Ch. 53 and 54

The nurse is teaching a preoperative client who is scheduled for a laparoscopic cholecystectomy ("lap chole"). What statement by the client indicates a need for further teaching? "I should only be hospitalized for 2 to 3 days after my surgery." "I will probably not be at risk for complications from this surgery." "I will likely need oral pain medications for the first few days after my surgery." "I should be able to go back to work in the next week or so."

"I should only be hospitalized for 2 to 3 days after my surgery." A "lap chole" surgery has many advantages over the open traditional surgical method, including a short hospital stay, usually same-day surgery, minimal risk for complications, and the ability to achieve pain control by using oral analgesics.

Which statement by a client with cirrhosis indicates that further instruction is needed about the disease? "Cirrhosis is a chronic disease that has scarred my liver." "The scars on my liver create problems with blood circulation." "Because of the scars on my liver, blood clotting and blood pressure are affected." "My liver is scarred, but the cells can regenerate themselves and repair the damage."

"My liver is scarred, but the cells can regenerate themselves and repair the damage." The client's statement that, although his liver is scarred, the cells can regenerate and repair the damage indicates that further instruction is needed. Although cells and tissues will attempt to regenerate, destroyed liver cells will result in permanent scarring and irreparable damage.

The family of a client who has hepatic encephalopathy asks why the client is restricted to moderate amounts of dietary protein and has to take lactulose. What is an appropriate response by the nurse? "These interventions help to prevent heart failure." "These interventions help the client's jaundice improve." "These interventions help to prevent nausea and vomiting." "These interventions help to reduce the ammonia level."

"These interventions help to reduce the ammonia level." The client's high ammonia level has caused encephalopathy which can become so severe that it causes death. These interventions help to reduce ammonia in the body so that this condition does not worsen.

The nurse assesses a client who is recovering from a paracentesis 1 hour ago. Which assessment finding would require immediate action by the nurse? a. Urine output via indwelling urinary catheter is 20 mL/hr b. Blood pressure increases from 110/58 to 120/62 mm Hg c. Respiratory rate decreases from 22 to 16 breaths/min d. A decrease in the client's weight by 3 lb (1.4 kg)

A Rapid removal of ascitic fluid causes decreased abdominal pressure, which can contribute to hypovolemia. This can be manifested by a decrease in urine output to below 30 mL/hr. A slight increase in systolic blood pressure is insignificant. A decrease in respiratory rate indicates that breathing has been made easier by the procedure. The nurse would expect the client's weight to drop as fluid is removed. To prevent hypovolemic shock, no more than 2000 mL are usually removed from the abdomen at one time. The patient's weight typically only decreases by less than 2 kg or 4.4 lb.

A nurse assesses a client who is recovering from a Whipple procedure. Which assessment finding alerts the nurse to immediately contact the primary health care provider? a. Drainage from a fistula b. Diminished bowel sounds c. Pain at the incision site d. Nasogastric (NG) tube drainage

ANS: A Complications of a Whipple procedure include secretions that drain from a fistula and peritonitis. Absent bowel sounds, pain at the incision site, and NG tube drainage are normal postoperative findings.

A nurse cares for a client with end-stage pancreatic cancer. The client asks, "Why is this happening to me?" How would the nurse respond? a. "I don't know. I wish I had an answer for you, but I don't." b. "It's important to keep a positive attitude for your family right now." c. "Scientists have not determined why cancer develops in certain people." d. "I think that this is a trial so you can become a better person because of it."

ANS: A The client is not asking the nurse to actually explain why the cancer has occurred. The client may be expressing his or her feelings of confusion, frustration, distress, and grief related to this diagnosis. Reminding the client to keep a positive attitude for his or her family does not address the client's emotions or current concerns. The nurse would validate that there is no easy or straightforward answer as to why the client has cancer. Telling a client that cancer is a trial is untrue and may negatively impact the client-nurse relationship.

The nurse is caring for a client who has late-stage (advanced) cirrhosis. What assessment findings would the nurse expect? (Select all that apply.) a. Jaundice b. Clay-colored stools c. Icterus d. Ascites e. Petechiae f. Dark urine

ANS: A, B, C, D, E, F All of these assessment findings are very common for a client who has late-stage cirrhosis due to biliary obstruction and poor liver function. The client has vascular lesions and excess fluid from portal hypertension.

