Chapter 49
A nurse is caring for a patient with cancer of the liver whose condition has required the insertion of a percutaneous biliary drainage system. The nurse's most recent assessment reveals the presence of dark green fluid in the collection container. What is the nurse's best response to this assessment finding? A)Document the presence of normal bile output. B)Irrigate the drainage system with normal saline as ordered. C)Aspirate a sample of the drainage for culture. D)Promptly report this assessment finding to the primary care provider.
A Bile is usually a dark green or brownish-yellow color, so this would constitute an expected assessment finding, with no other action necessary.
A group of nurses have attended an inservice on the prevention of occupationally acquired diseases that affect healthcare providers. What action has the greatest potential to reduce a nurse's risk of acquiring hepatitis C in the workplace? A)Disposing of sharps appropriately and not recapping needles B)Performing meticulous hand hygiene at the appropriate moments in care C)Adhering to the recommended schedule of immunizations D)Wearing an N95 mask when providing care for patients on airborne precautions
A 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.
A patient with a liver mass is undergoing a percutaneous liver biopsy. What action should the nurse perform when assisting with this procedure? A)Position the patient on the right side with a pillow under the costal margin after the procedure. B)Administer 1 unit of albumin 90 minutes before the procedure as ordered. C)Administer at least 1 unit of packed red blood cells as ordered the day before the scheduled procedure. D)Confirm that the patient's electrolyte levels have been assessed prior to the procedure.
A Immediately after a percutaneous liver biopsy, assist the patient to turn onto the right side and place a pillow under the costal margin. Prior administration of albumin or PRBCs is unnecessary. Coagulation tests should be performed, but electrolyte analysis is not necessary.
A nurse on a solid organ transplant unit is planning the care of a patient who will soon be admitted upon immediate recovery following liver transplantation. What aspect of nursing care is the nurse's priority? A)Implementation of infection-control measures B)Close monitoring of skin integrity and color C)Frequent assessment of the patient's psychosocial status D)Administration of antiretroviral medications
A 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.
A patient has developed hepatic encephalopathy secondary to cirrhosis and is receiving care on the medical unit. The patient's current medication regimen includes lactulose (Cephulac) four times daily. What desired outcome should the nurse relate to this pharmacologic intervention? A)Two to 3 soft bowel movements daily B)Significant increase in appetite and food intake C)Absence of nausea and vomiting D)Absence of blood or mucus in stool
A Lactulose (Cephulac) is administered to reduce serum ammonia levels. Two or three soft stools per day are desirable; this indicates that lactulose is performing as intended. Lactulose does not address the patient's appetite, symptoms of nausea and vomiting, or the development of blood and mucus in the stool.
A triage nurse in the emergency department is assessing a patient who presented with complaints of general malaise. Assessment reveals the presence of jaundice and increased abdominal girth. What assessment question best addresses the possible etiology of this patient's presentation? A)"How many alcoholic drinks do you typically consume in a week?" B)"To the best of your knowledge, are your immunizations up to date?" C)"Have you ever worked in an occupation where you might have been exposed to toxins?" D)"Has anyone in your family ever experienced symptoms similar to yours?"
A Signs or symptoms of hepatic dysfunction indicate a need to assess for alcohol use. Immunization status, occupational risks, and family history are also relevant considerations, but alcohol use is a more common etiologic factor in liver disease.
A 55-year-old female patient with hepatocellular carcinoma (HCC) is undergoing radiofrequency ablation. The nurse should recognize what goal of this treatment? A)Destruction of the patient's liver tumor B)Restoration of portal vein patency C)Destruction of a liver abscess D)Reversal of metastasis
A Using radiofrequency ablation, a tumor up to 5 cm in size can be destroyed in one treatment session. This technique does not address circulatory function or abscess formation. It does not allow for the reversal of metastasis.
During a health education session, a participant has asked about the hepatitis E virus. What prevention measure should the nurse recommend for preventing infection with this virus? A)Following proper hand-washing techniques B)Avoiding chemicals that are toxic to the liver C)Wearing a condom during sexual contact D)Limiting alcohol intake
A Avoiding contact with the hepatitis E virus through good hygiene, including hand-washing, is the major method of prevention. Hepatitis E is transmitted by the fecal-oral route, principally through contaminated water in areas with poor sanitation. Consequently, none of the other listed preventative measures is indicated.
