Liver Failure and Pancreatitis, NCLEX
8. Pierre who is diagnosed with acute pancreatitis is under the care of Nurse Bryan. Which intervention should the nurse include in the care plan for the client? A. Administration of vasopressin and insertion of a balloon tamponade B. Preparation for a paracentesis and administration of diuretics C. Maintenance of nothing-by-mouth status and insertion of nasogastric (NG) tube with low intermittent suction D. Dietary plan of a low-fat diet and increased fluid intake to 2,000 ml/day
8. Answer: C. Maintenance of nothing-by-mouth status and insertion of nasogastric (NG) tube with low intermittent suction With acute pancreatitis, the client is kept on nothing-by-mouth status to inhibit pancreatic stimulation and secretion of pancreatic enzymes. NG intubation with low intermittent suction is used to relieve nausea and vomiting, decrease painful abdominal distention, and remove hydrochloric acid. Vasopressin would be appropriate for a client diagnosed with bleeding esophageal varices. Paracentesis and diuretics would be appropriate for a client diagnosed with portal hypertension and ascites. A low-fat diet and increased fluid intake would further aggravate the pancreatitis.
9. When teaching a client about pancreatic function, the nurse understands that pancreatic lipase performs which function? A. Transports fatty acids into the brush border B. Breaks down fat into fatty acids and glycerol C. Triggers cholecystokinin to contract the gallbladder D. Breaks down protein into dipeptides and amino acids
9. Answer: B. Breaks down fat into fatty acids and glycerol Lipase hydrolyses or breaks down fat into fatty acids and glycerol. Lipase is not involved with the transport of fatty acids into the brush border. Fat itself triggers cholecystokinin release. Protein breakdown into dipeptides and amino acids is the function of trypsin, not lipase.
Which finding indicates to the nurse that lactulose (Cephulac) is effective for a 72-year-old man who has advanced cirrhosis? a. The patient is alert and oriented. b. The patient denies nausea or anorexia. c. The patient's bilirubin level decreases. d. The patient has at least one stool daily.
A
Identify the rationales for the following interventions in treating the cirrhotic patient with hepatic encephalopathy a. Lactulose (Cephulac) b. Neomycin c. Eliminating blood from the GI tract
A. reduction of ammonia formation by decreasing absorption of ammonia from bowel B. reduction of ammonia formation by reducing bacterial flora that produce ammonia C. Reduction of ammonia formation by removing red blood cells as a source of protein
After receiving lactulose the day before, the client reports having seven loose stools in the past 12 hours. Based on this data, what laboratory findings would the nurse expect? A. Hypokalemia B. Hyponatremia C. Hypercalcemia D. Hyperglycemia
...ANS: A Because lactulose can cause the client to have several loose stools daily, the nurse should monitor serum electrolyte levels, particularly the serum potassium level for hypokalemia.
A client had a transhepatic biliary catheter placed 3 days ago. Which clinical manifestation would indicate that the procedure was successful? A. The client's sclera remains icteric. B. The client's stools are brown in color. C. The client's urine is a dark amber color. D. The client's catheter has blood return on aspiration.
...ANS: B A transhepatic biliary catheter decompresses extrahepatic ducts to promote the flow of bile. When bile flows normally, it reaches the large intestine where bile is converted to urobilinogen, coloring the stools brown.
Which client is most at risk for the development of gallstones? A. 22-year-old woman who is 1 month postpartum B. 65-year-old woman after a liquid protein diet C. 70-year-old man with peptic ulcer disease D. 33-year-old man with type 2 diabetes
...ANS: B Liquid protein diets increase susceptibility to gallstones by releasing cholesterol from tissues, which is then excreted as crystals in the bile.
Twenty-four hours after endoscopic retrograde cholangiopancreatography (ERCP), a client develops left upper quadrant abdominal pain and has a temperature of 101° F (38.3° C). What is the nurse's best action? A. Administer acetaminophen for control of fever and pain. B. Document the finding, because it is a normal postprocedure event. C. Notify the health care provider. D. Increase the IV fluid rate.
...ANS: C The client who has undergone an ERCP may develop complications such as perforation or sepsis manifested by fever and abdominal pain. The nurse should report these symptoms to the health care provider immediately.
18. A client diagnosed with chronic cirrhosis who has ascites and pitting peripheral edema also has hepatic encephalopathy. Which of the following nursing interventions are appropriate to prevent skin breakdown? (Select all that apply.) A. Range of motion every 4 hours B. Turn and reposition every 2 hours C. Abdominal and foot massages every 2 hours D. Alternating air pressure mattress E. Sit in chair for 30 minutes each shift
18. Answer: B, D Edematous tissue must receive meticulous care to prevent tissue breakdown. Range of motion exercises preserve joint function but do not prevent skin breakdown. Abdominal or foot massage will not prevent skin breakdown but must be cleansed carefully to prevent breaks in skin integrity. The feet should be kept at the level of heart or higher so Fowler's position should be employed. An air pressure mattress, careful repositioning can prevent skin breakdown.
20. Spironolactone (Aldactone) is prescribed for a client with chronic cirrhosis and ascites. The nurse should monitor the client for which of the following medication-related side effects? A. Jaundice B. Hyperkalemia C. Tachycardia D. Constipation
20. Answer: B. Hyperkalemia This is a potassium-sparing diuretic so clients should be monitored closely for hyperkalemia. Diarrhea, dizziness, and headaches are other more common side effects. Tachycardia, jaundice, and constipation are not expected side effects of spironolactone (Aldactone).
For the client with cirrhosis, what nursing intervention(s) would be most appropriate to control fluid accumulation in the abdominal cavity? A. Monitoring intake and output B. Providing a low-sodium diet C. Increasing PO fluid intake D. Weighing the client daily
ANS: B A low-sodium diet is one means of controlling abdominal fluid collection. Sodium intake may be restricted to 500 mg to 1 g daily. ...
25. A patient who is vomiting bright red blood is admitted to the emergency department. Which assessment should the nurse accomplish first? a. Measuring the quantity of any emesis b. Checking the level of consciousness c. Auscultating the chest for breath sounds d. Taking the blood pressure (BP) and pulse
Answer: D Rationale: The nurse is concerned about blood loss and possible hypovolemic shock in a patient with acute GI bleeding; BP and pulse are the best indicators of these complications. The other information is also important to obtain, but BP and pulse rate are the best indicators for hypoperfusion. Cognitive Level: Application Text Reference: p. 997 Nursing Process: Assessment NCLEX: Physiological Integrity
A 55-year-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
Which topic is most important to include in patient teaching for a 41-year-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
Laboratory test results that the nurse would expect to find in a patient with cirrhosis include a. serum albumin 7.0 g/dL b. bilirubin total 3.2 mg/dL c. serum cholesterok 260 mg/dL d. aspartate aminotransferase (AST) 6.0 U/L
B- Serum bilirubin, both direct and indirect, would be expected to be increased in cirrhosis. Serum albumin and cholesterol are decreased, and liver enzymes, such as AST and ALT, are elevated
The nurse evaluates the effectiveness of a paracentesis in a patient who has ascites. Which measurement is most important for the nurse to note? a. Cardiac output b. Blood pressure c. Abdominal girth d. Intake and output
C. Paracentesis involves the removal of fluid from the abdominal cavity. A large-bore needle connected to tubing is inserted by the health care provider into the distended abdomen. The other end of the tubing also has a large-bore needle, which is inserted into a vacuum bottle. The vacuum bottle is then held below the level of the abdomen, facilitating gravity-flowed removal of the ascites. Several bottles of fluid can be removed, with the result measured by reduction in abdominal girth. Cardiac output may improve after paracentesis, but it is unlikely that this measurement needs to be recorded. Paracentesis has no major effect on blood pressure. Likewise, intake and output continue to be monitored to account for the paracentesis fluid but these are not as informative as abdominal girth. Text Reference - p. 1022
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: Pancreatic enzymes are used to help with digestion of nutrients and should be taken with every meal.
A 67-year-old male patient with acute pancreatitis has a nasogastric (NG) tube to suction and is NPO. 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.