The nurse is assessing a client with hepatitis C. The client asks the nurse how it was possible to have this disease. What questions might the nurse ask to help the client determine how the disease was contracted? (Select all that apply.) a. "How old are you?" b. "Do you work in health care? c. "Are you receiving hemodialysis?" d. "Do you use IV drugs?" e. "Did you receive blood before 1992?" f. "Have you even been in prison or jail?"

ANS: A, B, C, D, E, F The nurse would ask all of these questions because "baby boomers," people who use illicit drugs, people on hemodialysis, health workers, and prisoners are at a very high risk for hepatitis C. Additionally, individuals who received blood, blood products, or an organ transplant prior to 1992 before bloodborne disease screening of these products was mandated are at risk for hepatitis C.

The nurse is teaching assistive personnel (AP) about care of a client who has advanced cirrhosis. Which statements would the nurse include in the staff teaching? (Select all that apply.) a. "Apply lotion to the client's dry skin areas." b. "Use a basin with warm water to bathe the patient." c. "For the patient's oral care, use a soft toothbrush." d. "Provide clippers so the patient can trim the fingernails." e. "Bathe with antibacterial and water-based soaps."

ANS: A, C, D Clients with advanced cirrhosis often have pruritus. Lotion will help decrease itchiness from dry skin. A soft toothbrush would be used to prevent gum bleeding, and the client's nails would need to be trimmed short to prevent the patient from scratching himself or herself. These clients should use cool, not warm, water on their skin, and should not use excessive amounts of soap.

The nurse plans care for a patient who has hepatopulmonary syndrome. Which interventions would the nurse include in this client's plan of care? (Select all that apply.) a. Oxygen therapy b. Prone position c. Feet elevated on pillows d. Daily weights e. Physical therapy f. Respiratory therapy

ANS: A, C, D, F Care for a client who has hepatopulmonary syndrome would include oxygen therapy, the head of bed elevated at least 30 degrees or as high as the client wants to improve breathing, elevated feet to decrease dependent edema, and daily weights. There is no need to place the patient in a prone position, on the patient's stomach. Although physical therapy may be helpful to a patient who has been hospitalized for several days, physical therapy is not an intervention specifically for hepatopulmonary syndrome. However, respiratory support from a specialized therapist may be needed.

The nurse is caring for a client who has cirrhosis of the liver. What nursing action is appropriate to help control ascites? a. Monitor intake and output. b. Provide a low-sodium diet. c. Increase oral fluid intake. d. Weigh the patient daily.

ANS: B A low-sodium diet is one means of controlling abdominal fluid collection. Monitoring intake and output does not control fluid accumulation, nor does weighing the client. These interventions merely assess or monitor the situation. Increasing fluid intake would not be helpful.

A telehealth nurse speaks with a client who is recovering from a liver transplant 2 weeks ago. The client states, "I'm having right belly pain and have a temperature of 101° F (38.3° C)." How would the nurse respond? a. "The anti-rejection drugs you are taking make you susceptible to infection." b. "You should go to the hospital immediately to get checked out." c. "You should take an additional dose of cyclosporine today." d. "Take acetaminophen every 4 hours until you feel better soon."

ANS: B Fever, right abdominal quadrant pain, and jaundice are signs of possible liver transplant rejection; the client would be admitted to the hospital as soon as possible for intervention. Antirejection drugs do make a client more susceptible to infection, but this client has signs of rejection, not infection. The nurse would not advise the client to take an additional dose of cyclosporine or acetaminophen as these medications will not treat the acute rejection.

A client is admitted with acute pancreatitis. What priority problem would the nurse expect the client to report? a. Nausea and vomiting b. Severe boring abdominal pain c. Jaundice and itching d. Elevated temperature

ANS: B The client who has acute pancreatitis reports severe boring abdominal pain that is often rated by clients as a 10+ on a 0-10 pain scale. Nausea, vomiting, and fever may also occur, but that is not the client's priority for care.