A patient is being discharged after a liver transplant and the nurse is performing discharge education. When planning this patient's continuing care, the nurse should prioritize which of the following risk diagnoses? A)Risk for Infection Related to Immunosuppressant Use B)Risk for Injury Related to Decreased Hemostasis C)Risk for Unstable Blood Glucose Related to Impaired Gluconeogenesis D)Risk for Contamination Related to Accumulation of Ammonia
A Infection is the leading cause of death after liver transplantation. Pulmonary and fungal infections are common; susceptibility to infection is increased by the immunosuppressive therapy that is needed to prevent rejection. This risk exceeds the threats of injury and unstable blood glucose. The diagnosis of Risk for Contamination relates to environmental toxin exposure.
A nurse is caring for a patient with hepatic encephalopathy. While making the initial shift assessment, the nurse notes that the patient has a flapping tremor of the hands. The nurse should document the presence of what sign of liver disease? A)Asterixis B)Constructional apraxia C)Fetor hepaticus D)Palmar erythema
A The nurse will document that a patient 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.
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. A)Immunization B)Use of standard precautions C)Consumption of a vitamin-rich diet D)Annual vitamin K injections E)Annual vitamin B12 injections
A,B People who are at high risk, 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.
A patient's physician has ordered a "liver panel" in response to the patient's development of jaundice. When reviewing the results of this laboratory testing, the nurse should expect to review what blood tests? Select all that apply. A)Alanine aminotransferase (ALT) B)C-reactive protein (CRP) C)Gamma-glutamyl transferase (GGT) D)Aspartate aminotransferase (AST) E)B-type natriuretic peptide (BNP)
ACD Liver function testing includes GGT, ALT, and AST. CRP addresses the presence of generalized inflammation and BNP is relevant to heart failure; neither is included in a liver panel.
A patient with end-stage liver disease has developed hypervolemia. What nursing interventions would be most appropriate when addressing the patient's fluid volume excess? Select all that apply. A)Administering diuretics B)Administering calcium channel blockers C)Implementing fluid restrictions D)Implementing a 1500 kcal/day restriction E)Enhancing patient positioning
ACE Administering diuretics, implementing fluid restrictions, and enhancing patient positioning can optimize the management of fluid volume excess. Calcium channel blockers and calorie restriction do not address this problem.
A patient 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? A)Keep patient NPO until the results of test are known. B)Keep patient NPO until the patient's gag reflex returns. C)Administer analgesia until post-procedure tenderness is relieved. D)Give the patient a cold beverage to promote swallowing ability.
B After the examination, fluids are not given until the patient's gag reflex returns. Lozenges and gargles may be used to relieve throat discomfort if the patient'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.
A participant in a health fair has asked the nurse about the role of drugs in liver disease. What health promotion teaching has the most potential to prevent drug-induced hepatitis? A)Finish all prescribed courses of antibiotics, regardless of symptom resolution. B)Adhere to dosing recommendations of OTC analgesics. C)Ensure that expired medications are disposed of safely. D)Ensure that pharmacists regularly review drug regimens for potential interactions.
B Although any medication can affect liver function, use of acetaminophen (found in many over-the-counter medications used to treat fever and pain) has been identified as the leading cause of acute liver failure. Finishing prescribed antibiotics and avoiding expired medications are unrelated to this disease. Drug interactions are rarely the cause of drug-induced hepatitis.
A nurse is caring for a patient who has been admitted for the treatment of advanced cirrhosis. What assessment should the nurse prioritize in this patient's plan of care? A)Measurement of abdominal girth and body weight B)Assessment for variceal bleeding C)Assessment for signs and symptoms of jaundice D)Monitoring of results of liver function testing
B Esophageal varices are a major cause of mortality in patients with uncompensated cirrhosis. Consequently, this should be a focus of the nurse's assessments and should be prioritized over the other listed assessments, even though each should be performed.
A nurse is caring for a patient with a blocked bile duct from a tumor. What manifestation of obstructive jaundice should the nurse anticipate? A)Watery, blood-streaked diarrhea B)Orange and foamy urine C)Increased abdominal girth D)Decreased cognition
B 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.
A nurse is caring for a patient with cirrhosis secondary to heavy alcohol use. The nurse's most recent assessment reveals subtle changes in the patient's cognition and behavior. What is the nurse's most appropriate response? A)Ensure that the patient's sodium intake does not exceed recommended levels. B)Report this finding to the primary care provider due to the possibility of hepatic encephalopathy. C)Inform the primary care provider that the patient should be assessed for alcoholic hepatitis. D)Implement interventions aimed at ensuring a calm and therapeutic care environment.
