Chapter 43: Liver, Biliary Tract, and Pancreas Problems

The nurse recognizes that teaching a patient following a laparoscopic cholecystectomy has been effective when the patient makes which statement? a. "I can take a shower and walk around the house tomorrow." b. "I need to limit my activities and not return to work for 4 weeks." c. "I can expect yellowish drainage from the incision for a few days." d. "I will follow a low-fat diet for life because I do not have a gallbladder."

ANS: A After a laparoscopic cholecystectomy, patients are discharged the same (or next) day and have few restrictions on activities of daily living.

What risk factor will the nurse specifically ask about when a patient is being admitted with acute pancreatitis? a. diabetes b. alcohol use c. high-protein diet d. cigarette smoking

ANS: B Alcohol use is one of the most common risk factors for pancreatitis in the United States.

A 36-yr-old female patient is receiving treatment for chronic hepatitis B with pegylated interferon. Which finding is important to communicate to the health care provider to suggest a change in therapy? a. nausea and anorexia b. weight loss of 2 lb (1 kg) c. positive urine pregnancy test d. hemoglobin level of 10.4 g/dL

ANS: C Because ribavirin is teratogenic, the medication will need to be discontinued immediately.

A patient who has cirrhosis and esophageal varices is being treated with propranolol. Which finding is the best indicator to the nurse that the medication has been effective? a. patient reports no chest pain b. blood pressure is 130/80 c. stools test negative for occult blood d. apical pulse rate is 68

ANS: C Because the purpose of B-blocker therapy for patients with esophageal varices is to decrease the risk for bleeding from esophageal varices, the best indicator of the effectiveness for propranolol is the lack of blood in the stools.

A patient born in 1955 had hepatitis A infection 1 year ago. According to Centers for Disease Control and Prevention guidelines, which action should the nurse include in care when the patient is seen for a routine annual physical examination? a. start the hepatitis B immunization series b. teach the patient about hepatitis A immune globulin c. ask whether the patient has been screened for hepatitis C d. test for anti-hepatitis-A virus immune globulin M (anti-HAV-IgM)

ANS: C Current CDC guidelines indicate that all patients who were born between 1945 and 1965 should be screened for hepatitis C because many persons who are positive have not been diagnosed.

A serum potassium level of 3.2 mEq/L is reported for a patient with cirrhosis who has scheduled doses of spironolactone and furosemide due. Which action should the nurse take? a. withhold both drugs b. administer both drugs c. administer the furosemide d. administer the spironolactone

ANS: D Spironolactone is a potassium-sparing diuretic and will help increase the patient's potassium level.

A patient in the outpatient clinic is diagnosed with acute hepatitis C infection. Which action by the nurse is appropriate? a. schedule the patient for HCV genotype testing b. administer the HCV vaccine and immune globulin c. teach the patient about ribavirin treatment d. explain that the infection will resolve over a few months

ANS: A Genotyping of HCV has an important role in managing treatment and is done before drug therapy is initiated.

Which laboratory test result will the nurse monitor to evaluate the effects of therapy for a patient who has acute pancreatitis? a. lipase b. calcium c. bilirubin d. potassium

ANS: A Lipase is elevated in acute pancreatitis.

A patient has been admitted with acute liver failure. Which assessment data are most important for the nurse to communicate to the health care provider? a. asterixis and lethargy b. jaundiced sclera and skin c. elevated total bilirubin level d. liver 3 cm below costal margin

ANS: A The patient's findings of asterixis and lethargy are consistent with grade 2 hepatic encephalopathy. Patients with acute liver failure can deteriorate rapidly from grade 1 or 2 to grade 3 or 4 hepatic encephalopathy and need early transfer to a transplant center.

Which finding indicates to the nurse that lactulose is effective for an older adult who has advanced cirrhosis? a. patient is alert and oriented b. patient denies nausea or anorexia c. patient's bilirubin level decreases d. patient has at least one stool daily

ANS: A The purpose of lactulose in the patient with cirrhosis is to lower ammonia levels and prevent encephalopathy.

The nurse administering alpha-interferon and ribavirin to a patient with chronic hepatitis C will plan to monitor for...? a. leukopenia b. hypokalemia c. polycythemia d. hypoglycemia

ANS: A Therapy with ribavirin and -interferon may cause leukopenia.