A nurse assesses a client who is recovering from an open traditional Whipple surgical procedure. Which assessment finding(s) alert(s) the nurse to a complication from this surgery? (Select all that apply.) a. Clay-colored stools b. Substernal chest pain c. Shortness of breath d. Lack of bowel sounds or flatus e. Urine output of 20 mL/6 hr

ANS: B, C, D, E Myocardial infarction (chest pain), pulmonary embolism (shortness of breath), adynamic ileus (lack of bowel sounds or flatus), and acute kidney injury (urine output of 20 mL/6 hr) are common complications for which the nurse must assess the client after the Whipple procedure. Clay-colored stools are associated with cholecystitis and are not a complication of a Whipple procedure.

A nurse assesses a client who has cirrhosis of the liver. Which laboratory findings would the nurse expect in clients with this disorder? (Select all that apply.) a. Elevated aspartate transaminase b. Elevated international normalized ratio (INR) c. Decreased serum globulin levels d. Decreased serum alkaline phosphatase e. Elevated serum ammonia f. Elevated prothrombin time (PT)

ANS: B, E, F Elevated INR and PT are indications of clotting disturbances and alert the nurse to the increased possibility of hemorrhage. Elevated ammonia levels increase the client's confusion. The other values are abnormal and associated with liver disease but do not necessarily place the client at increased risk for complications.

After teaching a client who has alcohol-induced cirrhosis, a nurse assesses the client's understanding. Which statement made by the client indicates a need for further teaching? a. "I cannot drink any alcohol at all anymore." b. "I should not take over-the-counter medications." c. "I need to avoid protein in my diet." d. "I should eat small, frequent, balanced meals."

ANS: C Based on the degree of liver involvement and decreased function, protein intake may have to be decreased. However, some protein is necessary for the synthesis of albumin and normal healing. The other statements indicate accurate understanding of self-care measures for this client.

The nurse is caring for a client who has cirrhosis from substance abuse. The client states, "All of my family hates me." How would the nurse respond? a. "You should make peace with your family." b. "This is not unusual. My family hates me too." c. "I will help you identify a support system." d. "You must attend Alcoholics Anonymous."

ANS: C Clients who have cirrhosis due to addiction may have alienated relatives over the years because of substance abuse. The nurse would assist the client to identify a friend, neighbor, clergy/spiritual leader, or group for support. The nurse would not minimize the patient's concerns. Attending AA may be appropriate, but this response doesn't address the client's concern. "Making peace" with the client's family may not be possible. This statement is not client-centered.

The nurse documents the vital signs of a client diagnosed with acute pancreatitis: Apical pulse = 116 beats/min Respirations = 28 breaths/min Blood pressure = 92/50 What complication of acute pancreatitis would the nurse suspect that the client might have? a. Electrolyte imbalance b. Pleural effusion c. Internal bleeding d. Pancreatic pseudocyst

ANS: C The client is exhibiting signs of hypovolemia most likely due to internal bleeding or hemorrhage. Due to decreased blood volume, the blood pressure is low and the heart rate increases to compensate for hypovolemia to ensure organ perfusion. Respirations often increase to increase oxygen in the blood.

A client had an open traditional Whipple procedure this morning. For what priority complication would the nurse assess? a. Urinary tract infection b. Chronic kidney disease c. Heart failure d. Fluid and electrolyte imbalances

ANS: D Due to the length and complexity of this type of surgery, the client is at risk for fluid and electrolyte imbalances. The nurse would assess for signs and symptoms of these imbalances so they can be managed early to prevent potentially life-threatening complications.

The nurse is caring for a client who has cirrhosis of the liver. Which risk factor is the leading cause of cirrhosis? a. Metabolic syndrome b. Liver cancer c. Nonalcoholic fatty liver disease d. Hepatitis C

ANS: D Hepatitis C is the leading cause of cirrhosis and an also cause liver cancer. Clients with nonalcoholic fatty liver disease often have metabolic syndrome and can also develop cirrhosis.

A client is experiencing an attack of acute pancreatitis. Which nursing intervention is the highest priority for this client? Measure intake and output every shift. Do not administer food or fluids by mouth. Administer opioid analgesic medication. Assist the client to assume a position of comfort.

