Chapter 43: Liver, Pancreas, and Biliary Tract Problems

A 23 yr old has been admitted with acute liver failure. Which assessment data are most important for the nurse to communicate to the HCP a. asterixis and lethargy b. jaundice sclera and skin c. elevated total bilirubin level d. liver 3 cm below costal margin

a. asterixis and lethargy rationale: the patients findings of asterixis and lethargy are consistent with grade 2 hepatic encephalopathy.

For a patient with cirrhosis, which of the following nursing actions can the RN delegate to UAP. a. assessing the patient for jaundice b. providing oral hygiene after a meal c. palpating the abdomen for distention d. assisting the patient to choose the diet

b. providing oral hygiene after a meal rationale: providing oral hygiene is within the scope of UAP

Which laboratory test result will the nurse monirot when evaluating the effects of therapy for a 62 yr old female patient who has acute pancreatitis. a. calcium b. bilirubin c. amylase d. potassium

c. amylase rationale: amylase is elevated in acute pancreatitis.

A 67 yr old male patient with acute pancreatitis has a NG tube to suction and is NPO. Which information obtained by the nurse indicates that these therapies have been effective. a. bowel sounds are great. b. grey turner sign resolves c. electrolyte levels are normal d. abdominal pain is decreased.

d. abdominal pain is decreased. rationale: NG suction and NPO status will decrease the release of pancreatic enzymes into the pancreas and decrease pain.

Which data will the nurse monitor in relation to the 4+ pitting edema assessed in a patient with cirrhosis. a. hemoglobin b. temperature c. activity level d. albumin level

d. albumin level rationale: the low oncotic pressure caused by hypoalbuminemia is a major pathophysiologic factor in the development of edema.

After an unimmunized individual is exposed to hepatitis B through a needle-stick injury, which actions will the nurse plan to take. select all. a. administer hepatitis B vaccine b. test for antibodies to hepatitis B c. teach about a-interferon therapy d. give hepatitis B immune globulin e. teach about choices for oral antiviral therapy.

A, B, D. the recommendations for hepatitis B exposure include both vaccination and immune globulin administration.

A 36 yr old male patient in the outpatient clinic is diagnosed with acute hepatitis C (HCV) 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 (rebetol) treatment d. explain that the infection will resolve over a few months.

a. schedule the patient for HCV genotype testing. rationale: genotyping of HCV has an important role in managing treatment and is done before drug therapy is initiated.

Which finding indicates to the nurse that lactulose (Cephulac) is effective for a 72 yr old man who has advanced cirrhosis. a. the patient is alert and oriented b. the patient denies nausea or anorexia c. the patients bilirubin level decreases d. the patient has at least one stool daily.

a. the patient is alert and oriented. rationale: the purpose of lactulose in the patient with cirrhosis is to lower ammonia levels and prevent encephalopathy.

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

b. administer the spironolactone rationale: spironolactone is a potassium-sparing diuretic and will help increase the patients potassium level.

The nurse is caring for a 36 yr old 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.

c. administer prescribed opioids to relieve pain as needed rationale: effective pain management will be necessary in order for the patient to improve nutrition, be receptive to teaching, or manage anxiety or depression

Which action should the nurse in the ED 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, heart rate, and respirations d. place the patient in the supine position.

c. check blood pressure, heart rate, and respirations. rationale: the nurses first action should be to determine the patients hemodynamic status by assessing vital signs.

A 51 yr old woman had an incisional cholecystectomy 6 hours ago. The nurse will place the highest priority on assisting the patient to a. choose low fat foods from the menu b. perform leg exercises hourly while awake c. ambulate the evening of the operative day d. turn, cough, and deep breathe every 2 hours.

d. turn, cough, and deep breathe every 2 hours rationale: post-operative 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.

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

a. leukopenia rationale: therapy with ribavirin and a-interferon may cause leukopenia.

The nurse is planning care for a 48 yr old woman with acute severe pancreatitis. The highest priority patient outcome is a. maintaining normal respiratory function b. expressing satisfaction with pain control c. developing no ongoing pancreatic disease. d. having adequate fluid and electrolyte balance

a. maintaining normal respiratory function rationale: respiratory failure can occur as a complication of acute pancreatitis, and maintenance of adequate respiratory function is the priority goal.

The nurse recognizes that teaching a 4 yr old woman following a laparoscopic cholecystectomy has been effective when the patient states with of the following. a. I can expect yellow-green drainage from the incision for a few days b. I can remove the bandages on my incisions tomorrow and take a shower. c. I should plan to limit my activities and not return to work for 4 to 6 hours d. I will always need to maintain a low fat diet since I no longer have a gallbladder.

b. I can remove the bandages on my incision tomorrow and take a shower. rationale: after a laparoscopic cholecystectomy, the patient will have band-aids in place over the incisions.