B Monitoring is an essential nursing function to identify early deterioration in mental status. The nurse monitors the patient'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 patient's physiologic deterioration.
A patient with cirrhosis has experienced a progressive decline in his health; and liver transplantation is being considered by the interdisciplinary team. How will the patient's prioritization for receiving a donor liver be determined? A)By considering the patient's age and prognosis B)By objectively determining the patient's medical need C)By objectively assessing the patient's willingness to adhere to post-transplantation care D)By systematically ruling out alternative treatment options
B The patient would undergo a classification of the degree of medical need through an objective determination known as the Model of End-Stage Liver Disease (MELD) classification, which stratifies the level of illness of those awaiting a liver transplant. This algorithm considers multiple variables, not solely age, prognosis, potential for adherence, and the rejection of alternative options.
A patient with a history of injection drug use has been diagnosed with hepatitis C. When collaborating with the care team to plan this patient's treatment, the nurse should anticipate what intervention? A)Administration of immune globulins B)A regimen of antiviral medications C)Rest and watchful waiting D)Administration of fresh-frozen plasma (FFP)
B There is no benefit from rest, diet, or vitamin supplements in HCV treatment. Studies have demonstrated that a combination of two antiviral agents, Peg-interferon and ribavirin (Rebetol), is effective in producing improvement in patients with hepatitis C and in treating relapses. Immune globulins and FFP are not indicated.
A patient has been admitted to the critical care unit with a diagnosis of toxic hepatitis. When planning the patient's care, the nurse should be aware of what potential clinical course of this health problem? Place the following events in the correct sequence. 1. Fever rises. 2. Hematemesis. 3. Clotting abnormalities. 4. Vascular collapse. 5. Coma. A)1, 2, 5, 4, 3 B)1, 2, 3, 4, 5 C)2, 3, 1, 4, 5 D)3, 1, 2, 5, 4
B Recovery from acute toxic hepatitis is rapid if the hepatotoxin is identified early and removed or if exposure to the agent has been limited. Recovery is unlikely if there is a prolonged period between exposure and onset of symptoms. There are no effective antidotes. The fever rises; the patient becomes toxic and prostrated. Vomiting may be persistent, with the emesis containing blood. Clotting abnormalities may be severe, and hemorrhages may appear under the skin. The severe GI symptoms may lead to vascular collapse. Delirium, coma, and seizures develop, and within a few days the patient may die of fulminant hepatic failure unless he or she receives a liver transplant.
A patient has been diagnosed with advanced stage breast cancer and will soon begin aggressive treatment. What assessment findings would most strongly suggest that the patient may have developed liver metastases? A)Persistent fever and cognitive changes B)Abdominal pain and hepatomegaly C)Peripheral edema unresponsive to diuresis D)Spontaneous bleeding and jaundice
B The early manifestations of malignancy of the liver include pain—a continuous dull ache in the right upper quadrant, epigastrium, or back. Weight loss, loss of strength, anorexia, and anemia may also occur. The liver may be enlarged and irregular on palpation. Jaundice is present only if the larger bile ducts are occluded by the pressure of malignant nodules in the hilum of the liver. Fever, cognitive changes, peripheral edema, and bleeding are atypical signs.
A nurse has entered the room of a patient with cirrhosis and found the patient on the floor. The patient states that she fell when transferring to the commode. The patient's vital signs are within reference ranges and the nurse observes no apparent injuries. What is the nurse's most appropriate action? A)Remove the patient's commode and supply a bedpan. B)Complete an incident report and submit it to the unit supervisor. C)Have the patient assessed by the physician due to the risk of internal bleeding. D)Perform a focused abdominal assessment in order to rule out injury.
C A fall would necessitate thorough medical assessment due to the patient's risk of bleeding. The nurse's abdominal assessment is an appropriate action, but is not wholly sufficient to rule out internal injury. Medical assessment is a priority over removing the commode or filling out an incident report, even though these actions are appropriate
A previously healthy adult's sudden and precipitous decline in health has been attributed to fulminant hepatic failure, and the patient has been admitted to the intensive care unit. The nurse should be aware that the treatment of choice for this patient is what? A)IV administration of immune globulins B)Transfusion of packed red blood cells and fresh-frozen plasma (FFP) C)Liver transplantation D)Lobectomy
C Liver transplantation carries the highest potential for the resolution of fulminant hepatic failure. This is preferred over other interventions, such as pharmacologic treatments, transfusions, and surgery.
