EAQ- Liver Pancreas
A client with liver dysfunction states, "My gums have been bleeding spontaneously." The nurse identifies small hemorrhagic lesions on the client's face. Which vitamin does the nurse conclude the client needs? a) Vitamin D b) Vitamin E c) Vitamin A d) Vitamin K
D Petechiae are evidence of capillary bleeding; the diseased liver is no longer able to metabolize vitamin K, which is necessary to activate blood clotting factors. Vitamin D and E are not involved in the clotting process. Vitamin A is not involved in the clotting process, even though the transformation of carotene to vitamin A takes place in the liver.
A client with jaundice associated with hepatitis expresses concern over the change in skin color. What does the nurse explain is the cause of this color change? a) Stimulation of the liver to produce an excess quantity of bile pigments b) Inability of the liver to remove normal amounts of bilirubin from the blood c) Increased destruction of red blood cells during the acute phase of the disease d) Decreased prothrombin levels, leading to multiple sites of intradermal bleeding
B Damage to liver cells affects the ability to facilitate removal of bilirubin from the blood, with resulting deposition in the skin and sclera. With hepatitis, the liver does not secrete excess bile. Destruction of red blood cells does not increase in hepatitis. Decreased prothrombin levels cause spontaneous bleeding, not jaundice.
A client has a paracentesis during which 1500 mL of fluid is removed. The nurse should monitor the client carefully for what reaction? a) Hypertensive crisis b) Hypovolemic shock c) Abdominal distention d) Tenting of the integument
B Fluid may shift from the intravascular space to the abdomen as fluid is removed, leading to hypovolemia and compensatory tachycardia. Fluid shifts can cause hypovolemia with resulting hypotension, not hypertension. A paracentesis should decrease the degree of abdominal distention. Tenting of the integument, a sign of dehydration, may occur. However, this assessment is not as vital as assessing for signs of shock.
A client with esophageal varices has severe hematemesis, and a Sengstaken-Blakemore tube is inserted. What design and purpose does the tube have? a) Single-lumen; for gastric lavage b) Double-lumen; for intestinal decompression c) Triple-lumen; for esophageal compression d) Multilumen; for gastric and intestinal decompression
C The Sengstaken-Blakemore is a triple-lumen tube; one lumen inflates the esophageal balloon that compresses the esophagus, the second inflates the gastric balloon, and the third is attached to suction to decompress the stomach. The Sengstaken-Blakemore is not a single-lumen tube. The Sengstaken-Blakemore is not a double-lumen tube; the stomach, not the intestine, is decompressed. The intestine is not decompressed with a Sengstaken-Blakemore tube.
A client with hepatitis B (HBV) develops cirrhosis and is hospitalized. One potential sequela of chronic liver disease is fluid and electrolyte imbalance. The nurse determines that this may be attributed to a decrease in serum albumin level. Which of these conditions results from this imbalance? a) Hemorrhage with subsequent anemia b) Diminished resistance to bacterial insult c) Malnutrition of cells, especially hepatic cells d) Reduction of colloidal osmotic pressure in the blood
D Albumin is an essential component of the bloodstream that helps maintain both osmotic pressure and fluid and electrolytes. This is not a cause of hemorrhage. Blood components such as platelets, thrombin, and erythrocytes are involved in the prevention of hemorrhage or anemia. Diminished resistance to bacterial insult is not involved directly with immunity and resistance. Blood components, such as T and B lymphocytes, are involved in this process; the liver synthesizes specific proteins intrinsic to the function of antibodies. The serum albumin level is not related to nutrition of cells.
The serum ammonia level of a client with hepatic cirrhosis and ascites is elevated. What nursing intervention is the priority? a) Weigh the client daily. b) Restrict the client's oral fluid intake. c) Measure the client's urine specific gravity. d) Observe the client for increasing confusion.
D An increased serum ammonia level impairs the central nervous system, causing an altered level of consciousness. Increasing ammonia levels are not related to weight. An alteration in fluid intake will not affect the serum ammonia level. Measuring the client's urine specific gravity is not the priority; the priority is to monitor the client's neurological status.