After an unimmunized person is exposed to hepatitis B through a needle-stick injury, which actions will the nurse plan to take? (Select all that apply.) a. administer hepatitis B vaccine b. test for antibodies to hepatitis B c. teach about -interferon therapy d. give hepatitis B immune globulin e. explain options for oral antiviral therapy

ANS: A, B, D The recommendations for hepatitis B exposure include both vaccination and immune globulin administration. In addition, baseline testing for hepatitis B antibodies will be needed. Interferon and oral antivirals are not used for hepatitis B prophylaxis.

Which information from a 70-yr-old patient during a health history indicates to the nurse that the patient should be screened for hepatitis C? a. patient had a blood transfusion in 2005 b. patient used IV drugs about 20 years ago c. patient frequently eats in fast-food restaurants d. patient traveled to a country with poor sanitation

ANS: B Any patient with a history of IV drug use should be tested for hepatitis C.

The nurse is caring for a patient who has cirrhosis. Which data obtained by the nurse during the assessment will be of most concern? a. patient reports right upper-quadrant pain with palpation b. patient's hands flap back and forth when the arms are extended c. patient has ascites and a 2-kg weight gain from the previous day d. patient's abdominal skin has multiple spider-shaped blood vessels

ANS: B Asterixis indicates that the patient has hepatic encephalopathy, and hepatic coma may occur.

Which action should the nurse take to evaluate treatment effectiveness for a patient who has hepatic encephalopathy? a. request that the patient stand on one foot b. ask the patient to extend both arms forward c. request that the patient walk with eyes closed d. ask the patient to perform the Valsalva maneuver

ANS: B Extending the arms allows the nurse to check for asterixis, a classic sign of hepatic encephalopathy.

What topic should the nurse plan to teach the patient diagnosed with acute hepatitis B? a. administering alpha-interferon b. measures for improving appetite c. side effects of nucleotide analogs d. ways to increase activity and exercise

ANS: B Maintaining adequate nutritional intake is important for regeneration of hepatocytes.

What should the nurse teach a patient with chronic pancreatitis is the time to take the prescribed pancrelipase? a. bedtime b. mealtime c. when nauseated d. for abdominal pain

ANS: B Pancreatic enzymes are used to help with digestion of nutrients and should be taken with every meal.

Which action will the nurse include in the plan of care for a patient who has been diagnosed with chronic hepatitis B? a. advise limiting alcohol intake to 1 drink daily b. schedule for liver cancer screening every 6 months c. initiate administration of the hepatitis C vaccine series d. monitor anti-hepatitis B surface antigen (anti-HBs) levels

ANS: B Patients with chronic hepatitis are at higher risk for development of liver cancer and should be screened for liver cancer every 6 to 12 months.

For a patient who has cirrhosis, which nursing action can the registered nurse delegate to unlicensed assistive personnel? a. assessing the patient for jaundice b. providing oral hygiene after a meal c. palpating the abdomen for distention d. teaching the patient the prescribed diet

ANS: B Providing oral hygiene is within the scope of UAP.

The nurse is planning care for a patient with acute severe pancreatitis. What is the highest priority patient outcome? a. having fluid and electrolyte balance b. maintaining normal respiratory function c. expressing satisfaction with pain control d. developing no ongoing pancreatic disease

ANS: B Respiratory failure can occur as a complication of acute pancreatitis and maintenance of adequate respiratory function is the priority goal.

Which assessment information will be most important for the nurse to report to the health care provider about a patient who has acute cholecystitis? a. patient's urine is bright yellow b. patient's stools are tan colored c. patient reports chronic heartburn d. patient has increased pain after eating

ANS: B Tan or gray stools indicate biliary obstruction, which requires rapid intervention to resolve.

Which topic is most important to include in teaching for a 41-yr-old patient diagnosed with early alcoholic cirrhosis? a. taking lactulose b. avoiding all alcohol use c. maintaining good nutrition d. using vitamin B supplements

ANS: B The disease progression can be stopped or reversed by alcohol abstinence.

Which goal has the highest priority in the plan of care for a 26-yr-old patient who was admitted with viral hepatitis, has severe anorexia and fatigue, and is homeless? a. increase activity level b. maintain adequate nutrition c. establish a stable environment d. identify source of hepatitis exposure

ANS: B The highest priority outcome is to maintain nutrition because adequate nutrition is needed for hepatocyte regeneration.

