Main GI/Liver quizzes
The nurse is caring for a client with cirrhosis who has hepatic encephalopathy. The client is prescribed lactulose. Which assessment by the nurse will most likely indicate that the medication has achieved the desired therapeutic effect? 1. Higher potassium level 2. Improved mental status 3. Looser stool consistency 4. Reduced abdominal distension
2. Improved mental status
A client with deep vein thrombosis (DVT) is receiving a continuous infusion of unfractionated heparin. The client asks the nurse what the heparin is for. How should the nurse respond? 1. "Heparin is a blood thinner that will help to dissolve the clot in your leg." 2. "Heparin will help stabilize the clot in your leg and prevent it from breaking off and traveling to your lungs." 3. "Heparin will keep the current clot from getting bigger and help prevent new clots from forming." 4. "I'm sorry. This is something that your health care provider (HCP) can answer better upon arriving."
3. "Heparin will keep the current clot from getting bigger and help prevent new clots from forming."
A client has nausea, abdominal cramping, and persistent mucus-like, watery diarrhea that is positive for Clostridium difficile. The nurse anticipates the client will be prescribed which medication to treat this condition? 1. Ceftriaxone 2. Fluconazole 3. Metronidazole 4. Pantoprazole
3. Metronidazole
A nurse is assisting with serving dinner trays on the unit. Upon receiving the dinner tray for a patient admitted with acute gallbladder inflammation, the nurse will question which of the following foods on the tray? A. Fried chicken B. Mashed potatoes C. Dinner roll D. Tapioca pudding
A. Fried chicken
A physician has ordered a liver biopsy for a client with cirrhosis whose condition has recently deteriorated. The nurse reviews the clients recent laboratory findings and recognizes that which of the following findings will place the client at risk for complications? A. Low platelet count B. Low sodium level C. Decreased prothrombin time D. Low hemoglobin
A. Low platelet count (bleeding risk)
A nurse is caring for a client who is scheduled to undergo a liver biopsy for a suspected malignancy. Which of the following laboratory findings should the nurse monitor prior to the procedure? A. Prothrombin time B. Serum lipase C. Bilirubin D. Calcium
A. Prothrombin time A major complication following a liver biopsy is hemorrgage. Many clients who have liver disease have clotting defects and are at risk for bleeding.
A nurse is caring for a client who is 4 hr postoperative following a laparoscopic cholecystectomy. Which of the following findings should the nurse expect? A. Right shoulder pain B. Urine output 20 mL/hr C. Temperature 38.4 degrees Celsius (101.1 degrees Fahrenheit)
A. Right shoulder pain Carbon dioxide goes into shoulder- normal finding..
A 45-year old woman presents to the emergency department with severe right upper quadrant pain. This began as colicky pain, but is now steady and more intense. The pain radiates to the right shoulder. She is febrile and has vomited three times. What is the most likely diagnosis? Acute cholecystitis Chronic Pancreatitis Appendicitis
Acute cholecystitis
A 45-year-old Caucasian woman presents to the emergency department with a primary complaint of upper abdominal pain. She describes the pain as sharp in nature and occasionally crampy. The pain gradually increased after eating ice cream last night. Her temperature is 100.9°F, weight is 210 pounds, and height is 5'5". She is moderately tender in the right upper quadrant with no palpable mass. What is the most likely diagnosis? Acute cholecystitis Chronic Pancreatitis Appendicitis Liver Failure
Acute cholecystitis
A nurse is caring for a client who has a percutaneous endoscopic gastrostomy (PEG) tube and is receiving intermittent feedings. Prior to initiating the feeding, which of the following actions should the nurse take first? A. Flush the tube with water. B. Place the client in semi-Fowler's position. C. Cleanse the skin around the tube site. D. Aspirate the tube for residual contents.
B. Place the client in semi-Fowler's position.
The nurse is providing care for a patient who has peritonitis. The patient expresses anxiety about the impending surgery. Which of the following actions should the nurse take? A. "Why are you feeling so anxious?" B. "Tell me more about your concerns." C. "You should distract yourself by reading a magazine" D. "You have nothing to worry about. Your surgeon is excellent." E. "Others who have had this procedure have had great results."
B. "Tell me more about your concerns."
When evaluating a male client for complications of acute pancreatitis, the nurse would observe for: a. increased intracranial pressure. b. decreased urine output. c. bradycardia. d. hypertension.
B. Acute pancreatitis can cause decreased urine output, which results from the renal failure that sometimes accompanies this condition. Intracranial pressure neither increases nor decreases in a client with pancreatitis. Tachycardia, not bradycardia, usually is associated with pulmonary or hypovolemic complications of pancreatitis. Hypotension can be caused by a hypovolemic complication, but hypertension usually isn't related to acute pancreatitis.
A nurse is providing care to a client who is 1 day post paracentesis. The nurse observes clear, pale-yellow fluid leaking from the puncture site. Which of the following is an appropriate nursing intervention? A. Place a clean towel near the drainage site B. Apply a dry, sterile dressing C. Attach an ostomy back D. Place the client in a supine position
B. Apply a dry, sterile dressing
What laboratory finding is the primary diagnostic indicator for pancreatitis? a. Elevated blood urea nitrogen (BUN) b. Elevated serum lipase c. Elevated aspartate aminotransferase (AST) d. Increased lactate dehydrogenase (LD)
B. Elevation of serum lipase is the most reliable indicator of pancreatitis because this enzyme is produced solely by the pancreas. A client's BUN is typically elevated in relation to renal dysfunction; the AST, in relation to liver dysfunction; and LD, in relation to damaged cardiac muscle
Which dietary modification is utilized for a patient diagnosed with acute pancreatitis? A. High-protein diet B. Elimination of Coffee C. Low carbohydrate diet D. High-fat diet
B. Elimination of Coffee
Melena:
Black, tarry stools.
A nurse is caring for a client who has acute pancreatitis. Which of the following serum laboratory values should the nurse anticipate returning to the expected reference range within 72 hr after treatment begins? A. Aldolase B. Lipase C. Amylase D. Lactic dehydrogenase
C. Amylase Pancreatitis is the most common diagnosis for marked elevations of serum amylase. Serum amylase begins to increase about 3 to 6 hr following the onset of acute pancreatitis.