A nurse is assessing a client with severe liver disease. Which assessment finding will the nurse expect to observe? a) Icterus b) Urticaria c) Uremic frost d) Hemangioma
A Bile deposits will impart a yellowish tinge (jaundice or icterus) to the skin, often first observed in the sclerae. Urticaria (or hives) generally is characteristic of an allergic response. Uremic frost is characteristic of kidney failure. Hemangioma is a benign lesion composed of blood vessels.
A nurse is caring for a client who is positive for hepatitis A. Which precautions should the nurse take? a) Wear a gown when entering the client's room. b) Use caution when bringing in the client's food. c) Use gloves when removing the client's bedpan. d) Wear a protective mask when entering the client's room
C The virus is present in the stool of clients with hepatitis A therefore, standard precautions should be followed when handling excretions. The virus also may be present in urine and nasotracheal secretions.
pseudocyst of the pancreas. The client asks, "What is a pseudocyst?" Which information should the nurse include in a response to this question? a) Malignant growth b) Pocket of undigested food particles c) Sac filled with pus from necrotic pancreatic tissue d) Walled-off space of pancreatic enzymes and exudate
D A pseudocyst of the pancreas is a walled-off space that contains fluid, pancreatic enzymes, tissue debris, and inflammatory exudate. A malignant growth is cancer. A pseudocyst is not a pocket of undigested food particles. A pancreatic abscess is a sac filled with pus from necrotic pancreatic tissue.
A client is diagnosed with cancer of the pancreas and is apprehensive and restless. Which nursing action should be included in the plan of care? a) Encouraging expression of concerns b) Administering antibiotics as prescribed c) Teaching the importance of getting rest d) Explaining that everything will be all right
A Open communication helps to decrease anxiety. Antibiotics will have no direct effect on the client's anxiety. Knowledge does not always reduce anxiety and promote rest. Explaining that everything will be all right is false reassurance.
A nurse is taking care of a client with cirrhosis of the liver. Which clinical manifestations should the nurse assess in the client? Select all that apply. a) Ascites b) Hunger c) Pruritus d) Jaundice e) Headache
A, C, D Ascites is a result of portal hypertension that occurs with cirrhosis. Pruritus is common because bile pigments seep into the skin from the bloodstream. Jaundice occurs because the bile duct becomes obstructed and bile enters the bloodstream. The appetite decreases because of the pressure on the abdominal organs from the ascites and the liver's decreased ability to metabolize food. Headache is not a common manifestation of cirrhosis of the liver.
A client suspected of carcinoma of the liver is scheduled for a liver biopsy. For which procedural contraindication should the nurse assess the client? a) Confusion and disorientation b) Presence of any infectious disease process c) International normalized ratio (INR) greater than 4.5 d) Inclusion of foods high in vitamins E and phytonadione in the client's diet
C A normal INR range is 0.7 to 1.8. INR values over 4.5 increase the risk of major hemorrhage. This should be corrected before the biopsy to prevent hemorrhage. Confusion and disorientation are not a contraindication for a liver biopsy; however, if present, the client may need support and the healthcare provider may need assistance, but the biopsy can still be done. A biopsy is not contraindicated in the presence of an infectious disease. Phytonadione (vitamin K) is needed to produce prothrombin; however, this does not guarantee clotting activity because the liver also has to make an adequate supply of clotting factors and proteins for blood clotting to occur. Vitamin E is not involved in blood clotting.
The nurse administers 2 units of salt-poor albumin to a client with portal hypertension and ascites. What does the nurse explain to the client regarding the purpose of the albumin? a) It provides nutrients. b) It increases protein stores. c) Albumin elevates the circulating blood volume. d) Albumin temporarily diverts blood flow away from the liver.
C Increasing oncotic pressure increases the client's circulating blood volume; salt-poor albumin pulls interstitial fluid into the blood vessels, restoring blood volume and limiting ascites. Nutrients are provided by total parenteral nutrition, not salt-poor albumin. Salt-poor albumin is not given to increase protein stores. Salt-poor albumin has no effect on diverting blood flow away from the liver.