D
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
Describe the pathophysiologic changes of cirrhosis that cause the following a. Portal hypertension b. Esophageal varices
a. scarring and nodular changes in liver lead to compression of the veins and sinusoids, causing resistance of blood flow through the liver from the portal vein b. development of collateral channels of circulation in inelastic, fragile esophageal veins as a result of portal hypertension
a client with pancreatitis has a hx of alcohol abuse. the nurse will observe the client for agitation, nausea, vomiting, delirium tremens, and visual, auditory and tactile hallucinations. these are indications of: 1. possible cirrhosis of the liver 2. alcohol withdrawal 3. depression 4. suicidal thoughts
alcohol withdrawal
which client problem has priority for the client dx with acute pancreatitis? 1. risk for fluid volume deficit 2. alteration in comfort 3. imbalanced nutrition: less than body requirements 4. knowledge deficit
alteration in comfort: autodigestion of the pancreas results in severe epigastric pain, accompanied by nausea, vomiting, abdominal tenderness and muscle guarding
a 44 y/o client has cirrhosis of the liver with sever ascites. the nurse plans for the following intervention? 1. apply prolonged pressure to injection sites 2. administer aspirin for headache as needed 3. measure abdominal girth weekly 4. provide a low protein, high carb diet
apply prolonged pressure to injection sites: the client may have a tendency to bleed easily bc clotting factors are formed in the liver
the client is immediate postprocedure endoscopic retrograde cholangiopancreatogram (ERCP). which intervention should the nurse implement? 1. assess for rectal bleeding, 2, increase fluid intake 3. assess gag reflex 4. keep in supine position
assess gag reflex: the gag reflex will be suppressed as a result of the local anesthesia applied to the throat to insert the endoscope into the esophagus; therefore, the gag reflex must be assessed prior to allowing the client to resume eating or drinking
the client in end stage liver failure has vitamin K deficiency. which interventions should the nurse implement? select all that apply 1. avoid rectal temperatures 2. use only a soft toothbrush 3. monitor the platelet count 4. use small gauge needles 5. assess for asterixis
avoid rectal temps, use only a soft toothbrush, monitor platelet count, use small gauge needles: vitamin k deficiency causes impaired coagulation, therefore, rectal thermometers should be avoided to prevent bleeding. Soft bristle toothbrushes will help prevent bleeding of the gums. platelet count, ptt/pt, and INR should be monitored to assess coagulation status. Injections should be avoided, if at all possible, bc the client is unable to clot, but if they are absolutely necessarily, the nurse should use small gauge needles
the nurse is collecting data for a pt who develops jaundice and dark, amber colored urine. the nurse recognizes that which of the following is most likely the cause? a. encephalopathy b. pancreatitis c. bile duct obstruction d. cholecystitis
c: bile duct obstruction can result in jaundice and dark aber colored urine due to bile blockage
the nurse is caring for a pt with cirrhosis. the nurse would cautiously use sedatives for the pt based on which of the following? a. the livers ability to synthesize protein is altered. b. sedatives may increase the risk of jaundice c. sedatives are potentially toxic to the cirrhosis pt d. sedatives promote the conversion of ammonia to ammonium ion
c: sedatives are potentially toxic to the cirrhosis pt. due to impaired hepatic metabolism of these meds
a client has been given a dx of acute pancreatitis. the nurse will assess this client for: 1. hyperkalemia 2. metabolic acidosis 3. hypocalcemia 4. hyperglycemia
hyperglycemia: or hypoglycemia could occur if damage is done to the islets of langerhans
the client is admitted with end stage liver failure and is prescribed the laxative lactulose (chronulac). which statement indicates the client needs more teaching concerning this med? 1. i should have two to three soft stools a day 2. i must check my ammonia level daily 3. if i have diarrhea, i will call my dr 4. i should check my stool for any blood
i must check my ammonia level daily: there is no instrument used at home to test daily ammonia levels. the ammonia level is a serum level requiring venipuncture and laboratory diagnostic equipment
the client dx with acute pancreatitis is being discharged home. which statement by the client indicates the teaching has been effective? 1. i should decrease my intake of coffee, tea, and cola 2. i will eat a low fat diet and avoid spicy foods 3. i will check my amylase and lipase levels daily 4. i will return to work tomorrow but take it easy
i will eat a low fat diet and avoid spicy foods: high fat and spicy foods stimulate gastric and pancreatic secretions and may precipitate an acute pancreatic attack
a 38 y/o client has chronic cirrhosis and is jaundiced. to decrease pruritus from the jaundice, the nurse would: 1. use wool blankets 2. keep room temp above 75.8 3. keep the room temp below 70.8 4. use lots of soap in the bathwater
keep the room temp below 70.8: a decrease in sweating decreases pruritus
the client is dx with acute pancreatitis. which health care providers admitting order should the nurse question? 1. bedrest with bathroom privleges. 2. initiate iv therapy of D5W at 125 mL/hr 3. weigh client daily 4. low fat, low carb diet
low fat, low carb diet: the client will be NPO, which will decrease stimulation of the pancreatic enzymes, resulting in decreased autodigestion of the pancreas, therefore decreasing pain
which of the following conditions most places a pt. with cirrhosis at risk for bleeding? a. encephalopathy b. low vitamin K c. elevated liver enzymes d. hepatorenal syndrome
low vitamin K: vitamin k is needed for blood clotting, so a low level increases the risk of bleeding
the nurse is discussing complications of chronic pancreatitis with a client dx with the disease. which complication should the nurse discuss with the client? 1. diabetes insipudus 2. crohns disease 3. narcotic addiction 4. peritonitis
narcotic addiction: its related to the frequent, severe pain episodes often occurring with chronic pancreatitis which require narcotics for relief
the client dx with acute pancreatitis is in pain. which position should the nurse assist the client to assume to help decrease the pain? 1. recommend lying in the prone position with legs extended 2. maintain a tripod position over the bedside table 3. place in side lying position with knees flexed 4. encourage a supine position with a pillow under the knees
place in side lying position with knees flexed: this fetal lposition decreases pain caused by the stretching of the peritoneum as a result of edema
the nurse is developing a plan of care for a client who has a dx of acute pancreatitis. the rationale for maintaining the client on bed rest is to: 1. reduce pancreatic and gastric secretions 2. minimize the effects of hypoglycemia 3. reduce the risk of DVT 4. decrease the likelihood of orthostatic hypotension
reduce pancreatic and gastric secretions: bed rest decreases body metabolism and thus reduces pancreatic and gastric secretions in the client with acute pancreatitis
the client dx with end stage liver failure is admitted with hepatic encephalopathy. which dietary restriction should be implemented by the nurse to address this complication? 1. restrict sodium intake to 2g a day 2. limit oral fluids to 1500ml a day 3. decrease the daily fat intake 4. reduce protein intake to 60 to 80g a day
reduced protein intake 60-80 g a day: ammonia is a by product of protein metabolism and contributes to hepatic encephalopathy. reducing protein intake should decrease ammonia levels
after a liver biopsy the nurse should place the client in which position? 1. right side 2. left side 3. high fowlers 4. trendelenburg
right side:when the client is placed on the right side, the biopsy site of the liver capsule is compressed against the chest wall, and the escape of blood or bile is impeded
the client is admitted to the medical dept. with a dx of r/o acute pancreatitis. which laboratory values should the nurse monitor to confirm this dx? 1. creatinine and BUN 2. troponin and CK-MB 3. serum amylase and lipase 4. serum bilirubin and calcium
serum amylase and lipase: serum amylase increases within 2 to 12 hrs of the onset of acute pancreatitis to 2 to 3 times normal and returns to normal in 3 to 4 days; lipase elevates and remains elevated for 7 to 14 days
The client dx with end stage liver failure is admitted with esophageal bleeding. the hcp inserts and inflates a triple lumen nasogastric tube (sengstaken-blakemore). which nursing intervention should the nurse implement for this treatment? 1. assess the gag relex every shift 2. stay with the client at all times 3. administer the laxative lactulose (chronulac) 4. monitor the clients ammonia level
stay with the client at all times: while the balloons are inflated, the client must not be left unattended in case they become dislodged and occlude the airway. this is a safety issue
the client dx with liver failure is experiencing pruritus secondary to severe jaundice. which action by the unlicensed assistive personnel warrants intervention by the nurse? 1. the UAP is assisting the client to take a hot soapy shower 2. the UAP applies an emollient to the clients legs and back 3. the UAP puts mittens on both hands of the client 4. the cUAP pats the clients skin dry with a clean towel
the UAP is assisting the client to take a hot soapy shower: hot water increases pruritus and soap will cause dry skin, which increases pruritus, therefore, the nurse should discuss this with the UAP
the nurse identifies the client problem "excess fluid volume" for the client in liver failure. which short term goal would be most appropriate for this problem? 1. the client will not gain more than 2kg a day 2. the client will have no increase in abdominal girth 3. the clients v/s will remain WNL 4. the client will receive a low sodium diet
the client will have no increase in abdominal girth: excess fluid volume could be secondary to portal hypertension. therefore, no increase in abdominal girth would be an appropriate short term goal, indicating no excess of fluid volume
the client dx with liver problems asks the nurse, why are my stools clay colored? on which scientific rationale should the nurse base the response? 1. there is an increase in serum ammonia level. 2. the liver is unable to excrete bilirubin 3. the liver is unable to metabolize fatty foods 4. a damaged liver cannot detoxify vitamins
the liver is unable to excrete bilirubin: bilirubin, the by product of red blood cell destruction, is metabolized in the liver and excreted via the feces, which causes the feces to be brown in color, if the liver is damaged, the bilirubin is excreted via the urine and skin
which assessment question is priority for the nurse to ask the client dx with end stage liver failure secondary to alcoholic cirrhosis? 1. how many yrs have you been drinking alcohol 2. have you completed an advance directive 3. when did you have your last alcoholic drink 4. what foods did you eat at your last meal
when did you have your last alcoholic drink?: the nurse must know when the client had the last alcoholic drink to be able to determine when and if the client will experience delirium tremens, the physical withdrawal from alcohol
A patient has an increased ammonia level associated with hepatic encephalopathy. What assessment finding does the nurse expect? a. Aphasia b. Asterixis c. Hyperactivity d. Acute dementia
B. Asterixis is a twitching spasm of the hands and wrists seen in patients with increased ammonia levels in conditions such as hepatic encephalopathy. Aphasia, hyperactivity, and acute dementia are manifestations not associated with hepatic encephalopathy. Besides asterixis, an increased serum ammonia level causes sedation and confusion that progress to a comatose state. Text Reference - p. 1021
a pt with acute pacreatitis is NPO and has been receiving on IV hydration. which laboratory result indicates the need to consult the dietitian for nutritional support? a. potassium 4.2 mEq/L b. sodium 130 mEq/L c. fasting glucose 82 mg/dL d. serum albumin 2.9g/dL
d: low serum albumin level indicates malnutrition (normal albumin levels are 3.5-5.