A nurse is caring for a patient with hepatic encephalopathy. The nurse's assessment reveals that the patient 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? A)Stage 1 B)Stage 2 C)Stage 3 D)Stage 4
C Patients in the third stage of hepatic encephalopathy exhibit the following symptoms: stuporous, difficult to arouse, sleeps most of the time, exhibits marked confusion, incoherent in speech, asterixis, increased deep tendon reflexes, rigidity of extremities, marked EEG abnormalities. Patients in stages 1 and 2 exhibit clinical symptoms that are not as advanced as found in stage 3, and patients 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.
A patient with liver disease has developed jaundice; the nurse is collaborating with the patient to develop a nutritional plan. The nurse should prioritize which of the following in the patient's plan? A)Increased potassium intake B)Fluid restriction to 2 L per day C)Reduction in sodium intake D)High-protein, low-fat diet
C Patients with ascites require a sharp reduction in sodium intake. Potassium intake should not be correspondingly increased. There is no need for fluid restriction or increased protein intake.
A nurse is caring for a patient with severe hemolytic jaundice. Laboratory tests show free bilirubin to be 24 mg/dL. For what complication is this patient at risk? A)Chronic jaundice B)Pigment stones in portal circulation C)Central nervous system damage D)Hepatomegaly
C Prolonged jaundice, even if mild, predisposes to the formation of pigment stones in the gallbladder, and extremely severe jaundice (levels of free bilirubin exceeding 20 to 25 mg/dL) poses a risk for CNS damage. There are not specific risks of hepatomegaly or chronic jaundice resulting from high bilirubin.
A patient who has undergone liver transplantation is ready to be discharged home. Which outcome of health education should the nurse prioritize? A)The patient will obtain measurement of drainage from the T-tube. B)The patient will exercise three times a week. C)The patient will take immunosuppressive agents as required. D)The patient will monitor for signs of liver dysfunction.
C The patient is given written and verbal instructions about immunosuppressive agent doses and dosing schedules. The patient 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 patient to measure drainage from a T-tube as the patient wouldn't go home with a T-tube. The nurse may teach the patient 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.
A nurse is performing an admission assessment of a patient with a diagnosis of cirrhosis. What technique should the nurse use to palpate the patient's liver? A)Place hand under the right lower abdominal quadrant and press down lightly with the other hand. B)Place the left hand over the abdomen and behind the left side at the 11th rib. C)Place hand under right lower rib cage and press down lightly with the other hand. D)Hold hand 90 degrees to right side of the abdomen and push down firmly.
C To palpate the liver, the examiner places one hand under the right lower rib cage and presses downward with light pressure with the other hand. The liver is not on the left side or in the right lower abdominal quadrant.
A patient with portal hypertension has been admitted to the medical floor. The nurse should prioritize which of the following assessments related to the manifestations of this health problem? A)Assessment of blood pressure and assessment for headaches and visual changes B)Assessments for signs and symptoms of venous thromboembolism C)Daily weights and abdominal girth measurement D)Blood glucose monitoring q4h
C Obstruction to blood flow through the damaged liver results in increased blood pressure (portal hypertension) throughout the portal venous system. This can result in varices and ascites in the abdominal cavity. Assessments related to ascites are daily weights and abdominal girths. Portal hypertension is not synonymous with cardiovascular hypertension and does not create a risk for unstable blood glucose or VTE.
Diagnostic testing has revealed that a patient's hepatocellular carcinoma (HCC) is limited to one lobe. The nurse should anticipate that this patient's plan of care will focus on what intervention? A)Cryosurgery B)Liver transplantation C)Lobectomy D)Laser hyperthermia
C 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.
A patient with a diagnosis of cirrhosis has developed variceal bleeding and will imminently undergo variceal banding. What psychosocial nursing diagnosis should the nurse most likely prioritize during this phase of the patient's treatment? A)Decisional Conflict B)Deficient Knowledge C)Death Anxiety D)Disturbed Thought Processes
C The sudden hemorrhage that accompanies variceal bleeding is intensely anxiety-provoking. The nurse must address the patient's likely fear of death, which is a realistic possibility. For most patients, anxiety is likely to be a more acute concern than lack of knowledge or decisional conflict. The patient may or may not experience disturbances in thought processes.