Immediately after a liver biopsy the nurse places the client onto the right side. Which reason explains the use of the right side-lying position? a) Provides the greatest comfort b) Restores circulating blood volume c) Helps stop bleeding if any should occur d) Reduces the fluid trapped in the biliary ducts
C The right side-lying position applies pressure to the puncture site, thereby compressing blood vessels, preventing bleeding. Encouraging hemostasis, rather than providing comfort, is the purpose of the right side-lying position. The semi-Fowler or high-Fowler position, not the right side-lying position, is more comfortable because it decreases pressure against the diaphragm. However, these positions are contraindicated immediately after a liver biopsy because they do not promote hemostasis. The right lateral position will not restore the circulating blood volume. The right side-lying position will have little or no effect on the biliary ducts.
A client undergoes an abdominal cholecystectomy with common duct exploration. In the immediate postoperative period, what is the priority nursing action? a) Irrigating the T-tube every hour b) Changing the dressing every two hours c) Encouraging coughing and deep breathing d) Promoting an adequate fluid and food intake
C n an abdominal cholecystectomy, the incision is high, causing pain when the client is deep breathing. Self-splinting results in shallow breathing, which does not aerate or expand the lungs adequately, particularly the lower right lobe, leading to pneumonia. The client should be encouraged to deep breathe and cough, while splinting the incision with a pillow to help decrease the pain, yet expanding the lungs to decrease atelectasis or pneumonia. The T-tube is never irrigated; it drains by gravity until the edema in the operative area subsides; the primary healthcare provider then removes the tube. The nurse does not change the dressing in the immediate postoperative period; the client's respiratory status takes priority. The client will ingest nothing by mouth immediately after surgery.
A paracentesis is prescribed for a client recently admitted to a medical unit. The nurse recalls that the procedure is performed for what reasons? Select all that apply. a) Extract peritoneal fluid b) Improve respiratory status c) Decrease intrapleural fluid d) Increase intraabdominal tension e) Obtain peritoneal fluid for culture
A, B, E When a client has ascites, a peritoneal tap (paracentesis) may be prescribed to remove fluid for diagnostic purposes and for relief of discomfort. The removal of intraabdominal fluid relieves pressure against the diaphragm, which will improve the client's respiratory status. A culture of peritoneal fluid may provide information about the cause of the ascites. Closed-chest drainage, not a paracentesis, removes fluid from the pleural space. A paracentesis is done to decrease, not increase, intraabdominal pressure.
A client returns from surgery after an abdominal cholecystectomy for a gangrenous gallbladder. For which postoperative complication, associated with the location of the surgical site, should the nurse assess the client? a) Atelectasis b) Hemorrhage c) Paralytic ileus d) Wound infectio
A Subcostal incisional pain causes the client to splint and avoid deep breathing, which impedes air exchange in the alveoli. The location of the incision does not increase the risk of hemorrhage. Paralytic ileus can be a postoperative problem, but it is unrelated to the site of the incision. The subcostal incision site is not specifically vulnerable to infection.
A client is scheduled for a cholecystectomy and asks the primary nurse about the function of the gallbladder. What should the nurse identify is the function of the gallbladder when providing preoperative teaching? a) Stores and concentrates bile b) Releases bile into the pancreatic duct c) Connects the common bile duct and the pancreas d) Controls the flow of fat through the sphincter of Oddi
A The gallbladder concentrates and stores about 90 mL of bile, which is discharged in response to the entrance of fatty food into the duodenum. The gallbladder releases bile into the cystic duct. The common bile duct is connected directly to the pancreas. The sphincter of Oddi controls the release of bile into the duodenum; dietary fat progresses from the stomach to the duodenum and then to the rest of the intestinal tract.
A client with a long history of alcohol abuse is admitted to the hospital with ascites and jaundice. A diagnosis of hepatic cirrhosis is made. Which is a nursing priority? a) Institute fall prevention/safety measures. b) Monitor respiratory status. c) Measure abdominal girth daily. d) Test stool specimens for blood.