Administer opioid analgesic medication. Pain relief is the highest priority for the client with acute pancreatitis.Although measuring intake and output, NPO status, and positioning for comfort are all important, they are not the highest priority.

Which action by the nurse would most likely help to relieve symptoms associated with ascites? Administering oxygen therapy Lowering the head of the bed Monitoring serum albumin levels Administering intravenous fluids

Administering oxygen therapy The best action by the nurse caring for a client with ascites is to elevate the head of the bed and provide supplemental oxygen. The enlarged abdomen of ascites limits respiratory excursion. Fowler position will increase excursion and reduce shortness of breath.Monitoring serum albumin levels will detect anticipated decreased levels associated with cirrhosis and hepatic failure but does not relieve the symptoms of ascites. Administering IV fluids will contribute to fluid volume excess and fluid shifts into the peritoneal cavity, worsening ascites.

The nurse is reviewing laboratory results of a client recently admitted with a diagnosis of acute pancreatitis. Which values would the nurse expect to be elevated? (Select all that apply.) Calcium Amylase Lipase Trypsin Elastase Glucose

Amylase Lipase Trypsin Elastase Glucose The client who has acute pancreatitis experiences elevation of all pancreatic enzymes and glucose. The serum calcium level is usually decreased (rather than elevated) because the release of fatty acids combined with available calcium.

The nurse is planning care for a client who had a laparoscopic Whipple surgery. For which complications will the nurse assess? Select all that apply. A. Bleeding B. Wound infection C. Intestinal obstruction D. Diabetes mellitus E. Abdominal abscess

Answers: A, B, C, D, E Rationales: Clients having this complex surgery can develop any or all of the postoperative complications listed in the test item.

When preparing a client to undergo paracentesis, which action is necessary to reduce potential injury as a result of the procedure? Encourage the client to take deep breaths and cough. Ask the client to void prior to the procedure. Position the client with the head of the bed flat. Assist the provider to insert a trocar catheter into the abdomen.

Ask the client to void prior to the procedure. To avoid injury to the bladder during a paracentesis, the client would be asked to void prior to the procedure. Taking deep breaths and coughing does not prevent complications or injury as a result of paracentesis. Clients would be positioned with the head of the bed elevated. The trocar catheter is used to drain the ascetic fluid and does not reduce the risk of damage to the bladder.

The nurse is caring for a client who had a Whipple surgical procedure yesterday. For what serum laboratory test results would the nurse want to monitor frequently and carefully? Platelet count Blood glucose Phosphorus Blood urea nitrogen

Blood glucose During a Whipple procedure, most or all of the pancreas is manipulated, stressed, and possibly removed. Therefore, the client is at risk for hyperglycemia or hypoglycemia and blood glucose would need careful monitoring with a possible need for treatment.

A client has undergone the Whipple procedure (radical pancreaticoduodenectomy) for pancreatic cancer. Which nursing actions would the nurse implement to prevent potential complications? (Select all that apply.) Check blood glucose often. Check bowel sounds and stools. Ensure that drainage color is clear. Monitor mental status. Place the client in the supine position.

Check blood glucose often. Check bowel sounds and stools. Monitor mental status. To prevent potential complications after a Whipple procedure, the nurse would check the client's glucose often to monitor for diabetes mellitus. Bowels sounds and stools would be checked to monitor for bowel obstruction. A change in mental status or level of consciousness could be indicative of hemorrhage.Clear, colorless, bile-tinged drainage or frank blood with increased output may indicate disruption or leakage of a site of anastomosis but is not a precautionary action for the nurse to implement. The client should be placed in semi-Fowler and not supine position to reduce tension on the suture line and the anastomosis site and to optimize lung expansion.

After teaching a client who has a history of cholelithiasis, the nurse assesses the client's understanding. Which menu selection indicates that the client understands the dietary teaching? a. Lasagna, tossed salad with Italian dressing, and low-fat milk b. Grilled cheese sandwich, tomato soup, and coffee with cream c. Cream of potato soup, Caesar salad with chicken, and a diet cola d. Roasted chicken breast, baked potato with chives, and orange juice

D Clients with cholelithiasis should avoid foods high in fat and cholesterol, such as whole milk, butter, and fried foods. Lasagna, low-fat milk, grilled cheese, cream, and cream of potato soup all have high levels of fat. The meal with the least amount of fat is the chicken breast dinner.