A patient is being treated for bleeding esophageal varices with balloon tamponade. Which nursing action will be included in the plan of care? a. instruct the patient to cough every hour b. monitor the patient for shortness of breath c. verify the position of the balloon every 4 hours d. deflate the gastric balloon if the patient reports nausea

ANS: B The most common complication of balloon tamponade is aspiration pneumonia. In addition, if the gastric balloon ruptures, the esophageal balloon may slip upward and occlude the airway.

The nurse evaluates that administration of hepatitis B vaccine to a healthy patient has been effective when the patient's blood specimen reveals...? a. HBsAg b. anti-HBs c. anti-HBc IgG d. anti-HBc IgM

ANS: B The presence of surface antibody to HBV (anti-HBs) is a marker of a positive response to the vaccine.

What is most important for the nurse to monitor to detect possible complications in a patient with severe cirrhosis who has bleeding esophageal varices? a. bilirubin levels b. ammonia levels c. potassium levels d. prothrombin time

ANS: B The protein in the blood in the gastrointestinal tract will be absorbed and may result in an increase in the ammonia level because the liver cannot metabolize protein very well.

The nurse is caring for a patient with pancreatic cancer. Which nursing action is the highest priority? a. offer psychologic support for depression b. offer high-calorie, high-protein dietary choices c. administer prescribed opioids to relieve pain as needed d. teach about the need to avoid scratching any pruritic areas

ANS: C Effective pain management will be necessary in order for the patient to improve nutrition, be receptive to teaching, or manage anxiety or depression.

Which response by the nurse best explains the purpose of ranitidine for a patient who was admitted with bleeding esophageal varices? a. medication will reduce the risk for aspiration b. medication will inhibit development of gastric ulcers c. medication will prevent irritation of the enlarged veins d. medication will decrease nausea and improve the appetite

ANS: C Esophageal varices are dilated submucosal veins. The therapeutic action of H2-receptor blockers in patients with esophageal varices is to prevent irritation and bleeding from the varices caused by reflux of acid gastric contents.

Which assessment finding would the nurse need to report most quickly to the health care provider regarding a patient who has acute pancreatitis? a. nausea and vomiting b. hypotonic bowel sounds c. muscle twitching and finger numbness d. upper abdominal tenderness and guarding

ANS: C Muscle twitching and finger numbness indicate hypocalcemia, which may lead to tetany unless calcium gluconate is administered.

A patient had an incisional cholecystectomy 6 hours ago. The nurse will place the highest priority on assisting the patient to...? a. perform leg exercises hourly while awake b. ambulate the evening of the operative day c. turn, cough, and deep breathe every 2 hours d. choose preferred low-fat foods from the menu

ANS: C Postoperative nursing care after a cholecystectomy focuses on prevention of respiratory complications because the surgical incision is high in the abdomen and impairs coughing and deep breathing.

Which action should the nurse in the emergency department take first for a new patient who is vomiting blood? a. insert a large-gauge IV catheter b. draw blood for coagulation studies c. check blood pressure and heart rate d. place the patient in the supine position

ANS: C The nurse's first action should be to determine the patient's hemodynamic status by assessing vital signs.

How should the nurse prepare a patient with ascites for paracentesis? a. place the patient on NPO status b. assist the patient to lie flat in bed c. ask the patient to empty the bladder d. position the patient in the right side

ANS: C The patient should empty the bladder to decrease the risk of bladder perforation during the procedure.

When taking the blood pressure on the right arm of a patient who has severe acute pancreatitis, the nurse notices carpal spasms of the patient's right hand. Which action should the nurse take next? a. ask the patient about any arm pain b. retake the patient's blood pressure c. check the calcium level in the chart d. notify the health care provider immediately

ANS: C The patient with acute pancreatitis is at risk for hypocalcemia, and the assessment data indicate a positive Trousseau's sign.

A patient admitted with an abrupt onset of jaundice and nausea has abnormal liver function studies, but serologic testing is negative for viral causes of hepatitis. Which question by the nurse is appropriate? a. "Have you taken corticosteroids?" b. "Do you have a history of IV drug use?" c. "Do you use any over-the-counter drugs?" d. "Have you recently traveled to another country?"

ANS: C The patient's symptoms, lack of antibodies for hepatitis, and the abrupt onset of symptoms suggest toxic hepatitis, which can be caused by commonly used over-the-counter drugs such as acetaminophen.