the nurse is caring for a pt with chronic pancreatitis, the nurse would expect an elevation in which of the following lab tests? a. serum bilirubin b. serum calcium c. serum albumin d. serum amylase
d: the serum amylase level is elevated in chronic pancreatitis
the nurse is completing discharge teaching to the client dx with acute pancreatitis. which instruction should the nurse discuss with the client? 1. instruct client to decrease alcohol intake 2. explain the need to avoid all stress 3. discuss the importance of stopping smoking 4. teach the correct way to take pancreatic enzymes
discuss the importance of stopping smoking: smoking stimulates the pancreas to release pancreatic enaymes and should be stopped
the client has end stage liver failure secondary to alcoholic cirrhosis. which complication indicates the client is at risk for developing hepatic encephalopathy? 1. gastrointestinal bleeding 2. hypoalbuminemia 3. splenomegaly 4. hyperaldosteronism
gastrointestinal bleeding: blood in the intestinal tract is digested as a protein, which increases serum ammonia levels and increases the risk of developing hepatic encephalopathy
In a client admitted with cirrhosis of the liver, which serum levels would the nurse expect to be elevated? A. Serum amylase and lipase B. Serum ammonia C. Serum calcium D. Serum CEA
...ANS: B Serum ammonia levels are elevated in conditions that incur hepatocellular injury, such as cirrhosis of the liver. Increased serum amylase and lipase levels are indicators of pancreatitis. CEA levels are useful in assessing the success of cancer therapy or the recurrence of cancer.
10. A 52-year-old man was referred to the clinic due to increased abdominal girth. He is diagnosed with ascites by the presence of a fluid thrill and shifting dullness on percussion. After administering diuretic therapy, which nursing action would be most effective in ensuring safe care? A. Measuring serum potassium for hyperkalemia B. Assessing the client for hypervolemia C. Measuring the client's weight weekly D. Documenting precise intake and output
10. Answer: D. Documenting precise intake and output For the client with ascites receiving diuretic therapy, careful intake and output measurement is essential for safe diuretic therapy. Diuretics lead to fluid losses, which if not monitored closely and documented, could place the client at risk for serious fluid and electrolyte imbalances. Hypokalemia, not hyperkalemia, commonly occurs with diuretic therapy. Because urine output increases, a client should be assessed for hypovolemia, not hypervolemia. Weights are also an accurate indicator of fluid balance. However, for this client, weights should be obtained daily, not weekly.
11. Which assessment finding indicates that lactulose is effective in decreasing the ammonia level in the client with hepatic encephalopathy? A. Passage of two or three soft stools daily B. Evidence of watery diarrhea C. Daily deterioration in the client's handwriting D. Appearance of frothy, foul-smelling stools
11. Answer: A. Passage of two or three soft stools daily Lactulose reduces serum ammonia levels by inducing catharsis, subsequently decreasing colonic pH and inhibiting fecal flora from producing ammonia from urea. Ammonia is removed with the stool. Two or three soft stools daily indicate effectiveness of the drug. Watery diarrhea indicates overdose. Daily deterioration in the client's handwriting indicates an increase in the ammonia level and worsening of hepatic encephalopathy. Frothy, foul-smelling stools indicate steatorrhea, caused by impaired fat digestion.
12. Nurse Farrah is providing care for Kristoff who has jaundice. Which statement indicates that the nurse understands the rationale for instituting skin care measures for the client? A. "Jaundice is associated with pressure ulcer formation." B. "Jaundice impairs urea production, which produces pruritus." C. "Jaundice produces pruritus due to impaired bile acid excretion." D. "Jaundice leads to decreased tissue perfusion and subsequent breakdown."
12. Answer: C. "Jaundice produces pruritus due to impaired bile acid excretion." Jaundice is a symptom characterized by increased bilirubin concentration in the blood. Bile acid excretion is impaired, increasing the bile acids in the skin and causing pruritus. Jaundice is not associated with pressure ulcer formation. However, edema and hypoalbuminemia are. Jaundice itself does not impair urea production or lead to decreased tissue perfusion.
13. Which rationale supports explaining the placement of an esophageal tamponade tube in a client who is hemorrhaging? A. Allowing the client to help insert the tube B. Beginning teaching for home care C. Maintaining the client's level of anxiety and alertness D. Obtaining cooperation and reducing fear
13. Answer: D. Obtaining cooperation and reducing fear An esophageal tamponade tube would be inserted in critical situations. Typically, the client is fearful and highly anxious. The nurse therefore explains about the placement to help obtain the client's cooperation and reduce his fear. This type of tube is used only short term and is not indicated for home use. The tube is large and uncomfortable. The client would not be helping to insert the tube. A client's anxiety should be decreased, not maintained, and depending on the degree of hemorrhage, the client may not be alert.
14. For Rico who has chronic pancreatitis, which nursing intervention would be most helpful? A. Allowing liberalized fluid intake B. Counseling to stop alcohol consumption C. Encouraging daily exercise D. Modifying dietary protein
14. Answer: B. Counseling to stop alcohol consumption Chronic pancreatitis typically results from repeated episodes of acute pancreatitis. More than half of chronic pancreatitis cases are associated with alcoholism. Counseling to stop alcohol consumption would be the most helpful for the client. Dietary protein modification is not necessary for chronic pancreatitis. Daily exercise and liberalizing fluid intake would be helpful but not the most beneficial intervention.
15. Mr. Hasakusa is in end-stage liver failure. Which interventions should the nurse implement when addressing hepatic encephalopathy? (Select all that apply.) A. Assessing the client's neurologic status every 2 hours B. Monitoring the client's hemoglobin and hematocrit levels C. Evaluating the client's serum ammonia level D. Monitoring the client's handwriting daily E. Preparing to insert an esophageal tamponade tube F. Making sure the client's fingernails are short
15. Answer: A, C, D Hepatic encephalopathy results from an increased ammonia level due to the liver's inability to covert ammonia to urea, which leads to neurologic dysfunction and possible brain damage. The nurse should monitor the client's neurologic status, serum ammonia level, and handwriting. Monitoring the client's hemoglobin and hematocrit levels and insertion of an esophageal tamponade tube address esophageal bleeding. Keeping fingernails short address jaundice.
16. For a client with hepatic cirrhosis who has altered clotting mechanisms, which intervention would be most important? A. Allowing complete independence of mobility B. Applying pressure to injection sites C. Administering antibiotics as prescribed D. Increasing nutritional intake
16. Answer: B. Applying pressure to injection sites The client with cirrhosis who has altered clotting is at high risk for hemorrhage. Prolonged application of pressure to injection or bleeding sites is important. Complete independence may increase the client's potential for injury, because an unsupervised client may injure himself and bleed excessively. Antibiotics and good nutrition are important to promote liver regeneration. However, they are not most important for a client at high risk for hemorrhage.
17. A client with advanced cirrhosis has been diagnosed with hepatic encephalopathy. The nurse expects to assess for: A. Malaise B. Stomatitis C. Hand tremors D. Weight loss
17. Answer: C. Hand tremors Hepatic encephalopathy results from the accumulation of neurotoxins in the blood, therefore the nurse wants to assess for signs of neurological involvement. Flapping of the hands (asterixis), changes in mentation, agitation, and confusion are common. These clients typically have ascites and edema so experience weight gain. Malaise and stomatitis are not related to neurological involvement.
The patient with cirrhosis is being taught self-care. Which statement indicates the patient needs more teaching? a. "If I notice a fast heart rate or irregular beats, it is normal for cirrhosis." b. "I need to take good care of my belly and ankle skin where it is swollen." c. "A scrotal support may be more comfortable when I have scrotal edema." d. "I can use pillows to support my head to help me breathe when I am in bed."
A If the patient with cirrhosis experiences a fast or irregular heart rate, it may be indicative of hypokalemia and should be reported to the health care provider, because this is not normal for cirrhosis. Edematous tissue is subject to breakdown and needs meticulous skin care. A scrotal support may improve comfort if there is scrotal edema. Pillows and a semi-Fowler's or Fowler's position will increase respiratory efficiency. Text Reference - p. 1024
One of the most challenging nursing interventions to promote healing in the patient with viral hepatitis is a. providing adequate nutritional intake b. promoting strict bed rest during the icteric phase c. providing pain relief without using liver metabolized drugs. d. providing quiet diversional activities during periods of fatigue
A- Adequate nutrition is especially important in promoting regeneration of liver cells, but the anorexia of viral hepatitis is often severe, requiring creative and innovative nursing interventions. Strict bed rest is not usually required, and the patient usually has only minor discomfort from with hepatitis. Diversional activities may be required to promote psychologic rest but not during periods of fatigue
The patient with cirrhosis is being taught self-care. Which statement indicates the patient needs more teaching? A. "If I notice a fast heart rate or irregular beats, this is normal for cirrhosis." B. "I need to take good care of my belly and ankle skin where it is swollen." C. "A scrotal support may be more comfortable when I have scrotal edema." D. "I can use pillows to support my head to help me breathe when I am in bed."