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

b. ammonia level rationale: the protein in the blood in the GI tract will be absorbed and may result in an increase in the ammonia level because the liver cannot metabolize protein very well.

Administration of hepatitis B vaccine to a healthy 18 yr old patient has been effective when a specimen of the patients blood reveals a. HBsAg b. anti-HBs c. anti-HBc IgG d. anti-HBc IgM.

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

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.

b. ask the patient to extend both arms forward. rationale: extending the arms allows the nurse to check for asterixis, a classic sign of hepatic encephalopathy.

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

b. avoiding alcohol ingestion rationale: the disease progression can be stopped or reversed by alcohol abstinence.

A 55 yr old 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 most appropriate. a. is there any history of IV drug use b. do you use any over the counter drugs c. are you taking corticosteroids for any reason. d. have you recently traveled to a foreign country.

b. do you use any history of IV drug use. rationale: the patients 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 goal has the highest priority in the plan of care for a 26 yr old homeless patient admitted with viral hepatitis who has severe anorexia and fatigue a. increase activity level b. maintain adequate nutrition c. establish a stable environment d. identify sources of hepatitis exposure.

b. maintain adequate nutrition rationale: the highest priority outcome is to maintain nutrition because adequate nutrition is needed for hepatocyte regeneration.

The nurse will plan to teach the patient diagnosed with acute hepatitis B about a. side effects of nucleotide analogs b. measures for improving the appetite. c. ways to increase activity and exercise d. administering a-interferon (Intron A)

b. measures for improving the appetite. rationale: maintaining adequate nutritional intake is important for regeneration of hepatocytes.

A 53 yr old 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 SOB c. verify the position of the balloon every 4 hours d. deflate the gastric balloon if the patient reports nausea

b. monitor the patient for SOB rationale: 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.

A 34 yr old patient with chronic hepatitis C infection has several medications prescribed. Which medication requires further discussion with the HCP before administration a. ribavirin (Rebetol, Copegus) 600 mg PO bid b. pegylated a-interferon (PEG-Intron, Pegasys SQ daily) c. diphenhydramine (benadryl) 25 mg PO every 4 hours PRN itching. d. Dimenhydrinate (Dramamine) 50 mg PO every 6 hours PRN nausea.

b. pegylated a-interferon (PEG-Intron, Pegasys SQ daily). rationale: Pegylated a-interferon is administered weekly.

A 36 yr old patient is receiving treatment for chronic hepatitis C with pegylated interferon (PEG-intron, Pegasys), ribavirin (rebetol), and telaprevir (Incivek). Which finding is most important to communicate to the HCP a. weight loss of 2 lb (1kg) b. positive urine pregnancy test c. hemoglobin level of 10.4 g/dL d. complaints of nausea and anorexia.

b. positive urine pregnancy test rationale: because ribavirin is teratogenic, the medication will need to be discontinued immediately.

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 hours c. initiate administration of the hepatitis C vaccine series d. Monitor anti-hepatitis B surface antigen (anti-HBs) levels annually

b. schedule for liver cancer screening every 6 hours rationale: 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.

The nurse is caring for a 73 yr old man who has cirrhosis. Which data obtained by the nurse during the assessment will be of most concern. a. the patient complains of right upper quadrant pain with palpation b. the patient hands flap back and forth when the arms are extended c. the patient has ascites and a 2 kg weight gain from the previous day d. the patients skin has multiple spider shaped blood vessels on the abdomen.

b. the patient hands flap back and forth when the arms are extended. rationale: asterixis indicates that the patient has hepatic encephalopathy, and hepatic coma may occur.

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

b. the patient used IV drugs about 20 yrs ago rationale: any patient with a history of IV drug use should be tested for hepatitis C.

Which assessment information will be most important for the nurse to report to the HCP about a patient with acute cholecystitis a. the patients urine is bright yellow b. the patients stools are tan colored. c. the patient has increased pain after eating d. the patient complains of chronic heartburn.

b. the patients stools are tan colored. rationale: tan or grey stools indicate biliary obstruction, which requires rapid intervention to resolve.