The nurse is caring for a client who just had a paracentesis. Which client finding indicates that the procedure was effective? Increased blood pressure Increased pulse Decreased weight Decreased pain

Decreased weight A paracentesis is performed to remove ascitic fluid from the abdomen. Therefore, the client should weigh less after the procedure than before. Blood pressure should decrease due to less fluid volume and the pulse rate may not be affected. The client may report less abdominal discomfort or ease in breathing, but pain is not a common problem for cirrhotic clients.

The nurse is assessing a client who is diagnosed as having Hepatitis A and asks how someone gets this disease. What is the most likely cause of the client's Hepatitis A? Eating contaminated food or water Sharing needles for illicit drugs Having unprotected sex Being exposed to blood or blood products

Eating contaminated food or water Hepatitis A is transmitted through the fecal-oral route rather than via blood. Therefore, contaminated food or water with Escherichia coli or other microbes can cause this liver infection.

When caring for a client with portal hypertension, the nurse assesses for which potential complications? (Select all that apply.) Esophageal varices Hematuria Fever Ascites Hemorrhoids

Esophageal varices Ascites Hemorrhoids Potential complications of portal hypertension include esophageal varices, ascites, and hemorrhoids. Portal hypertension results from increased resistance to or obstruction (blockage) of the flow of blood through the portal vein and its branches. The blood meets resistance to flow and seeks collateral (alternative) venous channels around the high-pressure area. Veins become dilated in the esophagus (esophageal varices), rectum (hemorrhoids), and abdomen (ascites due to excessive abdominal [peritoneal] fluid).Hematuria may indicate insufficient production of clotting factors in the liver and decreased absorption of vitamin K. Fever indicates an inflammatory process.

The nurse is caring for a client who has been diagnosed with cirrhosis. Which laboratory result(s) would the nurse expect for this client? (Select all that apply.) Increased serum bilirubin Increased aspartate aminotransferase Increased serum alanine aminotransferase Decreased serum albumin Increased serum ammonia Increased lactate dehydrogenase

Increased serum bilirubin Increased aspartate aminotransferase Increased serum alanine aminotransferase Decreased serum albumin Increased serum ammonia Increased lactate dehydrogenase Cirrhosis is a chronic disease in which the liver progressively degenerates. As a result, liver enzymes and bilirubin increase. Additionally, the liver is unable to synthesize protein leading to decreased serum albumin. Elevated serum ammonia results from the inability of the liver to detoxify protein by-products.

The nurse is caring for a client who had a liver transplant last week. For which complication will the nurse teach the client and family to monitor? Hypertension Infection Pulmonary edema Acute kidney injury

Infection The client is at the most risk for rejection of the transplant which can be the result of an infection if not identified and managed effectively. Therefore, the nurse would teach the client and family to report cough, fever, skin redness, and other signs of infection.

What teaching does the home health nurse give the family of a client with hepatitis C to prevent the spread of the infection? The client must not consume alcohol. Avoid sharing the bathroom with the client. Members of the household must not share toothbrushes. Drink only bottled water and avoid ice.

Members of the household must not share toothbrushes. The nurse teaches the family of a client with hepatitis C that toothbrushes, razors, towels, and any other items may spread blood and body fluids and must not be shared.The client should not consume alcohol, but abstention will not prevent spread of the virus. The client may share a bathroom if he or she is continent. To prevent hepatitis A when traveling to foreign countries, bottled water should be consumed and ice made from tap water needs to be avoided.

When providing community education, the nurse emphasizes that which group needs to receive immunization for hepatitis B? Clients who work with shellfish. Men who engage in sex with men. Clients traveling to a third-world country. Clients with elevations of aspartate aminotransferase and alanine aminotransferase.

Men who engage in sex with men. Men who prefer sex with men are at increased risk for hepatitis B, which is spread by the exchange of blood and body fluids during sexual activity.Consuming raw or undercooked shellfish may cause hepatitis A, not hepatitis B. Travel to third-world countries exposes the traveler to contaminated water and risk for hepatitis A. Hepatitis B is not of concern, unless the client is exposed to blood and body fluids during travel. Clients who have liver disease should receive the vaccine, but men who have sex with men are at higher risk for contracting hepatitis B.

