client has severe abdominal pain, nausea, and has vomited several times. Based on these data, which nursing diagnosis would have the highest priority for intervention at this time? 1. Anxiety related to severe abdominal discomfort. 2. Deficient fluid volume related to vomiting. 3. Pain related to gallbladder inflammation. 4. Imbalanced nutrition: Less than body requirements related to vomiting.

3. The priority for nursing care at this time is to ↓ the pt severe abdominal pain. The pain, which is frequently accompanied by nausea & vomiting, is caused by biliary spasm. Opioid analgesics are given to relieve the severe pain & spasm of cholecystitis. Relief of pain may ↓ nausea & vomiting, thereby ↓ the pts likelihood of developing further complications, such as deficient fluid volume & imbalanced nutrition. There is no data to suggest that the pt is anxious.

56. The nurse is planning care for a client being admitted with bleeding esophageal varices. Vital signs are: Pulse 100; respiratory rate 22; and blood pressure 100/58. The nurse should prepare the client for which of the following? Select all that apply. 1. Administration of intravenous Octreotide (Sandostatin). 2. Endoscopy. 3. Administration of a blood product. 4. Minnesota tube insertion. 5. Transjugular intrahepatic portosystemic shunt (TIPS) procedure. 6. Immediate endotracheal intubation

1, 2, 3 The management of bleeding esophageal varices involves: - endoscopic therapy & drug therapy with octreotide, vasopressin, nitroglycerin, or beta blockers to ↓ portal hypertension & decompress the varices - IV access is needed for octreotide & potential blood product administration due to blood loss or altered clotting factors A patent airway should be maintained, but intubation is NOT needed for pts with adequate ventilation & oxygenation Balloon tamponade is used if variceal hemorrhage cannot be controlled by endoscopy A TIPS procedure may be considered AFTER a second major bleed to redirect portal blood flow away from the varices

THE CLIENT WITH CIRRHOSIS 44. A client with cirrhosis is receiving Lactulose (Cephulac). During the assessment the nurse notes increased confusion and asterixis. The nurse should: 1. Assess for GI bleeding. 2. Hold the Lactulose (Cephulac). 3. Increase protein in the diet. 4. Monitor serum bilirubin levels.

1. Clients with cirrhosis can develop hepatic encephalopathy caused by ↑ ammonia levels. Asterixis, a flapping tremor, is a characteristic symptom of ↑ ammonia levels. Bacterial action on ↑ protein in the bowel will ↑ ammonia levels & cause the encephalopathy to worsen. GI bleeding & protein consumed in the diet ↑ protein in the intestine & can ↑ ammonia levels. Lactulose is given to ↓ ammonia formation in the intestine & should NOT be held since neuro symptoms are worsening. Bilirubin is associated with jaundice.

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

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

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

3. Immediately after surgery, the client will drink liquids. A light diet can be resumed the day after surgery. There is no need for the pt to remain on NPO status after surgery because peristaltic bowel activity should not be affected. The pt will probably not be able to tolerate a full meal comfortably the day after surgery. There is no need for the pt to stay on a bland diet after a laparoscopic cholecystectomy. The client should, however, Ø excessive fats.