A patient with esophageal varices is being cared for in the ICU. The varices have begun to bleed and the patient is at risk for hypovolemia. The patient has Ringer's lactate at 150 cc/hr infusing. What else might the nurse expect to have ordered to maintain volume for this patient? A)Arterial line B)Diuretics C)Foley catheter D)Volume expanders
D Because patients with bleeding esophageal varices have intravascular volume depletion and are subject to electrolyte imbalance, IV fluids with electrolytes and volume expanders are provided to restore fluid volume and replace electrolytes. Diuretics would reduce vascular volume. An arterial line and Foley catheter are likely to be ordered, but neither actively maintains the patient's volume.
A nurse is caring for a patient with liver failure and is performing an assessment in the knowledge of the patient's increased risk of bleeding. The nurse recognizes that this risk is related to the patient's inability to synthesize prothrombin in the liver. What factor most likely contributes to this loss of function? A)Alterations in glucose metabolism B)Retention of bile salts C)Inadequate production of albumin by hepatocytes D)Inability of the liver to use vitamin K
D Decreased production of several clotting factors may be partially due to deficient absorption of vitamin K from the GI tract. This probably is caused by the inability of liver cells to use vitamin K to make prothrombin. This bleeding risk is unrelated to the roles of glucose, bile salts, or albumin.
A patient with liver cancer is being discharged home with a hepatic artery catheter in place. The nurse should be aware that this catheter will facilitate which of the following? A)Continuous monitoring for portal hypertension B)Administration of immunosuppressive drugs during the first weeks after transplantation C)Real-time monitoring of vascular changes in the hepatic system D)Delivery of a continuous chemotherapeutic dose
D In most cases, the hepatic artery catheter has been inserted surgically and has a prefilled infusion pump that delivers a continuous chemotherapeutic dose until completed. The hepatic artery catheter does not monitor portal hypertension, deliver immunosuppressive drugs, or monitor vascular changes in the hepatic system.
A nurse is participating in the emergency care of a patient who has just developed variceal bleeding. What intervention should the nurse anticipate? A)Infusion of intravenous heparin B)IV administration of albumin C)STAT administration of vitamin K by the intramuscular route D)IV administration of octreotide (Sandostatin)
D Octreotide (Sandostatin)—a synthetic analog of the hormone somatostatin—is effective in decreasing bleeding from esophageal varices, and lacks the vasoconstrictive effects of vasopressin. Because of this safety and efficacy profile, octreotide is considered the preferred treatment regimen for immediate control of variceal bleeding. Vitamin K and albumin are not administered and heparin would exacerbate, not alleviate, bleeding.
A nurse is performing an admission assessment for an 81-year-old patient who generally enjoys good health. When considering normal, age-related changes to hepatic function, the nurse should anticipate what finding? A)Similar liver size and texture as in younger adults B)A nonpalpable liver C)A slightly enlarged liver with palpably hard edges D)A slightly decreased size of the liver
D The most common age-related change in the liver is a decrease in size and weight. The liver is usually still palpable, however, and is not expected to have hardened edges.
A patient with liver cancer is being discharged home with a biliary drainage system in place. The nurse should teach the patient's family how to safely perform which of the following actions? A)Aspirating bile from the catheter using a syringe B)Removing the catheter when output is ≤ 15 mL in 24 hours C)Instilling antibiotics into the catheter D)Assessing the patency of the drainage catheter
D 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.
A local public health nurse is informed that a cook in a local restaurant has been diagnosed with hepatitis A. What should the nurse advise individuals to obtain who ate at this restaurant and have never received the hepatitis A vaccine? A)The hepatitis A vaccine B)Albumin infusion C)The hepatitis A and B vaccines D)An immune globulin injection
D For people who have not been previously vaccinated, hepatitis A can be prevented by the intramuscular administration of immune globulin during the incubation period, if given within 2 weeks of exposure. Administration of the hepatitis A vaccine will not protect the patient exposed to hepatitis A, as protection will take a few weeks to develop after the first dose of the vaccine. The hepatitis B vaccine provides protection again the hepatitis B virus, but plays no role in protection for the patient exposed to hepatitis A. Albumin confers no therapeutic benefit.
A nurse is amending a patient's plan of care in light of the fact that the patient has recently developed ascites. What should the nurse include in this patient's care plan? A)Mobilization with assistance at least 4 times daily B)Administration of beta-adrenergic blockers as ordered C)Vitamin B12 injections as ordered D)Administration of diuretics as ordered
D Use of diuretics along with sodium restriction is successful in 90% of patients with ascites. Beta-blockers are not used to treat ascites and bed rest is often more beneficial than increased mobility. Vitamin B12 injections are not necessary.