The nurse is providing care for a patient who just had a paracentesis to treat ascites. Which of the following findings indicate that the procedure was effective? A. Increased heart rate B. Presence of a fluid wave C. Decreased shortness of breath D. Post procedure weight unchanged from pre procedure weight
C. Decreased shortness of breath
A nurse is reviewing the health record of a client who has pancreatitis. The physical exam report by the provider indicates the presence of cullens 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 clients back. B. Palpate the clients Right lower quadrant C. Inspect the skin around the umbilicus D. Auscultate the area below the clients scapula
C. Inspect the skin around the umbilicus Sign of pancreatitis
A nurse is assisting with the admission of the client who has fulminant hepatic failure. Which of the following procedures should the nurse expect for this client? A. Endoscopic sclerotherapy B. Liver lobectomy C. Liver transplant D. Transjugular intrahepatic portal-systemic shunt placement
C. Liver transplant
A nurse is providing dietary instructions to a client with a history of pancreatitis. Which instruction is correct? A. Maintain a high-fat diet and drink at least 3 L of fluid a day. B. Maintain a high sodium, high-calorie diet C. Maintain a high carbohydrate, low-fat diet D. Maintain a high-fat, high-carbohydrate diet
C. Maintain a high carbohydrate, low-fat diet
A nurse is collecting data from a client who has chronic pancreatitis. Which of the following findings should the nurse identify as a likely cause of the client's condition? A. High-calorie diet B. Prior gastrointestinal illnesses C. Tobacco use D. Alcohol use
D. Alcohol use Alcohol consumption is one of the major causes of chronic pancreatitis in the US
A nurse is caring for a client who is 2 days postoperative following a gastric bypass. The nurse notes that bowel sounds are present. Which of the following foods should the nurse provide at the initial feeding? A. Vanilla pudding B. Apple juice C. Diet ginger ale D. Clear liquids
D. Clear liquids
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. Epigastric pain radiating to left shoulder
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. 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. Hand spasms present when blood pressure is checked "trouso's sign"
The nurse recognizes that which of the following infections is acute and likely will only last 4-8 weeks in duration: Hepatitis E Hepatitis B Hepatitis C
Hepatitis E (similar to A)
A nurse is caring for a client who had a Paracentesis. Which of the following findings indicate the bowel was perforated during the procedure? A. Client report of upper chest pain B. Decreased urine output C. Pallor D. Temperature elevation
D. Temperature elevation
Percutaneous liver biopsy:
Procedure in which a small core of liver tissue is obtained by placing a needle directly into the liver through the lateral abdominal wall.
Ultrasonography is use to DX what?
Reveals renal calculi with 96% accuracy Technique that uses high-frequency sound waves to show the size and location of organs and to outline structures and abnormalities.
A client is admitted to rule out acute pancreatitis. Which of the following laboratory tests will provide the most accurate information to support this medical diagnosis? a Serum lipase b Serum sodium c Serum amylase d Serum potassium
a The most commonly measured pancreatic enzymes are serum amylase and lipase. Measuring lipase levels provides a longer period for trending values than that provided by serum amylase levels.
The nurse is concerned that a 45-year-old female client with cholelithiasis will develop acute pancreatitis. Why is the nurse concerned? select all that apply a Because the client is a female. b The nurse is wrong because acute pancreatitis is seen in alcoholic syndrome. c Because the client has gallstones. d A triglyceride level should be drawn before coming to this conclusion. e A calcium level should be drawn before coming to this conclusion. f The nurse is wrong because acute pancreatitis is more prevalent in males.
a, c Gallstone-produced pancreatitis is more common in women.
Which observation by a nurse would indicate blocked flow of bile from the liver to the intestine? a. Clay-colored stools b. Jaundice c. High blood pressure d. Tachycardia
a. Clay-colored stools Bile is unable to get to feces to give it the normal brown color.
Which drugs and herbal remedies are considered harmful to the liver? (Select all that apply.) a. Comfrey (herbal remedy) b. Promethazine (Phenergan) c. Acetaminophen (Tylenol) d. Oral contraceptive (Yaz) e. Lavender (herbal remedy)
a. Comfrey (herbal remedy) c. Acetaminophen (Tylenol) Herbal remedies of comfrey, borage, coltsfoot, and chaparral can harm the liver. The over-the-counter drug Tylenol is also hepatoxic.
What actions should a nurse implement to correctly assess the progress of ascites on a daily basis? a. Daily weights and abdominal girth measurements b. Intake-output and electrolyte levels c. Blood pressure and pulse d. Daily temperatures and oxygen levels
a. Daily weights and abdominal girth measurements Daily weights and abdominal girth measurements will accurately measure the fluid accumulating in the peritoneal cavity.
The nurse knows that which are the functions of bile? Select all that apply. a. Emulsifies fat b. Removes some toxins c. Neutralizes alkalytic chime d. Helps absorb fat-soluble vitamins e. Converts urobilinogen to bilirubin f. Produced in the gallbladder, aids the liver
a. Emulsifies fat b. Removes some toxins d. Helps absorb fat-soluble vitamins Bile emulsifies fat, breaking it into small particles that can be absorbed. Bile is responsible for removing some toxins. In addition, bile plays a role in the absorption of fat-soluble vitamins. Bile neutralizes acidic rather than alkalytic chime as it leaves the stomach. In the large intestine, bile is converted to urobilinogen and then stercobilin, not bilirubin. Bile is produced in the liver and stored in the gallbladder.REF: p. 848
A nurse is leading an education class on the various types of hepatitis for newly hired certified nurse assistants (CNAs). Which statement best describes hepatitis A? a. Infectious hepatitis is the most common type and is rarely fatal. b. Serum hepatitis is found in body fluids and is of particular concern to health care workers. c. This type of hepatitis is most likely to result in the person becoming a chronic carrier of the virus. d. Chronic forms of this type do not exist and are considered to be very rare in the United States.
a. Infectious hepatitis is the most common type and is rarely fatal. Hepatitis A is called infectious or epidemic and is transmitted from one person to another through contaminated food, water, or medical equipment. It is the most common type and is rarely fatal. Serum hepatitis is also known as hepatitis B and is found in body fluids and medical equipment that is contaminated. Persons with hepatitis C are more likely to become chronic carriers of the virus. Hepatitis E is similar to hepatitis A; however, it is rarely seen in the United States.REF: p. 856
What is the highest nursing priority outcome when planning the care for the patient with pancreatitis? a. Patient claims satisfaction with pain control. b. Patient states an understanding of medications needed on discharge. c. Patients activity level tolerance shows an increase. d. Patient can maintain a normal bowel pattern.
a. Patient claims satisfaction with pain control. Pain control is the most important priority.