A. "If I notice a fast heart rate or irregular beats, this is normal for cirrhosis." If the patient with cirrhosis experiences a fast or irregular heart rate, it may be indicative of hypokalemia and should be reported to the health care provider, as this is not normal for cirrhosis. Edematous tissue is subject to breakdown and needs meticulous skin care. Pillows and a semi-Fowler's or Fowler's position will increase respiratory efficiency. A scrotal support may improve comfort if there is scrotal edema.
The nurse is caring for a woman recently diagnosed with viral hepatitis A. Which individual should the nurse refer for an immunoglobin (IG) injection? A. A caregiver who lives in the same household with the patient B. A friend who delivers meals to the patient and family each week C. A relative with a history of hepatitis A who visits the patient daily D. A child living in the home who received the hepatitis A vaccine 3 months ago
A. A caregiver who lives in the same household with the patient IG is recommended for persons who do not have anti-HAV antibodies and are exposed as a result of close contact with persons who have HAV or foodborne exposure. Persons who have received a dose of HAV vaccine more than 1 month previously or who have a history of HAV infection do not require IG.
When providing discharge teaching for the patient after a laparoscopic cholecystectomy, what information should the nurse include? A. A lower-fat diet may be better tolerated for several weeks. B. Do not return to work or normal activities for 3 weeks. C. Bile-colored drainage will probably drain from the incision. D. Keep the bandages on and the puncture site dry until it heals.
A. A lower-fat diet may be better tolerated for several weeks. Although the usual diet can be resumed, a low-fat diet is usually better tolerated for several weeks following surgery. Normal activities can be gradually resumed as the patient tolerates. Bile-colored drainage or pus, redness, swelling, severe pain, and fever may all indicate infection. The bandage may be removed the day after surgery, and the patient can shower.
4. A nurse is caring for a client who has cirrhosis. Which of the following medications can the nurse expect to administer to this client? (Select all that apply.) A. Diuretic B. Beta-blocking agent C. Opioid analgesic D. Lactulose (Cephulac) E. Sedative
A. CORRECT: Diuretics facilitate excretion of excess fluid from the body in a client who has cirrhosis. B. CORRECT: Beta-blocking agents are prescribed for a client who has cirrhosis to prevent bleeding from varices. D. CORRECT: Lactulose (Cephulac) is prescribed for a client who has cirrhosis to aid in the elimination of ammonia in the stool.
2. A nurse is reviewing nutrition teaching for a client who has cholecystitis. Which of the following food choices can trigger cholecystitis? A. Brownie with nuts B. Bowl of mixed fruit C. Grilled turkey D. Baked potato
A. CORRECT: Foods that are high in fat, such as a brownie with nuts, can cause cholecystitis.
5. A nurse is teaching a client who has hepatitis B about home care. Which of the following should the nurse include in the teaching? (Select all that apply.) A. Limit physical activity. B. Avoid alcohol. C. Take acetaminophen for comfort. D. Wear a mask when in public places. E. Eat small frequent meals.
A. CORRECT: Limiting physical activity and taking frequent rest breaks conserves energy and assists in the recovery process for a client who has hepatitis B. B. CORRECT: Alcohol is metabolized in the liver and should be avoided by the client who has hepatitis B. E. CORRECT: A client who has hepatitis B should eat small frequent meals to promote improved nutrition due to the presence of anorexia.
Which finding indicates to the nurse that a patient's 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
The patient with cirrhosis has an increased abdominal girth from ascites. The nurse should know that this fluid gathers in the abdomen for which reasons (select all that apply)? A. There is decreased colloid oncotic pressure from the liver's inability to synthesize albumin. B. Hyperaldosteronism related to damaged hepatocytes increases sodium and fluid retention. C. Portal hypertension pushes proteins from the blood vessels, causing leaking into the peritoneal cavity. D. Osmoreceptors in the hypothalamus stimulate thirst, which causes the stimulation to take in fluids orally. E. Overactivity of the enlarged spleen results in increased removal of blood cells from the circulation, which decreases the vascular pressure.
A. There is decreased colloid oncotic pressure from the liver's inability to synthesize albumin. B. Hyperaldosteronism related to damaged hepatocytes increases sodium and fluid retention. C. Portal hypertension pushes proteins from the blood vessels, causing leaking into the peritoneal cavity. The ascites related to cirrhosis are caused by decreased colloid oncotic pressure from the lack of albumin from liver inability to synthesize it and the portal hypertension that shifts the protein from the blood vessels to the peritoneal cavity, and hyperaldosteronism which increases sodium and fluid retention. The intake of fluids orally and the removal of blood cells by the spleen do not directly contribute to ascites
When caring for a patient with liver disease, the nurse recognizes the need to prevent bleeding resulting from altered clotting factors and rupture of varices. Which nursing interventions would be appropriate to achieve this outcome (select all that apply)? A. Use smallest gauge needle possible when giving injections or drawing blood. B. Teach patient to avoid straining at stool, vigorous blowing of nose, and coughing. C. Advise patient to use soft-bristle toothbrush and avoid ingestion of irritating food. D. Apply gentle pressure for the shortest possible time period after performing venipuncture. E. Instruct patient to avoid aspirin and NSAIDs to prevent hemorrhage when varices are present.
A. Use smallest gauge needle possible when giving injections or drawing blood. B. Teach patient to avoid straining at stool, vigorous blowing of nose, and coughing. C. Advise patient to use soft-bristle toothbrush and avoid ingestion of irritating food. E. Instruct patient to avoid aspirin and NSAIDs to prevent hemorrhage when varices are present. Using the smallest gauge needle for injections will minimize the risk of bleeding into the tissues. Avoiding straining, nose blowing, and coughing will reduce the risk of hemorrhage at these sites. The use of a soft-bristle toothbrush and avoidance of irritating food will reduce injury to highly vascular mucous membranes. The nurse should apply gentle but prolonged pressure to venipuncture sites to minimize the risk of bleeding. Aspirin and NSAIDs should not be used in patients with liver disease because they interfere with platelet aggregation, thus increasing the risk for bleeding
When caring for a patient with a biliary obstruction, the nurse will anticipate administering which vitamin supplements (select all that apply)? A. Vitamin A B. Vitamin D C. Vitamin E D. Vitamin K E. Vitamin B
A. Vitamin A B. Vitamin D C. Vitamin E D. Vitamin K Biliary obstruction prevents bile from entering the small intestine and thus prevents the absorption of fat-soluble vitamins. Vitamins A, D, E, and K are all fat-soluble and thus would need to be supplemented in a patient with biliary obstruction.
34. All of these orders are received for a patient who has vomited 1500 ml of bright red blood. Which order will the nurse act on first? a. Infuse 1000 ml of lactated Ringer's solution. b. Administer IV famotidine (Pepcid) 40 mg. c. Insert NG tube and connect to suction. d. Type and cross match for 4 units of packed red blood cells.
Answer: A Rationale: Because the patient has vomited a large amount of blood, correction of hypovolemia and prevention of hypovolemic shock are the priorities. The other actions are also important to implement quickly but are not the highest priorities. Cognitive Level: Application Text Reference: p. 996 Nursing Process: Implementation NCLEX: Physiological Integrity
4. A nurse is reviewing a new prescription for ursodiol (Ursodeoxycholic Acid) with a client who has cholelithiasis. Which of the following should be included in the teaching? A. This medication reduces biliary spasms. B. This medication reduces inflammation in the biliary tract. C. This medication dilates the bile duct to promote passage of bile. D. This medication dissolves gall stones.
D. CORRECT: Ursodiol is a bile acid that gradually dissolves cholesterol-based gall stones.
23. The health care provider orders insertion of a 20-gauge orogastric tube for a patient experiencing massive hematemesis. As the nurse inserts the tube, resistance is met in advancing the tube. The appropriate action by the nurse is to a. ask the patient to hyperextend the neck. b. stop and notify the health care provider of the resistance. c. inject additional lubricant through the tube. d. withdraw the tube a few inches and then reinsert.
Answer: B Rationale: No tube should be advanced against resistance because of the risk for mucosal damage or perforation of the esophagus. Hyperextension of the neck will increase the likelihood of insertion into the trachea. Because the tube may be in the trachea, injection of lubricant may cause aspiration. Withdrawal and reinsertion of the tube will increase the risk for mucosal damage or perforation. Cognitive Level: Application Text Reference: p. 996 Nursing Process: Implementation NCLEX: Physiological Integrity
38. A patient with acute GI bleeding is receiving normal saline IV at a rate of 500 ml/hr. Which assessment data obtained by the nurse are most important to communicate immediately to the health care provider? a. The NG suction is returning coffee-ground material. b. The patient's lungs have crackles audible to the midline. c. The patient's BP has increased to 142/94 mm Hg. d. The bowel sounds are very hyperactive in all four quadrants.