A The high ammonia levels contribute to deterioration of mental function and then to hepatic encephalopathy and hepatic coma; safety is the priority. Although the client may have dyspnea as a result of ascites, it is not life threatening; safety is the priority. Although measuring abdominal girth daily is done to monitor ascites, it is not the priority for a confused client; safety is the priority. Testing stool specimens for blood is not the priority; providing for client safety is the priority.
A client with an acute attack of cholecystitis has a cholecystectomy with a choledochostomy. The client returns from surgery with a T-tube connected to a drainage bag. What does the nurse conclude is the purpose of the T-tube? a) Decrease edema b) Permit drainage of bile c) Insert antibiotic medication d) Provide for irrigation of the gallbladder
B The T-tube provides a passageway for bile to move through the common bile duct in the presence of edema; it does not reduce edema. When the common bile duct is explored, the T-tube maintains patency until edema subsides. The T-tube will not reduce edema. Antibiotics usually are not necessary postoperatively unless infected bile or pus is in the ducts (cholangitis). The gallbladder has been excised and therefore cannot be irrigated.
The nurse is providing care to a client with ascites secondary to liver failure. What is appropriate to include in this client's care? Select all that apply. a) High protein diet b) Low sodium diet c) Daily abdominal girth measurements d) Encourage increased by mouth fluid intake e) Daily weights
B, C, E In the client with liver failure and ascites, the liver has lost its ability to synthesize proteins. This leads to hypoalbuminemia and decreased oncotic pressure in the vessels. This decrease in oncotic pressure leads to fluids leaking out of the vessels and into the interstitial spaces and peritoneum, causing edema and ascites. A low sodium and low protein diet is recommended. A high protein diet will worsen the symptoms, and often these clients are on a fluid restriction. Taking daily weights is the most reliable indicator of fluid retention.
A client who had a laparoscopic cholecystectomy reports pain in the shoulder. In what position should the nurse place the client? a) Prone b) Supine c) Left Sims d) Trendelenburg
C Retained carbon dioxide can irritate the phrenic nerve. Placing the client in the left Sims position helps to move the gas pocket away from the diaphragm. Deep breathing and ambulation should be encouraged. Prone, supine, and Trendelenburg positions will not help to alleviate the problem but could aggravate the problem.
A client with cirrhosis of the liver has a prolonged prothrombin time and a low platelet count. A regular diet is prescribed. What should the nurse instruct the client to do considering the client's condition? a) Avoid foods high in phytonadione. b) Check the pulse several times a day. c) Drink a glass of milk when taking aspirin. d) Report signs of bleeding no matter how slight.
D One of the many functions of the liver is the manufacture of clotting factors; there is interference in this process with cirrhosis of the liver, resulting in bleeding tendencies. The storage of fat-soluble vitamins (A, D, E, and K), water-soluble vitamins (B1, B2, folic acid, and cobalamin), and minerals (including iron) is compromised in cirrhosis; therefore, these nutrients, including phytonadione, should not be limited. Should the client bleed, the pulse rate may be increased, but it is not necessary for the client to check the pulse rate several times daily. A client whose prothrombin time is prolonged and platelet count is low should not be taking aspirin, even with milk.
A client with cholelithiasis has a laser laparoscopic cholecystectomy. What is most appropriate for the nurse to do postoperatively? a) Maintain the client's nothing by mouth status for the first 24 hours b) Monitor the client's abdominal incision for bleeding c) Offer clear carbonated beverages to the client d) Ambulate the client when the client is alert and oriented
D The client should be ambulated as soon as they are alert and oriented. Recovery will be rapid because there is no large abdominal incision. Clear liquids may be started as soon as the client is awake and a gag reflex has returned. With a laparoscopic cholecystectomy there will be one or more puncture wounds, not an incision, on the abdomen. Carbonated beverages will create gas, which will distend the intestines and increase pain.