A patient is having blood drawn for suspected liver disease. The PT is 12, and the INR is 1. The laboratory has called the nurse with the results. What is the nurse's best action? a. Place the results in the chart. b. Call the care provider immediately. c. Prepare for assisting with a liver biopsy. d. Institute safety precautions because of an increased risk for bleeding.
a. Place the results in the chart. The PT of 11.0 to 12.6 seconds and the INR of 1 to 1.2 are within normal limits, so no further action is needed unless the care provider has specifically instructed to do so. The patient's results are not indicative of a prolonged clotting time or evidence of liver disease, so a liver biopsy may not be done. The results of the PT and INR do not demonstrate increased risk for bleeding.REF: p. 853
What is necessary to restrict when the ammonia level of a patient diagnosed with cirrhosis continues to rise? a. Protein b. Carbohydrates c. Fats d. Water-soluble vitamins
a. Protein Ammonia is the waste product of protein breakdown. Decreasing protein intake will decrease the end product.
A client has acute pancreatitis due to a gallstone blocking a bile duct. Which diagnostic test would be the most useful to expedite the recovery of this client? a Pancreatic ultrasound b CT scan of the pancreas c Aspiration biopsy d ERCP
d ERCP provides the opportunity to remove mechanical obstructions such as a gallstone or pancreatic stone.
The client has been admitted with a diagnosis of acute pancreatitis. The nurse would assess this client for pain that is: a Severe and unrelenting, located in the epigastric area and radiating to the back. b Severe and unrelenting, located in the left lower quadrant and radiating to the groin. c Burning and aching, located in the epigastric area and radiating to the umbilicus. d Burning and aching, located in the left lower quadrant and radiating to the hip.
a. The pain associated with acute pancreatitis is often severe and unrelenting, is located in the epigastric region, and radiates to the back.
A client is admitted with acute pancreatitis. What will the nurse expect to find upon assessment of this client? select all that apply a Hyperactive bowel sounds b Brown foamy urine c Heart rate 72 and regular d Constipation e Elevated blood pressure f Diarrhea
b, f brown foamy urine is due to bile being excreted through the kidneys. Abdominal pain, other GI manifestations, skin changes, cardiopulmonary changes, neurological changes, renal changes, hematologic changes, and electrolyte imbalances.
The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750ml of green-brown drainage. Which nursing intervention is most appropriate? a Notify the physician b Document the findings c Irrigate the T-tube d Clamp the T-tube
b. Following cholecystectomy, drainage from the T-tube is initially bloody and then turns to green-brown. The drainage is measured as output. The amount of expected drainage will range from 500 to 1000 ml per day. The nurse would document the output.
Which instruction should be given to a patient with portal hypertension to reduce the threat of hemorrhage? a. Eat bland foods. b. Avoid straining to have a bowel movement. c. Increase fluid intake. d. Use an electric razor to shave.
b. Avoid straining to have a bowel movement. Straining can increase pressure and may cause the dilated vessels in the gastrointestinal tract to bleed. Shaving with an electric razor does not prevent serious bleeding.
A client is diagnosed with an infected pancreatic abscess. Which of the following procedures should the nurse prepare this client for? a Surgery b Pancreatic angiography c ERCP d Percutaneous drainage
d Pancreatic abscess is treated by percutaneous drainage.
The nurse is providing instructions for a patient who will be having a percutaneous transhepatic cholangiography in 2 days. Which statement by the patient indicates understanding of this procedure? a. "I will be able to leave the facility as soon as the procedure is finished." b. "The nurses will monitor the puncture site and check my blood pressure frequently." c. "This procedure requires that I be on bed rest for a minimum of 12 hours afterward." d. "Results of the test will be discussed with my family while I am recovering from the procedure."
b. "The nurses will monitor the puncture site and check my blood pressure frequently." The percutaneous transhepatic cholangiography is an invasive procedure performed while a needle is inserted into the liver and dye injected. The nurse must closely monitor the puncture site for bleeding and must also monitor vital signs frequently. The patient will be maintained on bed rest for a minimum of 8 hours and will stay at the facility while this is accomplished. The results of the test will be discussed with the patient after the procedure.REF: p. 853
Which factors predispose a patient to disorders of the gallbladder? Select all that apply. a. Male b. 40 years of age c. Obesity d. Fertile e. Sedentary f. Family history
b. 40 years of age c. Obesity d. Fertile e. Sedentary f. Family history The age of 40 years is one of the five factors used to describe persons at risk for gallbladder disorders. Obesity or being overweight is a factor, as is being fertile. A sedentary lifestyle is also a risk factor. Family history can show a tendency toward gallbladder issues. Being female is a greater risk factor than being male.REF: p. 871
The nurse is providing discharge instructions that include education for a patient who was recently diagnosed with hepatitis B. Which information should be included in the teaching plan for this patient? a. The diet should be regular with added vitamin and mineral supplements. b. Activity levels will depend on the patient's signs and symptoms and liver function test results. c. When the patient has completed an antiviral medication, he or she will no longer be contagious. d. It is important to take a medication such as diphenhydramine (Benadryl) around the clock to prevent severe itching.
b. Activity levels will depend on the patient's signs and symptoms and liver function test results. Activity levels depend on the individual patient's signs and symptoms. The diet for a patient who has hepatitis should be high-calorie, high-carbohydrate, moderate- to high-protein, and moderate- to low-fat with supplementary vitamins. Antiviral medications may help to lessen symptoms; however, the patient may still be contagious. Benadryl is helpful for itching when it occurs; however, there is no need to take it routinely.REF: p. 858
The nurse would assess the client experiencing an acute episode of cholecysitis for pain that is located in the right a Upper quadrant and radiates to the left scapula and shoulder b Upper quadrant and radiates to the right scapula and shoulder c Lower quadrant and radiates to the umbilicus d Lower quadrant and radiates to the back
b. During an acute "gallbladder attack," the client may complain of severe right upper quadrant pain that radiates to the right scapula and shoulder. This is governed by the pattern on dermatones in the body.
What should a nurse include in the discharge teaching for a patient after a laparoscopic procedure for cholelithiasis? a. Take water-soluble vitamins. b. Follow a low-fat diet. c. Expect light-colored stools for several days. d. Keep dressing over the T-tube dry.
b. Follow a low-fat diet. After the laparoscopic procedure, the patient is to follow a low-fat diet and take fat-soluble vitamins. Placement of the T-tube is not done with the laparoscopic procedure.