Answer: B Rationale: The patient's lung sounds indicate that pulmonary edema may be developing as a result of the rapid infusion of IV fluid and that the fluid infusion rate should be slowed. The return of coffee-ground material in an NG tube is expected for a patient with upper GI bleeding. The BP is slightly elevated but would not be an indication to contact the health care provider immediately. Hyperactive bowel sounds are common when a patient has GI bleeding. Cognitive Level: Application Text Reference: p. 999 Nursing Process: Assessment NCLEX: Physiological Integrity
A patient with advanced cirrhosis has a nursing diagnosis of imbalanced nutrition: less than body requirements r/t anorexia and inadequate food intake. An appropriate midday snack for the patient would be a. peanut butter and salt free crackers b. a fresh tomato sandwich with salt free butter c. popcorn with salt free butter and herbal seasoning d. canned chicken noodle soup with low protein bread
B- The patient with advanced, complicated cirrhosis requires a high calore, high carbohydrate diet with moderate to low fat. Patients with cirrhosis are at risk for edema and ascites and their sodium intake should be limited. The tomato sandwich with salt free butter best meets these requirements. Rough foods, such as popcorn, may irritate the esophagus and stomach and lead to bleeding. Peanut butter is high in sodium and fat, and canned chicken noodle soup is very high in sodium
The patient with advanced cirrhosis asks why his or her skin is so yellow. The nurse's response is based on the knowledge that: a. Decreased peristalsis in the gastrointestinal tract contributes to a buildup of bile salts. b. Jaundice results from the body's inability to conjugate and excrete bilirubin. c. A lack of clotting factors promotes the collection of blood under the skin surface. d. Decreased colloidal oncotic pressure from hypoalbuminemia causes the yellowish skin discoloration.
B. Jaundice results from the functional derangement of liver cells and compression of bile ducts by connective tissue overgrowth. Jaundice occurs as a result of the decreased ability to conjugate and excrete bilirubin Jaundice is not caused by a build-up of bile salts, a lack of clotting factors, or decreased colloidal oncotic pressure. Test-Taking Tip: The most reliable way to ensure that you select the correct response to a multiple-choice question is to recall it. Depend on your learning and memory to furnish the answer to the question. To do this, read the stem, and then stop! Do not look at the response options yet. Try to recall what you know and, based on this, what you would give as the answer. After you have taken a few seconds to do this, then look at all of the choices and select the one that most nearly matches the answer you recalled. It is important that you consider all the choices and not just choose the first option that seems to fit the answer you recall. Remember the distractors. The second choice may look okay, but the fourth choice may be worded in a way that makes it a slightly better choice. If you do not weigh all the choices, you are not maximizing your chances of correctly answering each question. Text Reference - p. 1009
The nurse provides discharge instructions to a patient with newly diagnosed cirrhosis. Which statement made by the patient indicates the need for further teaching? a. "I should take frequent rest periods." b. "I can eat anything that appeals to me." c. "I can do without my glass of wine with dinner." d. "I should take only medications that have been prescribed."
B. Even though a low-protein diet has been questioned in the treatment of patients with cirrhosis, it remains in use. In light of this, it is incorrect for the patient to say that he may eat anything. Patients with cirrhosis must also avoid alcohol. Frequent rest and limitation of medications to those that have been prescribed are appropriate resolutions in a newly diagnosed case of cirrhosis and therefore do not indicate the need for further teaching. Text Reference - p. 1022
3. A nurse is caring for a client who has advanced cirrhosis with worsening hepatic encephalopahy. Which of the following is an expected assessment finding? (Select all that apply.) A. Anorexia B. Change in orientation C. Asterixis D. Ascites E. Fetor hepaticus
B. CORRECT: A change in orientation indicates worsening hepatic encephalopathy in a client who has advanced cirrhosis. C. CORRECT: Asterixis, a coarse tremor of the wrists and fingers, is observed as a late complication in a client who has cirrhosis and hepatic encephalopathy E. CORRECT: Fetor hepaticus, a fruity breath odor, is a clinical finding of worsening hepatic encephalopathy in the client who has advanced cirrhosis.
3. A nurse is completing preoperative teaching for a client who will undergo a laparoscopic cholecystectomy. Which of the following should be included in the teaching? A. "The scope will be passed through your rectum." B. "You may have shoulder pain after surgery." C. "The T-tube will remain in place for 1 to 2 weeks." D. "You should limit how often you walk for 1 to 2 weeks."
B. CORRECT: Shoulder pain occurs due to free air that is introduced into the abdomen during laparoscopic surgery.
1. A nurse is providing discharge teaching to a client who is postoperative following open cholecystectomy with T-tube placement. Which of the following instructions should the nurse include in the teaching? (Select all that apply.) A. Take baths rather than showers. B. Clamp T-tube for 1 to 2 hr before and after meals. C. Keep the drainage system above the level of the gallbladder. D. Expect to have constipation. E. Empty drainage bag every 8 hr.
B. CORRECT: The T-tube should be clamped 1 to 2 hr before and after meals to assess tolerance to food postcholecystectomy, and prior to removal. E. CORRECT: The drainage bag attached to the T-tube should be emptied every 8 hr.
2. A nurse is preparing to administer pancrelipase (Viokase) to a client who has pancreatitis. Which of the following is an appropriate nursing action? A. Administer medication 30 min after a snack. B. Offer a glass of water following medication administration. C. Administer the medication 30 min before meals. D. Sprinkle the contents on peanut butter.
B. CORRECT: The client should drink a full glass of water following administration of pancrelipase.
2. A nurse is caring for a client who has a new diagnosis of hepatitis C. Which of the following is an expected laboratory finding? A. Presence of immunoglobin G antibodies (IgG) B. Presence of enzyme immunoassay (EIA) C. Aspartate aminotransferase (AST) 35 units/L D. Alanine aminotransferase (ALT) 15 IU/L
B. CORRECT: The presence of enzyme immunoassay is an expected laboratory finding in a client who has a new diagnosis of hepatitis C.
The patient with right upper quadrant abdominal pain has an abdominal ultrasound that reveals cholelithiasis. What should the nurse expect to do for this patient? A. Prevent all oral intake. B. Control abdominal pain. C. Provide enteral feedings. D. Avoid dietary cholesterol.
B. Control abdominal pain. Patients with cholelithiasis can have severe pain, so controlling pain is important until the problem can be treated. NPO status may be needed if the patient will have surgery but will not be used for all patients with cholelithiasis. Enteral feedings should not be needed, and avoiding dietary cholesterol is not used to treat cholelithiasis
The patient with sudden pain in the left upper quadrant radiating to the back and vomiting was diagnosed with acute pancreatitis. What intervention(s) should the nurse expect to include in the patient's plan of care? A. Immediately start enteral feeding to prevent malnutrition. B. Insert an NG and maintain NPO status to allow pancreas to rest. C. Initiate early prophylactic antibiotic therapy to prevent infection. D. Administer acetaminophen (Tylenol) every 4 hours for pain relief.
B. Insert an NG and maintain NPO status to allow pancreas to rest. Initial treatment with acute pancreatitis will include an NG tube if there is vomiting and being NPO to decrease pancreatic enzyme stimulation and allow the pancreas to rest and heal. Fluid will be administered to treat or prevent shock. The pain will be treated with IV morphine because of the NPO status. Enteral feedings will only be used for the patient with severe acute pancreatitis in whom oral intake is not resumed. Antibiotic therapy is only needed with acute necrotizing pancreatitis and signs of infection.
The nurse is caring for a 55-year-old man patient with acute pancreatitis resulting from gallstones. Which clinical manifestation would the nurse expect the patient to exhibit? A. Hematochezia B. Left upper abdominal pain C. Ascites and peripheral edema D. Temperature over 102o F (38.9o C)
B. Left upper abdominal pain Abdominal pain (usually in the left upper quadrant) is the predominant manifestation of acute pancreatitis. Other manifestations of acute pancreatitis include nausea and vomiting, low-grade fever, leukocytosis, hypotension, tachycardia, and jaundice. Abdominal tenderness with muscle guarding is common. Bowel sounds may be decreased or absent. Ileus may occur and causes marked abdominal distention. Areas of cyanosis or greenish to yellow-brown discoloration of the abdominal wall may occur. Other areas of ecchymoses are the flanks (Grey Turner's spots or sign, a bluish flank discoloration) and the periumbilical area (Cullen's sign, a bluish periumbilical discoloration).
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 levels. c. potassium levels. d. prothrombin time.
B: The protein in the blood in the gastrointestinal (GI) 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 73-year-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's 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 patient's skin has multiple spider-shaped blood vessels on the abdomen.
B: Asterixis indicates that the patient has hepatic encephalopathy, and hepatic coma may occur.
A 53-year-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 shortness of breath. c. Verify the position of the balloon every 4 hours. d. Deflate the gastric balloon if the patient reports nausea.
B: The most common complication of balloon tamponade is aspiration pneumonia
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:Extending the arms allows the nurse to check for asterixis, a classic sign of hepatic encephalopathy
When taking the blood pressure (BP) on the right arm of a patient with 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.