A nurse is caring for a client who is admitted to the hospital with ascites and a diagnosis of cirrhosis of the liver. What does the nurse conclude is the probable cause of ascites? a) Impaired portal venous return b) Inadequate secretion of bile salts c) Excess production of serum albumin d) Decreased interstitial osmotic pressure
A An enlarged liver impairs venous return, leading to an increased portal vein hydrostatic pressure and a fluid shift into the abdominal cavity. Bile plays an important role in digestion of fats, but it is not a major factor in fluid balance. Increased serum albumin causes hypervolemia, not ascites. Ascites is not associated with the interstitial fluid compartment.
A healthcare provider schedules a paracentesis. What should the nurse instruct the client to do to prepare for the procedure? a) Empty the bladder before the procedure. b) Take a laxative the evening before the procedure. c) Ingest nothing by mouth for eight hours before the procedure. d) Self-administer a low soapsuds enema two hours before the procedure.
A Emptying the bladder before a paracentesis prevents its accidental puncture during the procedure. No bowel preparation is indicated. The client may eat and drink as tolerated. A low soapsuds enema two hours before the procedure is not indicated for a paracentesis.
A client is diagnosed with hepatitis A. The nurse takes the client's history. Which employment history is most likely linked to the development of hepatitis A? a) Works at a plumbing business b) Works in a hemodialysis unit at a hospital c) Works as a dishwasher at a local restaurant d) Works at an occupational arsenic compound business
A Hepatitis A primarily is spread via a fecal-oral route; sewage-polluted water may harbor the virus. Working at a hemodialysis unit is closely linked to hepatitis types B, C, and D; these types are more often spread via the blood-borne route. Using disposable equipment and proper handling of syringes decreases the risk of spreading the virus. Working as a dishwasher at a local restaurant does not increase the risk of developing the disease, but it will increase the risk of an infected individual spreading the disease to others. Exposure to arsenic or carbon tetrachloride will not cause hepatitis A.
A nurse is providing discharge instructions to a client diagnosed with cirrhosis and varices. Which information should the nurse include in the teaching session? Select all that apply. a) Adhering to a low-carbohydrate diet b) Avoiding aspirin and aspirin-containing products c) Limiting alcohol consumption to two drinks weekly d) Avoiding acetaminophen and products containing acetaminophen e) Avoiding coughing, sneezing, and straining to have a bowel movement
B, D, E Aspirin can damage the gastric mucosa and precipitate hemorrhage when esophageal or gastric varices are present. Acetaminophen is hepatotoxic and should not be used by the client with cirrhosis. The client with cirrhosis should avoid coughing, sneezing, and straining to have a bowel movement. These activities increase pressure in the portal venous system and increase the client's risk of variceal hemorrhage. A high-carbohydrate diet is encouraged as the diseased liver's ability to synthesize and store glucose is diminished. To decrease the risk of complications, the client must abstain from alcohol.
The nurse is administering lactulose to a client with a history of cirrhosis of the liver. The client asks the nurse why this medication is needed because the client is not constipated. How will the nurse respond? a) "This medication helps you to stop drinking so much alcohol." b) "This medication helps you relax and not feel anxious." c) "This medication helps you lower the high ammonia level caused by your liver disease." d) "This medication helps you keep your abdomen from being so distended."
C Lactulose is a hyperosmotic laxative and ammonia detoxicant. It decreases serum ammonia concentration by preventing reabsorption of ammonia. Lactulose has been used to lower blood ammonia content in clients with portal hypertension and hepatic encephalopathy secondary to chronic liver disease. Lactulose has no effect on the craving for alcohol or anxiety and is not prescribed to reduce abdominal distension.
A client with cirrhosis of the liver develops ascites, and the health care provider prescribes spironolactone. What should the nurse monitor the client for? a) Bruising b) Tachycardia c) Hyperkalemia d) Hypoglycemia
C Spironolactone is a potassium-sparing diuretic that is used to treat clients with ascites; therefore the nurse should monitor the client for signs and symptoms of hyperkalemia. Bruising and purpura are associated with cirrhosis, not with the administration of spironolactone. Spironolactone does not cause tachycardia. Spironolactone does not cause hypoglycemia.