A licensed practical nurse (LPN) is caring for a patient who is being treated with neomycin sulfate. What is the HIGHEST priority instruction that the nurse should give related to this medication? a. Report any changes in gastrointestinal function. b. Report any ringing in the ears or loss of balance. c. Take the medication as ordered by the physician. d. Report frequent episodes of nausea and vomiting.
b. Report any ringing in the ears or loss of balance. The patient should immediately report symptoms of ringing in the ears or loss of balance because these signs are indicative of toxicity. Although taking the medication as ordered and reporting any changes in gastrointestinal function are important, these are not the highest priority instructions. Although the patient may experience nausea, the patient is not likely to experience vomiting associated with this medication. REF: p.863
What precaution should a nurse initiate when caring for a patient with hepatitis B? a. Reverse isolation b. Standard precautions c. Respiratory precautions d. Enteric precautions
b. Standard precautions Standard precautions protect the nurse from organisms that may be in all body fluids.
A nurse reminds a patient with liver disease that the level of _____ in the blood is an indicator of the how well the liver is functioning.
bilirubin The level of indirect bilirubin indicates the effectiveness of the metabolism of proteins by the liver.
During the assessment of a client with acute pancreatitis the nurse notes a decrease in breath sounds bilaterally in the lung bases. What should the nurse do with this information? a Document the finding. b Increase the client's intravenous fluids. c Report the information to the physician. d Encourage the client to use the incentive spirometer.
c Atelectasis may result from decreased diaphragmatic excursion because of abdominal distention or from direct injury from exposure to pancreatic enzymes.
What is pruritus related to in the patient diagnosed with hepatitis? a. Decreased fat intake b. Poor appetite and therefore poor protein intake c. Accumulation of bile salts under the skin d. Altered urinary output of bile
c. Accumulation of bile salts under the skin Bile salts accumulate under the skin, causing irritation.
Which dietary selection should lead the nurse to conclude that the dietary teaching is successful for a patient on a low-sodium diet? a. Bologna sandwich with tomato juice b. Hotdog on a bun with pickle relish and skim milk c. Baked chicken, white rice, and apple juice d. Peanut butter and jelly sandwich with tomato soup
c. Baked chicken, white rice, and apple juice A meal of baked chicken, white rice, and apple juice has the lowest sodium levels.
For which complication should a nurse be careful to monitor a patient after a liver biopsy? a. Headache b. Muscle cramps c. Bleeding d. Respiratory distress
c. Bleeding Liver biopsy places the patient at risk for hemorrhage. Liver disorders make patients especially vulnerable to hemorrhage.
An LPN is caring for a patient who has undergone a liver biopsy. What should be the FIRST action by the nurse after the patient has completed the procedure? a. Maintain the patient on bed rest. b. Maintain the patient on the right side. c. Check the pressure dressing for bleeding. d. Reinforce the pressure dressing as needed.
c. Check the pressure dressing for bleeding. Although all of the nursing actions are important and should be implemented at some point postprocedurally, checking the pressure dressing for bleeding is the first intervention that the nurse should implement after the test. Keeping the patient on his right side maintains the pressure on the puncture site. Bed rest may be maintained even after the patient is allowed to turn off of his right side. The nurse should also reinforce the pressure dressing as needed, but only after the nurse has checked the pressure dressing for bleeding. REF: p. 855
Which chronic condition is related to the presence of chronic pancreatitis? a. Chronic obstructive pulmonary disease (COPD) b. Urinary tract infection (UTI) c. Diabetes mellitus (DM) d. Arteriosclerotic heart disease (ASD)
c. Diabetes mellitus (DM) Patients with chronic pancreatitis are at risk for developing DM because of the destruction of the insulin-secreting cells in the pancreas.
Which risk is significantly increased in patients diagnosed with liver disease? a. Urinary infections b. Systemic infection c. Drug toxicity d. Drug allergy
c. Drug toxicity Because many drugs are metabolized in the liver and a diseased liver does not adequately clear the system of drugs, drug toxicity is an ongoing problem.
A patient is sent to you with an elevated amylase and lipase and an abnormal endoscopic retrograde cholangiopancreatography report (ERCP), showing evidence of an autoimmune process and irregular narrowing of specific ducts. What is the most likely diagnosis? Chronic Pancreatitis Appendicitis Cholecystitis
chronic pancreatitis
A nurse is providing information on the medication Pancrease (lipase, protease, amylase) to a patient diagnosed with pancreatitis. Which important instruction should the nurse be sure to include? a. Taken before meals b. Sprinkled on warm food c. Mixed with juice d. Taken 1 hour after eating
c. Mixed with juice Lipase is an enzyme primarily produced by the pancreas to help digest dietary fats Proteolytic enzymes (proteases) are enzymes that break down protein. amylase: an enzyme, found chiefly in saliva and pancreatic fluid, that converts starch and glycogen into simple sugars. Pancreatic enzyme medication takes the place of enzymes missing from the damaged pancreas. The drug should be mixed with juice or applesauce or sprinkled on cold food, but it should not be chewed because it will irritate the mouth and lips. Pancreatic enzymes, also known as pancreases or pancrelipase and pancreatin, are commercial mixtures of amylase, lipase, and protease. They are used to treat malabsorption syndrome due to certain pancreatic problems.
Which nursing measure takes priority in relation to the care of a patient with a gastroesophageal balloon tube? a. Deflate the balloon periodically. b. Advance the tube as instructed. c. Monitor respiratory status. d. Withhold medications that could decrease restlessness.
c. Monitor respiratory status. Because of the close proximity of the esophagus and trachea, any upward movement of the tube could cause airway obstruction.
The nurse is assigned to observe a patient immediately after a needle biopsy of the liver is performed. Which nursing action would be most appropriate? a. Monitor vital signs every 15 minutes for 1 hour and then hourly. Position the patient on the left side. b. Monitor vital signs every 30 minutes for 2 hours and then hourly. Position the patient in the right side-lying position. c. Monitor vital signs every 15 minutes four times and then every 30 minutes two times. Position the patient on the right side. d. Monitor vital signs every 15 minutes for 1 hour followed by every 30 minutes for the next hour. Position the patient on the left side.
c. Monitor vital signs every 15 minutes four times and then every 30 minutes two times. Position the patient on the right side. Vital signs should be monitored every 15 minutes for the first hour, then every 30 minutes for the next hour, and then hourly. While assessing vital signs, the pressure dressing should be assessed for bleeding. The patient is placed on the right side for at least 2 hours. The patient would be placed on the right side rather than the left side to maintain pressure on the puncture site.REF: p. 855
Which sign indicates that the need for increased fluid intake would be contraindicated in a patient diagnosed with a hepatic disorder? a. Low blood pressure b. Increased urinary output c. Signs of edema d. Bradycardia
c. Signs of edema Edema may indicate fluid overload; therefore, question the intake, as well as electrolyte and cardiac status.