C
Which laboratory test result will the nurse monitor when evaluating the effects of therapy for a 62-year-old female patient who has acute pancreatitis? a. Calcium b. Bilirubin c. Amylase d. Potassium
C
In discussing long term management with the patient with alcoholic cirrhosis, the nurse advises the patient that a. a daily exercise regimen is important to increase the blood flow through the liver b. cirrhosis can be reversed if the patient follows a regimen of proper rest and nutrition c. abstinence from alcohol is the most important factor in improvement of the patient's condition d. the only over the counter analgesic that should be used for minor aches and pains is acetaminophen
C- Abstinence from alcohol is very important in alcoholic cirrhosis and may result in improvement if started when liver damage is reduced by rest and nutrition, most changes in the liver cannot be reversed. Exercise does not promote portal circulation, and very moderate exercise is recommended. Acetaminophen should not be used by the patient with liver disease because it is potentially hepatotoxic.
During the treatment of the patient with bleeding esophageal varices, it is most important that the nurse a. prepare the patient for immediate portal shunting surgery b. perform guaiac testing on all stools to detect occult blood c. maintain the patient's airway and prevent aspiration of blood d. monitor for the cardiac effects of IV vasopressin and nitroglycerin
C- Bleeding esophageal varices are a medical emergency. During an episode of bleeding, management of the airway and prevention of aspiration of blood are critical factors. Occult blood as well as fresh blood from the GI tract would be expected and is not tested. Vasopressin causes vasoconstriction, decreased HR, and decreased coronary blood flow; nitroglycerin is given with the vasopressin to counter these side effects. Portal shunting surgery is performed for esophageal varices but not during an acute hemorrhage
When caring for a patient with autoimmune hepatitis, the nurse recognizes that, unlike viral hepatitis, the patient a. does not manifest hepatomegaly or jaundice b. experiences less liver inflammation and damage c. is treated with corticosteroids or other immunosuppressant agents d. is usually an older adult who has used a wide variety of prescription and over the counter drugs
C- Immunosuppressive agents are indicated i hepatitis associated with immune disorders to decrease liver damage caused by autoantibodies. Autoimmune hepatitis is similar to viral hepatitis in presenting signs and symptoms and may become chronic and lead to cirrhosis.
A patient admitted to the hospital with cirrhosis of the liver suddenly starts vomiting blood. What is the priority action that the nurse should take in this situation? a. Send for endoscopic variceal ligation. b. Give propronalol orally. c. Stabilize the patient and manage the airway. d. Check for signs of cirrhosis
C. Individuals with cirrhosis of the liver are at risk of bleeding from esophageal and gastric varices. Hematemesis in the patient with cirrhosis of the liver is likely to be variceal bleeding. In this case, the nurse should first stabilize the patient and manage the airway. Once the patient is stable, other steps in treatment can be initiated, such as assessing further and administering necessary medications. Text Reference - p. 1025
The nurse provides discharge instructions for a 64-year-old woman with ascites and peripheral edema related to cirrhosis. Which statement, if made by the patient, indicates teaching was effective? A. "It is safe to take acetaminophen up to four times a day for pain." B. "Lactulose (Cephulac) should be taken every day to prevent constipation." C. "Herbs and other spices should be used to season my foods instead of salt." D. "I will eat foods high in potassium while taking spironolactone (Aldactone)."
C. "Herbs and other spices should be used to season my foods instead of salt." A low-sodium diet is indicated for the patient with ascites and edema related to cirrhosis. Table salt is a well-known source of sodium and should be avoided. Alternatives to salt to season foods include the use of seasonings such as garlic, parsley, onion, lemon juice, and spices. Pain medications such as acetaminophen, aspirin, and ibuprofen should be avoided as these medications may be toxic to the liver. The patient should avoid potentially hepatotoxic over-the-counter drugs (e.g., acetaminophen) because the diseased liver is unable to metabolize these drugs. Spironolactone is a potassium-sparing diuretic. Lactulose results in the acidification of feces in bowel and trapping of ammonia, causing its elimination in feces.
The nurse instructs a 50-year-old woman about cholestyramine to reduce pruritis caused by gallbladder disease. Which statement by the patient to the nurse indicates she understands the instructions? A. "This medication will help me digest fats and fat-soluble vitamins." B. "I will apply the medicated lotion sparingly to the areas where I itch." C. "The medication is a powder and needs to be mixed with milk or juice." D. "I should take this medication on an empty stomach at the same time each day."
C. "The medication is a powder and needs to be mixed with milk or juice." For treatment of pruritus, cholestyramine may provide relief. This is a resin that binds bile salts in the intestine, increasing their excretion in the feces. Cholestyramine is in powder form and should be mixed with milk or juice before oral administration.
The nurse is caring for a group of patients. Which patient is at highest risk for pancreatic cancer? A. A 38-year-old Hispanic female who is obese and has hyperinsulinemia B. A 23-year-old who has cystic fibrosis-related pancreatic enzyme insufficiency C. A 72-year-old African American male who has smoked cigarettes for 50 years D. A 19-year-old who has a 5-year history of uncontrolled type 1 diabetes mellitus
C. A 72-year-old African American male who has smoked cigarettes for 50 years Risk factors for pancreatic cancer include chronic pancreatitis, diabetes mellitus, age, cigarette smoking, family history of pancreatic cancer, high-fat diet, and exposure to chemicals such as benzidine. African Americans have a higher incidence of pancreatic cancer than whites. The most firmly established environmental risk factor is cigarette smoking. Smokers are two or three times more likely to develop pancreatic cancer as compared with nonsmokers. The risk is related to duration and number of cigarettes smoked.
A patient with cholelithiasis needs to have the gallbladder removed. Which patient assessment is a contraindication for a cholecystectomy? A. Low-grade fever of 100° F and dehydration B. Abscess in the right upper quadrant of the abdomen C. Activated partial thromboplastin time (aPTT) of 54 seconds D. Multiple obstructions in the cystic and common bile duct
C. Activated partial thromboplastin time (aPTT) of 54 seconds An aPTT of 54 seconds is above normal and indicates insufficient clotting ability. If the patient had surgery, significant bleeding complications postoperatively are very likely. Fluids can be given to eliminate the dehydration; the abscess can be assessed, and the obstructions in the cystic and common bile duct would be relieved with the cholecystectomy.
A 54-year-old patient admitted with diabetes mellitus, malnutrition, osteomyelitis, and alcohol abuse has a serum amylase level of 280 U/L and a serum lipase level of 310 U/L. To what diagnosis does the nurse attribute these findings? A. Malnutrition B. Osteomyelitis C. Alcohol abuse D. Diabetes mellitus
C. Alcohol Use The patient with alcohol abuse could develop pancreatitis as a complication, which would increase the serum amylase (normal 30-122 U/L) and serum lipase (normal 31-186 U/L) levels as shown.
4. A nurse is reviewing the health record of a client who has pancreatitis. The physical exam report by the provider indicates the presence of Cullen's sign. Which of the following is an appropriate action by the nurse to identify this finding? A. Tap lightly at the costovertebral margin on the client's back. B. Palpate the client's right lower quadrant. C. Inspect the skin around the umbilicus. D. Auscultate the area below the client's scapula.
C. CORRECT: Cullen's sign is indicated by a bluish-grey discoloration in the periumbilical area.
5. A nurse in a clinic is reviewing the laboratory reports of a client who has suspected cholelithiasis. Which of the following is an expected finding? A. Serum albumin 4.1 g/dL B. WBC 9,511/uL C. Direct bilirubin 2.1 mg/dL D. Serum cholesterol 171 mg/dL
C. CORRECT: This finding is outside the expected reference range and is increased in the client who has cholelithiasis.
The condition of a patient who has cirrhosis of the liver has deteriorated. Which diagnostic study would help determine if the patient has developed liver cancer? A. Serum α-fetoprotein level B. Ventilation/perfusion scan C. Hepatic structure ultrasound D. Abdominal girth measurement
C. Hepatic structure ultrasound Correct Hepatic structure ultrasound, CT, and MRI are used to screen and diagnose liver cancer. Serum α-fetoprotein level may be elevated with liver cancer or other liver problems. Ventilation/perfusion scans do not diagnose liver cancer. Abdominal girth measurement would not differentiate between cirrhosis and liver cancer.
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: 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
To prepare a 56-year-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. asks the patient to empty the bladder. d. positions the patient on the right side.
C: The patient should empty the bladder to decrease the risk of bladder perforation during the procedure
A 38-year-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: 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 beats/minute.
C: the purpose of Beta-blocker therapy for patients with esophageal varices is to decrease the risk for bleeding from esophageal varices,
A patient with hepatitis A is in the acute phase. The nurse plans care for the patient based on the knowledge that a. pruritus is a common problem with jaundice in this phase. b. the patient is most likely to transmit the disease during this phase. c. gastrointestinal symptoms are not as severe in hepatitis A as they are in hepatitis B. d. extrahepatic manifestations of glomerulonephritis and polyarteritis are common in this phase.
Correct answer: a Rationale: The acute phase of jaundice may be icteric or anicteric. Jaundice results when bilirubin diffuses into the tissues. Pruritus sometimes accompanies jaundice. Pruritus is the result of an accumulation of bile salts beneath the skin.
The patient with advanced cirrhosis asks why his abdomen is so swollen. The nurse's response is based on the knowledge that a. a lack of clotting factors promotes the collection of blood in the abdominal cavity. b. portal hypertension and hypoalbuminemia cause a fluid shift into the peritoneal space. c. decreased peristalsis in the GI tract contributes to gas formation and distention of the bowel. d. bile salts in the blood irritate the peritoneal membranes, causing edema and pocketing of fluid.