A client who had a Whipple surgical procedure develops an internal fistula between the pancreas and stomach. For which complication would the nurse monitor? Peptic ulcer disease Cirrhosis Peritonitis Crohn disease

Peritonitis Leakage of pancreatic enzymes, bile, and/or gastric secretions into the abdomen (peritoneal cavity) often causes peritonitis, which requires IV antibiotic therapy to manage.

How would the home care nurse best modify the client's home environment to manage side effects of lactulose? Removes throw rugs to prevent falls. Rearranges furniture to declutter the home. Obtains a walker for the client. Requests a bedside commode for the client.

Requests a bedside commode for the client. The home care nurse would modify the client's home environment to manage side effects of lactulose by making a bedside commode available to the client. Lactulose therapy increases the frequency of stools. A bedside commode is especially necessary if the client has difficulty reaching the toilet.

A client is admitted to the emergency department with possible acute pancreatitis. What is the nurse's priority assessment at this time? Pain intensity assessment Cardiovascular assessment Abdominal assessment Respiratory assessment

Respiratory assessment As for any client, the nurse would want to continually assess for airway, breathing, and circulation. Clients who have acute pancreatitis often develop pleural infusions, atelectasis, or pneumonia. Necrotizing hemorrhagic pancreatitis places the client at risk for acute respiratory distress syndrome (ARDS).

The nurse collaborates with the registered dietitian nutritionist in providing teaching for a client who has ascites from cirrhosis. What daily dietary restriction would the nurse include in the health teaching? Sodium Potassium Magnesium Calcium

Sodium Mild to moderate sodium restriction is often tried as the first intervention to decrease body fluid retention, including ascites.

The nurse is teaching a client with gallbladder disease about diet modification. Which meal would the nurse suggest to the client? Steak and french fries Fried chicken and mashed potatoes Turkey sandwich on wheat bread Sausage and scrambled eggs

Turkey sandwich on wheat bread Turkey is an appropriate low-fat selection for this client. High fiber, from the wheat bread, also helps reduce the risk. Typically, diets high in fat, high in calories, low in fiber, and high in refined white carbohydrates place clients at higher risk for developing gallstones.Steak, french fries, fried chicken and mashed potatoes, and sausage are too fatty. Eggs are too high in cholesterol for a client with gallbladder disease.

After receiving change-of-shift report on these clients, which client does the nurse plan to assess first? Young adult client with acute pancreatitis who is dyspneic and has a respiratory rate of 34 to 38 breaths/min. Adult client admitted with cholecystitis who is experiencing severe right upper quadrant abdominal pain. Middle-age client who has an elevated temperature after undergoing endoscopic retrograde cholangiopancreatography. Older adult client who is receiving total parenteral nutrition after a Whipple procedure and has a glucose level of 235 mg/dL (13.1 mmol/L).

Young adult client with acute pancreatitis who is dyspneic and has a respiratory rate of 34 to 38 breaths/min. The nurse would first assess the young adult client with acute pancreatitis who is dyspneic and has a respiratory rate of 34 to 38 breaths/min. Airway and breathing are the two most important criteria the nurse will use to determine which client to assess first. The dyspneic client is at greatest risk for rapid deterioration and requires immediate assessment and intervention. Acute respiratory distress syndrome is a possible complication of acute pancreatitis.The client with cholecystitis and the client with an elevated temperature will require further assessment and intervention, but these are not medical emergencies requiring the nurse's immediate attention. The older adult client's glucose level will require intervention but, again, is not a medical emergency.

The nurse is caring for a client who has cirrhosis of the liver. The client's latest laboratory testing shows a prolonged prothrombin time. For what assessment finding would the nurse monitor: deep vein thrombosis. hematemesis. pressure injury. jaundice.

hematemesis. The client who has cirrhosis is at risk for bleeding due to decreased production of prothrombin by the liver. Portal hypertension that occurs in clients with cirrhosis causes esophageal blood veins to become fragile, distended, and tortuous. Therefore, these veins tend to bleed as evidenced by either hematemesis or melena.