What action should a nurse implement to prevent complications in a patient with hepatitis who has been prescribed bedrest? a. Raise the knee gatch to prevent the patient from sliding down in bed. b. Provide undisturbed periods of 6 hours to encourage rest. c. Restrict fluids. d. Encourage turning, coughing, and deep breathing every 2 hours.
d. Encourage turning, coughing, and deep breathing every 2 hours. The nurse must encourage measures that will prevent pneumonia and improve impaired skin integrity because of the increased risk factors associated with bedrest.
The nurse is reviewing the physician's orders written for a client admitted with acute pancreatitis. Which physician order would the nurse question if noted on the client's chart? a NPO status b Insert a nasogastric tube c An anticholinergic medication d Morphine for pain
d. Meperidine (Demerol) rather than morphine is the medication of choice because morphine can cause spasm in the sphincter of Oddi.
An LPN is caring for a patient who has been diagnosed with cholelithiasis. The nurse is contributing to the discharge plan for the patient. What is the HIGHEST priority discharge instruction that the patient should be given? a. Maintain a low-fat diet supplemented with fat-soluble vitamins. b. Keep appointments to have blood drawn for liver function tests. c. Use a second form of birth control other than oral contraceptives. d. Report experiencing light stools, dark urine, jaundice, and itching.
d. Report experiencing light stools, dark urine, jaundice, and itching. Although all of the instructions are important, reporting light stools, dark urine, jaundice and itching is the most important instruction because these symptoms are indicative of bile duct obstruction. The patient should also be instructed to maintain a low-fat diet supplemented with fat-soluble vitamins, keep appointments to have blood drawn for liver function tests, and use a second form of birth control other than oral contraceptives, but these instructions are not the most important. REF: p. 875
A patient in acute pain is admitted with pancreatitis. A nurse reviews a laboratory report showing an elevation that is diagnostic for acute pancreatitis. Which laboratory report did the nurse most likely review? a. Serum bilirubin b. Serum calcium c. Serum lipids d. Serum amylase
d. Serum amylase Serum amylase is the most significant of the diagnostic findings.
Serious Side effects of ranitidine (Zantac):
neutropenia, Agranulocytosis, Thrombocytopenia Aplastic anemia
A nurse is alert for bleeding in a patient with hepatic disorders because the inflamed liver may not be able to synthesize two clotting factors, which are _____ and _____.
prothrombin; fibrinogen Prothrombin and fibrinogen, which are necessary components for blood clotting, are deficit in liver disorders, leading to bleeding episodes.
The prototype drug for H2 Receptor antagonists:
ranitidine (Zantac)
In assessing a dark-skinned patient for jaundice, the nurse would assess the _____ for a yellow color.
sclera Jaundice can be assessed by the yellow pigment on the sclera of a dark-skinned person.
You're caring for Jane, a 57 y.o. patient with liver cirrhosis who develops ascites and requires paracentesis. Before her paracentesis, you instruct her to: 1 Empty her bladder. 2 Lie supine in bed. 3 Remain NPO for 4 hours. 4 Clean her bowels with an enema
1. A full bladder can interfere with paracentesis and be punctured inadvertently
A patient with chronic alcohol abuse is admitted with liver failure. You closely monitor the patient's blood pressure because of which change that is associated with the liver failure? 1 Hypoalbuminemia 2 Increased capillary permeability 3 Abnormal peripheral vasodilation 4 Excess rennin release from the kidneys
1. Blood pressure decreases as the body is unable to maintain normal oncotic pressure with liver failure, so patients with liver failure require close blood pressure monitoring. Increased capillary permeability, abnormal peripheral vasodilation, and excess rennin released from the kidney's aren't direct ramifications of liver failure.
You're caring for Lewis, a 67 y.o. patient with liver cirrhosis who develops ascites and requires paracentesis. Relief of which symptom indicated that the paracentesis was effective? 1. Pruritus 2 Dyspnea 3 Jaundice 4 Peripheral Neuropathy
2. Ascites puts pressure on the diaphragm. Paracentesis is done to remove fluid and reducing pressure on the diaphragm. The goal is to improve the patient's breathing. The others are signs of cirrhosis that aren't relieved by paracentesis.
A client who is recently has been started on enteral feedings begins to complain of abdominal cramping, followed by the passage of two liquid stools. A nurse notes that the client has abdominal distention as well. The nurse reviews the nutritional content on the label of the can of feeding to see if it has which of the following ingredients? a) lactose b) sucrose c) fructose d) maltose
A - several tube feeding formulas contain lactose. A client with an unreported history of lactose intolerance would develop symptoms such as abdominal cramping, distention, and the passage of liquid stool in response to nutritional therapy with these formulas. If the client is diagnosed as lactose intolerant, a lactose-free formula should be prescribed by the physician. This will resolve the client's symptoms and promote adequate nutrition for the client.
A nurse is caring for a client with cirrhosis of the liver. To minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the dietary measures to follow if the client states an intention to increase the intake of: a) pork b) milk c) chicken d) broccoli
A - the client with cirrhosis needs to consume foods high in thiamine. Thiamine is present in a variety of foods of plants and animal origin. Pork products are especially rich in this vitamin. Other good food sources include nuts, whole grain cereals, and legumes. Milk contains vitamin A, D, and B2. Poultry contains niacin. Broccoli contains vitamin C, E and K and folic acid.
Michael, a 42 y.o. man is admitted to the med-surg floor with a diagnosis of acute pancreatitis. His BP is 136/76, pulse 96, Resps 22 and temp 101. His past history includes hyperlipidemia and alcohol abuse. The doctor prescribes an NG tube. Before inserting the tube, you explain the purpose to patient. Which of the following is a most accurate explanation? a "It empties the stomach of fluids and gas." b "It prevents spasms at the sphincter of Oddi." c "It prevents air from forming in the small intestine and large intestine." d "It removes bile from the gallbladder."
A An NG tube is inserted into the patients stomach to drain fluid and gas
The student nurse is teaching the family of a patient with liver failure. You instruct them to limit which foods in the patient's diet? a Meats and beans. b Butter and gravies. c Potatoes and pastas. d Cakes and pastries.
A Meats and beans are high-protein foods. In liver failure, the liver is unable to metabolize protein adequately, causing protein by-products to build up in the body rather than be excreted.
Sharon has cirrhosis of the liver and develops ascites. What intervention is necessary to decrease the excessive accumulation of serous fluid in her peritoneal cavity? a Restrict fluids b Encourage ambulation c Increase sodium in the diet d Give antacids as prescribed
A Restricting fluids decrease the amount of body fluid and the accumulation of fluid in the peritoneal space.