Which finding is most important for the nurse to communicate to the health care provider about a patient who received a liver transplant 1 week ago? a. dry palpebral and oral mucosa b. crackles at bilateral lung bases c. temperature 100.8° F (38.2° C) d. no bowel movement for 4 days

ANS: C The risk of infection is high in the first few months after liver transplant, and fever is frequently the only sign of infection.

During change-of-shift report, the nurse learns about the following four patients. Which patient requires assessment first? a. 58-yr-old patient who has compensated cirrhosis and reports anorexia b. 40-yr-old patient with chronic pancreatitis who has gnawing abdominal pain c. 55-yr-old patient with cirrhosis and ascites who has an oral temperature of 102° F (38.8° C) d. 36-yr-old patient recovering from a laparoscopic cholecystectomy who has severe shoulder pain

ANS: C This patient's history and fever suggest possible spontaneous bacterial peritonitis, which would require rapid assessment and interventions such as antibiotic therapy.

Which assessment finding is of most concern for a patient with acute pancreatitis? a. absent bowel sounds b. abdominal tenderness c. left upper quadrant pain d. palpable abdominal mass

ANS: D A palpable abdominal mass may indicate the presence of a pancreatic abscess, which will require rapid surgical drainage to prevent sepsis.

A young adults contracts hepatitis from contaminated food. What should the nurse expect serologic testing to reveal during the acute (icteric) phase of the patient's illness? a. antibody to hepatitis D (anti-HDV) b. hepatitis B surface antigen (HBsAg) c. anti-hepatitis A virus immunoglobulin G (anti-HAV IgG) d. anti-hepatitis A virus immunoglobulin M (anti-HAV IgM)

ANS: D Hepatitis A is transmitted through the oral-fecal route, and antibody to HAV IgM appears during the acute phase of hepatitis A.

A patient with acute pancreatitis is NPO and has a nasogastric tube to suction. Which information obtained by the nurse indicates that these therapies have been effective? a. bowel sounds are present b. grey Turner sign resolves c. electrolyte levels are normal d. abdominal pain is decreased

ANS: D NG suction and NPO status will decrease the release of pancreatic enzymes into the pancreas and decrease pain.

A patient with chronic hepatitis B infection has several medications prescribed. Which medication order requires clarification with the health care provider before administration? a. tenofovir orally once daily b. adefovir orally once daily c. entecarvir orally once daily d. pegylated alpha-interferon orally once daily

ANS: D Pegylated a-interferon is administered subcutaneously, not orally. The medications are all appropriate for a patient with chronic hepatitis B infection.

Which action will be included in the care for a patient who has recently been diagnosed with asymptomatic nonalcoholic fatty liver disease? a. teach symptoms of variceal bleeding. b. draw blood for hepatitis serology testing. c. discuss the need to increase caloric intake. d. review the patient's current medication list.

ANS: D Some medications can increase the risk for NAFLD, and they should be discontinued.

Which finding indicates to the nurse that a patient's transjugular intrahepatic portosystemic shunt placed 3 months ago has been effective? a. increased serum albumin level b. decreased indirect bilirubin level c. improved alertness and orientation d. fewer episodes of bleeding varices

ANS: D TIPS is used to lower pressure in the portal venous system and decrease the risk of bleeding from esophageal varices.

Which focused data should the nurse assess after identifying 4+ pitting edema on a patient who has cirrhosis? a. hemoglobin b. temperature c. activity level d. albumin level

ANS: D The low oncotic pressure caused by hypoalbuminemia is a major pathophysiologic factor in the development of edema.

A nurse is considering which patient to admit to the same room as a patient who is hospitalized with acute rejection 3 weeks after a liver transplant. Which patient would be the best choice? a. patient who is receiving chemotherapy for liver cancer b. patient who is receiving treatment for acute hepatitis C c. patient who has a wound infection after cholecystectomy d. patient who requires pain management for chronic pancreatitis

ANS: D The patient with chronic pancreatitis does not present an infection risk to the immunosuppressed patient who had a liver transplant.

A patient with cirrhosis has ascites and 4+ edema of the feet and legs. Which nursing action will be included in the plan of care? a. restrict daily dietary protein intake. b. reposition the patient every 4 hours. c. perform passive range of motion twice daily. d. place the patient on a pressure-relief mattress.

ANS: D The pressure-relieving mattress will decrease the risk for skin breakdown for this patient. Adequate dietary protein intake is necessary in patients with ascites to improve oncotic pressure.