During change of shift report, the nurse learns about the following four patients. Which patient requires assessment first. a. 40 yr old with chronic pancreatitis who has gnawing abdominal pain b. 58 yr old who has compensated cirrhosis and is complaining of anorexia. c. 55 yr old with cirrhosis and ascites who has an oral temp of 102 d. 36 yr old recovering from a laparoscopic cholecystectomy who has severe shoulder pain

c. 55 yr old with cirrhosis and ascites who has an oral temp of 102 rationale: this patients history and fever suggest possible spontaneous bacterial peritonitis, which would require rapid assessment and interventions such as antibiotic therapy

To prepare a 56 yr old male patient with ascites for paracentesis, the nurse a. places the patient on NPO status b. assists the patient to lie flat in bed c. ask the patient to empty the bladder d. positions the patient on the right side.

c. ask the patient to empty the bladder. rationale: the patient should empty the bladder to decrease the risk of bladder perforation during the procedure.

A patient born in 1955 had hepatitis A infection 1 year ago. According to Centers of Disease control and prevention guidelines, which action should the nurse include in care when the patient is seen for a routine annual physical exam 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)

c. ask whether the patient has been screened for hepatitis C. rationale: current CDC guidelines indicate that all patients who were born between 1945 and 1965 should be screened for hepatitis C because many individuals who are positive have not been diagnosed.

When taking the blood pressure on the right arm of a patient with severe acute pancreatitis, the nurse notices carpal spasms of the patients right hand. Which action should the nurse take next. a. ask the patient about any arm pain b. retake the patients blood pressure c. check the calcium level in the chart d. notify the HCP immediately.

c. check the calcium level in the chart. rationale: the patient with acute pancreatitis is at risk for hypocalcemia and the assessment data indicate a positive trousseau's sign.

A 38 yr old 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. place the patient on a pressure-relieving mattress d. perform passive range of motion daily.

c. place the patient on a pressure-relieving mattress rationale: the pressure relieving mattress will decrease the risk for skin breakdown for this patient.

A 49 year old female patient with cirrhosis and esophageal varices has a new prescription for propranolol (Inderal). Which finding is the best indicator that the medication has been effective. a. the patient reports no chest pain b. blood pressure is 140/90 mm Hg c. stools test negative for occult blood d. the apical pulse rate is 68 bpm

c. stools test negative for occult blood. rationale: 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 of the propranolol is the lack of blood in the stools.

Which finding is most important for the nurse to communicate to the HCP 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 d. no bowel movement for 4 days.

c. temp of 100.8 rationale: the risk if infection is high in the first few months after liver transplant and fever is frequently the only sign of infection.

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

c. the medication will prevent irritation of the enlarged ulcers. rationale: 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.

The nurse will teach a patient with chronic pancreatitis to take the prescribed pancrelipase (Viokase). a. at bedtime b. in the morning c. with each meal d. for abdominal pain

c. with each meal rationale: pancreatic enzymes are used to help with digestion of nutrients and should be taken with every meal

The nurse will ask a 64 year old patient being admitted with acute pancreatitis specifically about a history of a. diabetes mellitus b. high-protein diet c. cigarette smoking d. alcohol consumption

d. alcohol consumption rationale: alcohol use is one of the most common risk factors for pancreatitis in the United States.

A 24 yr old female contracts hepatitis from contaminated food. During the acute (icteric) phase of the patients illness, the nurse would expect serologic testing to reveal 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).

d. anti-hepatitis A virus immunoglobulin M (anti-HAV IgM). rationale: Hepatitis A is transmitted through the oral fecal route, and antibody to HAV IgM

Which finding indicates to the nurse that a patients transjugular intrahepatic portosystemic shunt (TIPS) 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.

d. fewer episodes of bleeding varices. rationale: TIPS is used to lower pressure in the portal venous system and decrease the risk of bleeding from esophageal varices.

Which assessment finding would the nurse need to report most quickly to the HCP regarding a patient with acute pancreatitis. a. nausea and vomiting b. hypotonic bowel sounds c. abdominal tenderness and guarding d. muscle twitching and finger numbness.

d. muscle twitching and finger numbness rationale: muscle twitching and finger numbness indicate hypocalcemia, which may lead to tetany unless calcium gluconate is administered.

Which assessment finding is of most concern for a 46 year old woman with acute pancreatitis. a. absent bowel sounds b. abdominal tenderness c. left upper quadrant pain d. palpable abdominal mass

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

A nurse is considering which patient to admit to the same room as a patient who had a liver transplant 3 weeks ago and is now hospitalized with acute rejection. 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.

d. patient who requires pain management for chronic pancreatitis. rationale: The patient with chronic pancreatitis does not present an infection risk to the immunosuppressed patient who had a liver transplant.

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

d. review the patients current medication list. rationale: some medications can increase the risk for NAFLD, and they should be eliminated.