Glenda has cholelithiasis (gallstones). You expect her to complain of: a Pain in the right upper quadrant, radiating to the shoulder. b Pain in the right lower quadrant, with rebound tenderness. c Pain in the left upper quadrant, with shortness of breath. d Pain in the left lower quadrant, with mild cramping.
A The gallbladder is located in the RUQ and a frequent sign of gallstones is pain radiating to the shoulder.
You're caring for Betty with liver cirrhosis. Which of the following assessment findings leads you to suspect hepatic encephalopathy in her? a Asterixis b Chvostek's sign c Trousseau's sign d Hepatojugular reflex
A. Asterixis is an early neurologic sign of hepatic encephalopathy elicited by asking the patient to hold her arms stretched out. Asterixis is present if the hands rapidly extend and flex.
A 53 y.o. patient has undergone a partial gastrectomy for adenocarcinoma of the stomach. An NG tube is in place and is connected to low continuous suction. During the immediate postoperative period, you expect the gastric secretions to be which color? a Brown. b Clear. c Red. d Yellow.
C Coffee-ground emesis occurs when there is upper GI bleeding that has undergone gastric digestion. For blood to appear as coffee-ground emesis, it would have to be digested for approximately 2 hours.
A nurse is caring for a client who is 4 hr postoperative following a laparoscopic cholecystectomy. Which of the following findings should the nurse expect? A. Right shoulder pain B. Urine output 20 mL/hr C. Temperature 38.4 degrees C (101.1 degrees F) D. Oxygen saturation 92%
A. CORRECT: The client can experience pain in the right upper shoulder due to gas (carbon dioxide) injected into the abdominal cavity during the laparoscopic procedure, which can irritate the diaphragm and cause referred pain in the shoulder area. The pain disappears in 1-2 days. Mild analgesics and a recumbent position can help with client comfort. B. Urine output following surgery should be at least 30 mL/hr. Less than this amount can indicate hypovolemia or renal complications and should be reported to the provider immediately. C. A temperature greater than 38.4. C (101.1 F) can indicate infection and should be reported to the provider immediately. D. An oxygen saturation of less than 95% can indicate an impaired gas exchange following surgery and should be reported to the provider immediately.
GOOD A nurse in the emergency dependent is caring for a client who has bleeding esophageal varies. The nurse should anticipate a prescription for which of the following medications? A. Famotidine B. Esomeprazole C. Vasopressin D. Omeprazole
A. Famotidine is an H2 receptor antagonist used to treat stress ulcers. B. Esomeprazole is a proton pump inhibitor used to treat gastrointestinal reflux disease. C. CORRECT: Vasopressin constricts the splanchnic bed and decreases portal pressure. Vasopressin also constricts the distal esophageal and proximal gastric veins, which reduces inflow into the portal system and is used to treat bleeding varies. D. Omeprazole is a proton pump inhibitor used to treat duodenal and gastric ulcers.
A nurse is assessing a client who is in the early stages of hepatitis A. which of the following manifestations should the nurse expect? A. Jaundice B. Anorexia C. Dark urine D. Pale feces
A. Jaundice is a late manifestation of hepatitis A. B. CORRECT: Anorexia is an early manifestation of hepatitis A and is often severe. It is thought to result from the release of a toxin by the damaged liver or by the failure of the damaged liver cells to detoxify an abnormal product. C. Dark urine is a late manifestation of hepatitis A. D. Pale feces is a late manifestation of hepatitis A.
Which of the following symptoms will a nurse observe most commonly in clients with pancreatitis? A. Severe, radiating abdominal pain B. Black, tarry stools and dark urine C. Increased and painful urination D. Increased appetite and weight gain
A. Severe, radiating abdominal pain
A nurse is assessing a client who is experiencing perforation of a peptic ulcer. Which of the following manifestations should the nurse expect? A. Increased blood pressure B. Decreased heart rate C. Yellowing of the skin D. Boardlike abdomen
A. The nurse should expect the client who is experiencing perforation of a peptic ulcer to exhibit manifestations of shock, including hypotension. B. The nurse should expect the client who is experiencing perforation of a peptic ulcer to exhibit manifestations of shock, including tachycardia. C. The nurse should expect a client who has liver disease to exhibit jaundice, or yellowing of the skin. D. CORRECT: The nurse should expect the client who is experiencing perforation of a peptic ulcer to exhibit manifestations of a boardlike abdomen and severe pain in the abdomen or back that radiates to the right shoulder. Vomiting of blood and shock can occur if the perforation causes hemorrhaging.
A male client with cholelithiasis has a gallstone lodged in the common bile duct. When assessing this client, the nurse expects to note: a. yellow sclerae. b. light amber urine. c. circumoral pallor. d. black, tarry stools.
A. Yellow sclerae may be the first sign of jaundice, which occurs when the common bile duct is obstructed. Urine normally is light amber. Circumoral pallor and black, tarry stools don't occur in common bile duct obstruction; they are signs of hypoxia and GI bleeding, respectively.
You are developing a careplan on Sally, a 67 y.o. patient with hepatic encephalopathy. Which of the following do you include? a Administering a lactulose enema as ordered. b Encouraging a protein-rich diet. c Administering sedatives, as necessary. d Encouraging ambulation at least four times a day.
A. You may administer the laxative lactulose to reduce ammonia levels in the colon.
George has a T tube in place after gallbladder surgery. Before discharge, what information or instructions should be given regarding the T tube drainage? a "If there is any drainage, notify the surgeon immediately." b "The drainage will decrease daily until the bile duct heals." c "First, the drainage is dark green; then it becomes dark yellow." d "If the drainage stops, milk the tube toward the puncture wound."
B As healing occurs from the bile duct, bile drains from the tube; the amount of bile should decrease. Teach the patient to expect dark green drainage and to notify the doctor if drainage stops.
Ralph has a history of alcohol abuse and has acute pancreatitis. Which lab value is most likely to be elevated? a Calcium b Glucose c Magnesium d Potassium
B Glucose level increases and diabetes mellitus may result d/t the pancreatic damage to the islets of langerhans.
When preparing a male client, age 51, for surgery to treat appendicitis, the nurse formulates a nursing diagnosis of Risk for infection related to inflammation, perforation, and surgery. What is the rationale for choosing this nursing diagnosis? a. Obstruction of the appendix may increase venous drainage and cause the appendix to rupture. b. Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix. c. The appendix may develop gangrene and rupture, especially in a middle-aged client. d. Infection of the appendix diminishes necrotic arterial blood flow and increases venous drainage.