Correct answer: b Rationale: Ascites is the accumulation of serous fluid in the peritoneal or abdominal cavity and is a common manifestation of cirrhosis. With portal hypertension, proteins shift from the blood vessels through the larger pores of the sinusoids (capillaries) into the lymph space. When the lymphatic system is unable to carry off the excess proteins and water, those substances leak through the liver capsule into the peritoneal cavity. Osmotic pressure of the proteins pulls additional fluid into the peritoneal cavity. A second mechanism of ascites formation is hypoalbuminemia, which results from the inability of the liver to synthesize albumin. Hypoalbuminemia results in decreased colloidal oncotic pressure. A third mechanism is hyperaldosteronism, which occurs when aldosterone is not metabolized by damaged hepatocytes. The increased level of aldosterone causes increases in sodium reabsorption by the renal tubules. Sodium retention and an increase in antidiuretic hormone levels cause additional water retention.
A patient with acute hepatitis B is being discharged in 2 days. In the discharge teaching plan the nurse should include instructions to a. avoid alcohol for the first 3 weeks. b. use a condom during sexual intercourse. c. have family members get an injection of immunoglobulin. d. follow a low-protein, moderate-carbohydrate, moderate-fat diet.
Correct answer: b Rationale: Hepatitis B virus may be transmitted by mucosal exposure to infected blood, blood products, or other body fluids (e.g., semen, vaginal secretions, saliva). Hepatitis B is a sexually transmitted disease that is acquired through unprotected sex with an infected person. Condom use should be taught to patients to prevent transmission of hepatitis B.
A patient has been told that she has elevated liver enzymes caused by nonalcoholic fatty liver disease (NAFLD). The nursing teaching plan should include a. having genetic testing done. b. recommending a heart-healthy diet. c. the necessity to reduce weight rapidly. d. avoiding alcohol until liver enzymes return to normal.
Correct answer: b Rationale: Nonalcoholic fatty liver disease (NAFLD) can progress to liver cirrhosis. There is no definitive treatment, and therapy is directed at reduction of risk factors, which include treatment of diabetes, reduction in body weight, and elimination of harmful medications. For patients who are overweight, weight reduction is important. Weight loss improves insulin sensitivity and reduces liver enzyme levels. No specific dietary therapy is recommended. However, a heart-healthy diet as recommended by the American Heart Association is appropriate.
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
A patient with cirrhosis that is refractory to other treatments for esophageal varices undergoes a peritoneovenous shunt. As a result of this procedure, the nurse would expect the patient to experience a. an improved survival rate b. decreased serum ammonia levels c. improved metabolism of nutrients d. improved hemodynamic function and renal perfusion
D- By shunting fluid sequestered in the peritoneum into the venous system, pressur eon esophageal veins is decreased, and more volume is returned to the circulation, improving CO and renal perfusion. However, because ammonia is diverted past the liver, hepatic encephalopathy continues. These procedures do not prolong life or promote liver function.
The nurse recognizes early signs of hepatic encephalopathy in the patient who a. manifests asterixis b. becomes unconscious c. has increasing oliguria d. is irritable and lethargic
D- Early signs of this neurologic condition include euphoria, depression, apathy, irritability, confusion, agitation, drowsiness, and lethargy. Loss of consciousness is usually preceded by asterixis, disorientation, hyperventilation, hypothermia, and alterations in reflexes. Increasing oliguria is a sign of hepatorenal syndrome.
The nurse is admitting a patient with cirrhosis. The nurse checks the patient's history for which most frequent risk factor associated with cirrhosis? a. Polypharmacy b. Intravenous drug abuse c. Hepatitis A d. Alcohol abuse
D. Cirrhosis is highly correlated with alcohol abuse. Polypharmacy, drug abuse, and hepatitis A are not linked to cirrhosis. Text Reference - p. 1017
A patient with a 3-year history of liver cirrhosis is hospitalized for treatment of recently diagnosed esophageal varices. What is the most important information for the nurse to include in the teaching plan for this patient? a. Decrease fluid intake to avoid ascites. b. Eat foods quickly so they do not get cold and cause distress. c. Avoid exercise because it may cause bleeding of the varices. d. Avoid straining during defecation to keep venous pressure low
D. Straining during a bowel movement increases venous pressure and could cause rupture of the varices. Fluid restrictions may be a recommendation for ascites but are not directly associated with esophageal varices. If the patient is able to eat, meals should be soft or liquid, and the patient should be instructed to eat slowly and avoid extremes in food temperature to prevent irritation. Excessive exercise and activity should be avoided in a patient with esophageal varices to prevent hypertension, however, avoiding straining and other activities that cause the Valsalva maneuver is still a higher-priority recommendation. Text Reference - p. 1022
The family of a patient newly diagnosed with hepatitis A asks the nurse what they can do to prevent becoming ill themselves. Which response by the nurse is most appropriate? A. "The hepatitis vaccine will provide immunity from this exposure and future exposures." B. "I am afraid there is nothing you can do since the patient was infectious before admission." C. "You will need to be tested first to make sure you don't have the virus before we can treat you." D. "An injection of immunoglobulin will need to be given to prevent or minimize the effects from this exposure."
D. "An injection of immunoglobulin will need to be given to prevent or minimize the effects from this exposure." Immunoglobulin provides temporary (1-2 months) passive immunity and is effective for preventing hepatitis A if given within 2 weeks after exposure. It may not prevent infection in all persons, but it will at least modify the illness to a subclinical infection. The hepatitis vaccine is only used for preexposure prophylaxis.
When teaching the patient with acute hepatitis C (HCV), the patient demonstrates understanding when the patient makes which statement? A. "I will use care when kissing my wife to prevent giving it to her." B. "I will need to take adofevir (Hepsera) to prevent chronic HCV." C. "Now that I have had HCV, I will have immunity and not get it again." D. "I will need to be checked for chronic HCV and other liver problems."
D. "I will need to be checked for chronic HCV and other liver problems." The majority of patients who acquire HCV usually develop chronic infection, which may lead to cirrhosis or liver cancer. HCV is not transmitted via saliva, but percutaneously and via high-risk sexual activity exposure. The treatment for acute viral hepatitis focuses on resting the body and adequate nutrition for liver regeneration. Adofevir (Hepsera) is taken for severe hepatitis B (HBV) with liver failure. Chronic HCV is treated with pegylated interferon with ribavirin. Immunity with HCV does not occur as it does with HAV and HBV, so the patient may be reinfected with another type of HCV.
3. A nurse is completing an admission assessment of a client who has pancreatitis. Which of the following is an expected finding? A. Pain in right upper quadrant radiating to right shoulder B. Report of pain being worse when sitting upright C. Pain relieved with defecation D. Epigastric pain radiating to left shoulder
D. CORRECT: A client who has pancreatitis will report severe, boring epigastric pain that radiates to the back, left flank, or left shoulder.
1. A nurse on a medical-surgical unit is admitting a client who has hepatitis B with ascites. Which of the following actions should the nurse include in the plan of care? A. Initiate contact precautions. B. Weigh client weekly. C. Measure abdominal girth 7.5 cm (3 in) above the umbilicus. D. Provide a high-calorie, high-carbohydrate diet.
D. CORRECT: A high-calorie, high-carbohydrate diet is recommended for clients who have hepatitis B.
5. A nurse is completing nutrition teaching for a client who has pancreatitis. Which of the following statements by the client requires further teaching? A. "I plan to eat small, frequent meals." B. "I will eat easy-to-digest foods with limited spice." C. "I will use skim milk when cooking." D. "I plan to drink regular cola."
D. CORRECT: Caffeine-free beverages are recommended for the client who has pancreatitis. Regular cola contains caffeine.
1. A nurse is completing the admission assessment of a client who has acute pancreatitis. Which of the following findings is the priority to be reported to the provider? A. History of cholelithiasis B. Serum amylase levels three times greater than the expected value C. Client report of severe pain radiating to the back that is rated at an "8" D. Hand spasms present when blood pressure is checked
D. CORRECT: The greatest risk to the client is hypocalcemia due to the risk of cardiac dysrhythmia. Hand spasms when taking a blood pressure is an indication of hypocalcemia and is the priority finding to report to the provider
The patient with suspected pancreatic cancer is having many diagnostic studies done. Which one can be used to establish the diagnosis of pancreatic adenocarcinoma and for monitoring the response to treatment? A. Spiral CT scan B. A PET/CT scan C. Abdominal ultrasound D. Cancer-associated antigen 19-9
D. Cancer-associated antigen 19-9 The cancer-associated antigen 19-9 (CA 19-9) is the tumor marker used for the diagnosis of pancreatic adenocarcinoma and for monitoring the response to treatment. Although a spiral CT scan may be the initial study done and provides information on metastasis and vascular involvement, this test and the PET/CT scan or abdominal ultrasound do not provide additional information.