B. A client with appendicitis is at risk for infection related to inflammation, perforation, and surgery because obstruction of the appendix causes mucus fluid to build up, increasing pressure in the appendix and compressing venous outflow drainage. The pressure continues to rise with venous obstruction; arterial blood flow then decreases, leading to ischemia from lack of perfusion. Inflammation and bacterial growth follow, and swelling continues to raise pressure within the appendix, resulting in gangrene and rupture. Geriatric, not middle-aged, clients are especially susceptible to appendix rupture.
Develop a teaching care plan for Angie who is about to undergo a liver biopsy. Which of the following points do you include? a. "You'll need to lie on your stomach during the test." b. "You'll need to lie on your right side after the test." c. "During the biopsy you'll be asked to exhale deeply and hold it." d. "The biopsy is performed under general anesthesia.
B. After a liver biopsy, the patient is placed on the right side to compress the liver and to reduce the risk of bleeding or bile leakage.
Which condition is most likely to have a nursing diagnosis of fluid volume deficit? a. Appendicitis b. Pancreatitis c. Cholecystitis d. Gastric ulcer
B. Hypovolemic shock from fluid shifts is a major factor in acute pancreatitis. The other conditions are less likely to exhibit fluid volume deficit.
Brenda, a 36 y.o. patient is on your floor with acute pancreatitis. Treatment for her includes: a Continuous peritoneal lavage. b Regular diet with increased fat. c Nutritional support with TPN. d Insertion of a T tube to drain the pancreas.
C With acute pancreatitis, you need to rest the GI tract by TPN as nutritional support.
Which of the following is an appropriate nursing intervention for a pt. who has gastritis? A. Lavage the NG tube with iced saline. B. Give sucralfate with meals and follow it with antacids. C. Advise the pt. to avoid irritating foods such as spicy foods. D. Advise the pt. to drink milk every two hours.
C. Advise the pt. to avoid irritating foods such as spicy foods.
A nurse is assessing a client who was admitted with a bowel obstruction. The client reports severe abdominal pain. Which of the following findings should indicate to the nurse that a possible bowel perforation has occurred? A. Elevated blood pressure B. Bowel sounds increased in frequency and pitch C. Rigid abdomen D. Emesis of undigested food
C. CORRECT: Abdominal tenderness and rigidity occur with a bowel perforation. As fluid escapes into the peritoneal cavity, there is a reduction in circulating blood volume and a lowered blood pressure. or hypotension, results. A. A client who has experienced a bowel perforation will not display an elevated blood pressure. However, hypotension or shock can be present. B. Intestinal peristalsis increases in frequency and intensity as the bowel attempts to move intestinal contents past the obstructed area. Bowel sounds are silent with a bowel perforation D. Vomiting is frequent and copious with a small bowel obstruction. This does not indicate a bowel perforation.
A nurse is caring for a client who has fulminant hepatic failure. Which of the following procedures should the nurse anticipate for this client? A. Endoscopic sclerotherapy B. Liver lobectomy C. Liver transplant D. Transjugular intrahepatic portal-systemic shunt placement
C. CORRECT: Fulminant hepatic failure, most often caused by viral hepatitis, is characterized by the development of hepatic encephalopathy within weeks of the onset of disease in a client without prior evidence of hepatic dysfunction. Mortality remains high. even with treatment modalities such as blood or plasma exchanges, charcoal hemoperfusion, and corticosteroids. Consequently, liver transplantation has become the treatment of choice for these clients. A. Endoscopic sclerotherapy is the injection of a sclerotherapy agent during endoscopy to target esophageal varies that are actively bleeding. This promotes thrombosis, which eventually leads to sclerosis. B. A liver lobectomy is used for a client who has localized cancer of a lobe of the liver. This is not appropriate for a client experiencing rapidly progressive liver failure. D. A transjugular intrahepatic portal-systemic shunt is placed to treat esophageal varies through placement of a stent into the portal vein. The stent serves as a shunt between the portal circulation and the hepatic vein, thereby reducing portal hypertension. It is not used for fulminant hepatic failure.
A nurse is caring for a client who has acute pancreatitis. Which of the following serum laboratory values should the nurse anticipate returning to the expected reference range within 72 hr after treatment begins? A. Aldolase B. Lipase C. Amylase D. Lactic dehydrogenase
C. CORRECT: Pancreatitis is the most common diagnosis for marked elevations in serum amylase. Serum amylase begins to increase about 3 to 6 hr following the onset of acute pancreatitis. The amylase level peaks in 20 to 30 hr and returns to the expected reference range within 2 to 3 days. A. Elevated aldolase levels are caused by inflammation of the muscles, also known as myositis. The levels of aldolase are not affected by pancreatic disorders. B. Lipase levels in clients who have pancreatitis increase after a rise in serum amylase and stay elevated for up to 14 days longer than amylase. D. Lactic dehydrogenase (LDH) increases are typically seen in clients who have anemia, leukemia, or liver damage.
Britney, a 20 y.o. student is admitted with acute pancreatitis. Which laboratory findings do you expect to be abnormal for this patient? a Serum creatinine and BUN b Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) c Serum amylase and lipase d Cardiac enzymes
C. Pancreatitis involves activation of pancreatic enzymes, such as amylase and lipase. These levels are elevated in a patient with acute pancreatitis.
Leigh Ann is receiving pancrelipase (Viokase) for chronic pancreatitis. Which observation best indicates the treatment is effective? a There is no skin breakdown. b Her appetite improves. c She loses more than 10 lbs. d Stools are less fatty and decreased in frequency.
D Pancrelipase provides the exocrine pancreatic enzyme necessary for proper protein, fat, and carb digestion. With increased fat digestion and absorption, stools become less frequent and normal in appearance.
A nurse is completing a history and physical assessment for a client who has chronic pancreatitis. Which of the following findings should the nurse identify as a likely cause of the client's condition? A. High-calorie diet B. Prior gastrointestinal illnesses C. Tobacco use D. Alcohol use
D. CORRECT: Alcohol consumption is one of the major causes of chronic pancreatitis in the U.S. Long-term alcohol use disorder produces hyper secretion of protein in pancreatic secretions. The result is protein plugs and calculi within the pancreatic ducts. Alcohol also has a direct toxic effect on the cells of the pancreas. Damage to these cells is more likely to occur and to be more severe in clients whose diets are poor in protein content and either very high or very low in fat. A. A high-calorie diet can contribute to heart disease and obesity but it does not cause chronic pancreatitis. B. A prior gastrointestinal illness does not cause or contribute to chronic pancreatitis. C. tobacco use can contribute to heart disease and increases the risk of cancer development. but it does not cause chronic pancreatitis.