The health care provider orders lactulose for a patient with hepatic encephalopathy. The nurse will monitor for effectiveness of this medication for this patient by assessing what? A. Relief of constipation B. Relief of abdominal pain C. Decreased liver enzymes D. Decreased ammonia levels
D. Decreased ammonia levels. Hepatic encephalopathy is a complication of liver disease and is associated with elevated serum ammonia levels. Lactulose traps ammonia in the intestinal tract. Its laxative effect then expels the ammonia from the colon, resulting in decreased serum ammonia levels and correction of hepatic encephalopathy
A patient who has hepatitis B surface antigen (HBsAg) in the serum is being discharged with pain medication after knee surgery. Which medication order should the nurse question because it is most likely to cause hepatic complications? A. Tramadol (Ultram) B. Hydromorphone (Dilaudid) C. Oxycodone with aspirin (Percodan) D. Hydrocodone with acetaminophen (Vicodin)
D. Hydrocodone with acetaminophen (Vicodin) The analgesic with acetaminophen should be questioned because this patient is a chronic carrier of hepatitis B and is likely to have impaired liver function. Acetaminophen is not suitable for this patient because it is converted to a toxic metabolite in the liver after absorption, increasing the risk of hepatocellular damage.
When planning care for a patient with cirrhosis, the nurse will give highest priority to which nursing diagnosis? A. Impaired skin integrity related to edema, ascites, and pruritus B. Imbalanced nutrition: less than body requirements related to anorexia C. Excess fluid volume related to portal hypertension and hyperaldosteronism D. Ineffective breathing pattern related to pressure on diaphragm and reduced lung volume
D. Ineffective breathing pattern related to pressure on diaphragm and reduced lung volume Although all of these nursing diagnoses are appropriate and important in the care of a patient with cirrhosis, airway and breathing are always the highest priorities.
The patient with a history of lung cancer and hepatitis C has developed liver failure and is considering liver transplantation. After the comprehensive evaluation, the nurse knows that which factor discovered may be a contraindication for liver transplantation? A. Has completed a college education B. Has been able to stop smoking cigarettes C. Has well-controlled type 1 diabetes mellitus D. The chest x-ray showed another lung cancer lesion.
D. The chest x-ray showed another lung cancer lesion. Contraindications for liver transplant include severe extrahepatic disease, advanced hepatocellular carcinoma or other cancer, ongoing drug and/or alcohol abuse, and the inability to comprehend or comply with the rigorous post-transplant course.
Which assessment finding would the nurse need to report most quickly to the health care provider 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 indicate hypocalcemia,
In planning care for a patient with metastatic liver cancer, the nurse should include interventions that a. focus primarily on symptomatic and comfort measures. b. reassure the patient that chemotherapy offers a good prognosis. c. promote the patient's confidence that surgical excision of the tumor will be successful. d. provide information necessary for the patient to make decisions regarding liver transplantation.
a Rationale: Nursing intervention for a patient with liver cancer focuses on keeping the patient as comfortable as possible. The prognosis for patients with liver cancer is poor. The cancer grows rapidly, and death may occur within 4 to 7 months as a result of hepatic encephalopathy or massive blood loss from gastrointestinal (GI) bleeding.
Nursing management of the patient with acute pancreatitis includes (select all that apply) a. checking for signs of hypocalcemia. b. providing a diet low in carbohydrates. c. giving insulin based on a sliding scale. d. observing stools for signs of steatorrhea. e. monitoring for infection, particularly respiratory tract infection.
a, e Rationale: During the acute phase, it is important to monitor vital signs. Hemodynamic stability may be compromised by hypotension, fever, and tachypnea. Intravenous fluids are ordered, and the response to therapy is monitored. Fluid and electrolyte balances are closely monitored. Frequent vomiting, along with gastric suction, may result in decreased levels of chloride, sodium, and potassium. Because hypocalcemia can occur in acute pancreatitis, the nurse should observe for symptoms of tetany, such as jerking, irritability, and muscular twitching. Numbness or tingling around the lips and in the fingers is an early indicator of hypocalcemia. The patient should be assessed for Chvostek's sign or Trousseau's sign. A patient with acute pancreatitis should be observed for fever and other manifestations of infection. Respiratory infections are common because the retroperitoneal fluid raises the diaphragm, which causes the patient to take shallow, guarded abdominal breaths.
in planning care for the newly admitted pt with acute pancreatitis, which pt outcome should receive highest priority? a. pt expresses satisfaction with pain control b. pt verbalizes understanding of medications for home c. pt increases activity intolerance d. pt maintains normal bowl function
a: because pancreatitis is very painful, pt satisfaction with pain control is a priority
the male client dx with chronic pancreatitis calls and reports to the clinic nurse he has been having a lot of gas along with frothy and very foul smelling stools. which intervention should the nurse implement? 1. explain this is common for chronic pancreatitis 2. ask the client to bring in a stool specimen to the clinic 3. arrange an appointment with the hcp for today 4. discuss the need to decrease fat in the diet so this wont happen
arrange an appointment with the hcp for today: steatorrhea (fatty, frothy, foul smelling stool) is caused by a decrease in pancreatic enzyme secretion and indicates impaired digestion and possibly an increase in the severity of the pancreatitis. the client should see the hcp
Teaching in relation to home management after a laparoscopic cholecystectomy should include a. keeping the bandages on the puncture sites for 48 hours. b. reporting any bile-colored drainage or pus from any incision. c. using over-the-counter antiemetics if nausea and vomiting occur. d. emptying and measuring the contents of the bile bag from the T tube every day.
b Rationale: The following discharge instructions are taught to the patient and caregiver after a laparoscopic cholecystectomy: First, remove the bandages on the puncture site the day after surgery and shower. Second, notify the surgeon if any of the following signs and symptoms occur: redness, swelling, bile-colored drainage or pus from any incision; and severe abdominal pain, nausea, vomiting, fever, or chills. Third, gradually resume normal activities. Fourth, return to work within 1 week of surgery. Fifth, resume a usual diet, but a low-fat diet is usually better tolerated for several weeks after surgery.
which gastrointestinal assessment data should the nurse expect to find when assessing the client in end stage liver failure? 1. hypoalbuminemia and muscle wasting 2. oligomenorrhea and decreased body hair 3. clay colored stools and hemorrhoids 4. dyspnea and caput medusae
clay colored stools and hemorrhoids: clay colored stools and hemorrhoids are gastrointestinal effects of liver failure
The nursing management of the patient with cholecystitis associated with cholelithiasis is based on the knowledge that a. shock-wave therapy should be tried initially. b. once gallstones are removed, they tend not to recur. c. the disorder can be successfully treated with oral bile salts that dissolve gallstones. d. laparoscopic cholecystectomy is the treatment of choice in most patients who are symptomatic.
d Rationale: Laparoscopic cholecystectomy is the treatment of choice for symptomatic cholelithiasis.
the nurse is administering a pancreatic enzyme to the client dx with chronic pancreatitis. which statement best explains the rationale for administering this med? 1. it is an exogenous source of protease, amylase, and lipase 2. this enzyme increases the number of bowel movements 3. this medication breaks down in the stomach to help with digestion 4. pancreatic enzymes help break down fat in the small intestine
it is an exogenous source of protease, amylase, and lipase: pancreatic enzymes enhance the digestion of starches (carbohydrates) in the gastrointestinal tract by supplying an exogenous (outside) source of the pancreatic enzymes protease, amylase and lipase
the client with an acute exacerbation of chronic pancreatitis has a nasogastric tube. which interventions should the nurse implement? select all that apply 1. monitor the clients bowel sounds 2. monitor the clients food intake 3. assess the clients intravenous site 4. provide oral and nasal care 5. monitor the clients blood glucose
monitor the clients bowel sounds, assess the clients intravenous site, provide oral and nasal care, provide oral and nasal care, monitor the clients blood glucose: the return of bowel sounds indicates the return of peristalsis, and the nasogastric suction is usually discontinued within 24 to 48 hrs thereafter. the nurse should assess for signs of infection or infiltration. fasting and the ng tube increase the clients risk for mucous membrane irritation and brk dwn. blood glucose levels are monitored because clients with chronic pancreatitis can develop diabetes mellitus
the nurse is preparing to administer am medications to clients. which medication should the nurse question before administering? 1. pancreatic enzymes to the client who has finished breakfast 2. the pain medication, morphine, to the client who has a respiratory rate of 20 3. the loop diuretic to the client who has a serum potassium level of 3.9 mEq/L 4. the beta blocker to the client who has an apical pulse of 68
pancreatic enzymes to the client who has finished breakfast: pancreatic enzymes must be administered with meals to enhance the digestion of starches and fats in the gastrointestinal tract
The client has had a liver biopsy. which postprocedure intervention should the nurse implement? 1. instruct the client to void immediatly 2. keep the client NPO for 8 hours 3. place the client on the right side 4. monitor BUN and creatinine level
place the client on the right side: direct pressure is applied to the site, and then the client is placed on the right side to maintain site pressure
a client has acute pancreatitis. to determine its severity, the nurse would look at which lab test? 1. serum transaminase 2. serum amylase 3. serum sodium 4. serum magnesium
serum amylase: severity of pancreatitis is directly correlated to the level of amylase, a pancreatic enzyme
the client dx with end stage liver failure. the client asks the nurse,, why is my dr decreasing the dose of my meds? which statement is the nurses best response? 1. you are worried bc your dr has decreased the dosage 2. you really should ask your dr. i am sure there is a good reason 3. you may have an overdose of the meds because your liver is damaged 4. the half life of the meds is altered bc the liver is damaged
you may have an overdose of the meds bc your liver is damaged: this is the main reason the hcp decreases the clients medication dose and is an explanation appropriate for the client