A nurse is caring for a client who is 2 days postoperative following a gastric bypass. The nurse notes that bowel sounds are present. Which of the following foods should the nurse provide at the initial feeding? A. Vanilla pudding B. Apple juice C. Diet ginger ale D. Clear liquids
D. CORRECT: Clear liquids. such as water or broth. can be given for the first oral feedings. but should be limited to only 30 mL (1 oz) per feeding. Water does not contain sugar. which could cause diarrhea due to hyperosmolarity. A. Vanilla pudding contains sugar, which can cause diarrhea due to hyperosmolarity. Clear liquids should be given as the first oral feeding. B. The sugar content of apple juice can cause diarrhea due to hyperosmolarity. Clear liquids should be given as the first oral feeding. C. The client should avoid carbonated beverages because they can distend the stomach. causing pressure on the internal sutures or staples. Pressure can cause leaking into the peritoneum resulting in peritonitis.
A nurse is caring for a client who is receiving total parenteral nutrition (TPN) therapy and has just returned to the room following physical therapy. The nurse notes that the infusion pump for the client's TPN is turned off. After restarting the infusion pump, the nurse should monitor the client for which of the following findings? A. Hypertension B. Excessive thirst C. Fever D. Diaphoresis
D. CORRECT: The nurse should recognize that the client has the potential for the development of hypoglycemia due to the sudden withdrawal of the TPN solution. In addition to diaphoresis. other potential manifestations of hypoglycemia can include weakness, anxiety, confusion. and hunger. A. A client experiencing fluid volume overload will exhibit hypertension. B. A client experiencing hyperglycemia will exhibit excessive thirst. C. A client who has an infection will have an increased temperature.
A nurse is caring for a patient with liver failure and is performing an assessment in the knowledge of the patients increased risk of bleeding. The nurse recognizes that this risk is related to the patients inability to synthesize prothrombin in the liver. What factor most likely contributes to this loss of function? A. Alterations in glucose metabolism B. Retention of bile salts C. Inadequate production of albumin by hepatocytes D. Inability of the liver to use vitamin K
D. Inability of the liver to use vitamin K
Use of H2 Receptor Antagonists (ranitidine) : The action of H2 Receptor Antagonists :
Pancreatitis- , prevent activation of pancreatic enzymes They block histamine and reduce gastric acid production
A nurse is educating a patient diagnosed with hepatitis A. What should the nurse instruct this patient to avoid sharing? a. Food b. Bodies c. Needles d. Housing
a. Food Hepatitis A is spread from contact with saliva, which can be transmitted by shared food or drinks.
A goal of medical treatment for patients with cirrhosis is to prevent complications and limit cell damage. A major approach is to promote rest. What rationale supports this approach? a. Allows time for a transplant b. Allows the liver to regenerate c. Prevents red cell destruction d. Decreases the risk of trauma
b. Allows the liver to regenerate With rest, the liver will regenerate healthy tissue and return to normal functioning. Rest must include other measures to promote healing, such as dietary measures and no alcohol.
What intervention should a nurse implement when assessing a patient with jaundice who has been given the nursing diagnosis of impaired skin integrity? a. Sedate the patient. b. Apply mittens or socks to the hands. c. Restrain the hands. d. Distract the patient with conversation.
b. Apply mittens or socks to the hands. Jaundice causes itching, which can cause the patient to scratching and create a break in the skin. Mittens provide some comfort without causing further skin impairment.
The nurse is caring for a patient who is returning to the unit after a liver biopsy. Which intervention implemented by the nurse is appropriate during the postintervention care of this patient? a. Maintain the patient on the left side for at least 2 hours after the procedure. b. Check vital signs every 15 minutes for the first hour and then according to protocol. c. Encourage the patient to keep the right arm above the head and to take frequent deep breaths. d. Change the pressure dressing every 30 minutes for the first 2 hours and assess the puncture site.
b. Check vital signs every 15 minutes for the first hour and then according to protocol. To monitor for potential complications after a liver biopsy, vital signs are checked every 15 minutes for the first hour and then according to protocol. The patient must remain on the right side for at least 2 hours to maintain pressure on the puncture site. The patient is encouraged to keep the right arm above the head and to take frequent deep breaths during the actual procedure, not postprocedure. The pressure dressing should be checked for bleeding every 15 minutes for the first hour and then every 30 minutes during the second hour; however, the dressing should not be removed or changed.REF: p. 855
Which vaccination does the Occupational Health and Safety Administration (OSHA) require all health care providers to receive? a. Hepatitis A b. Hepatitis B c. Hepatitis C d. All strains of hepatitis
b. Hepatitis B OSHA requires that all health care providers be vaccinated against hepatitis B.
A high ammonia level contributes to hepatic encephalopathy. Which nursing implementation needs to be added to the nursing care plan as this level continues to increase? a. Mouth care b. Increased frequency of neurologic checks c. Oxygen saturation monitoring d. Intake and output
b. Increased frequency of neurologic checks As the ammonia level rises, the patient becomes at greater risk for confusion and hepatic coma related to encephalopathy.
Which medication would be given to promote elimination of ammonia in fecal matter and to treat hepatic encephalopathy in a patient with cirrhosis? a. Furosemide (Lasix) b. Lactulose (Cephulac) c. Propranolol (Inderal) d. Spironolactone (Aldactone)
b. Lactulose (Cephulac) Lactulose is used to help eliminate ammonia in feces and to prevent or treat hepatic encephalopathy. Furosemide is used for excretion of excess fluid. Propanolol reduces pressure in veins, decreasing the risk for bleeding. Spironolactone is used to decrease excess fluid.REF: p. 863
What is the meaning of a dropping bilirubin level in a patient diagnosed with hepatitis? a. Red blood cell destruction is decreasing. b. Liver function is improving. c. Kidneys are compensating for liver dysfunction. d. Kupffer cell damage is continuing.
b. Liver function is improving. As liver function improves, the bilirubin level will decrease because of the livers ability to conjugate and excrete the bilirubin. The flow of bile out of the liver increases.
A young woman with severe jaundice has a nursing diagnosis of Altered body image, related to jaundice. The patient says, Will I always be this horrible color? What is the best response by the nurse? a. Yes, but your sclera will return to their previous white color. b. No. The color will fade gradually as liver inflammation decreases. c. Yes, but cosmetics can disguise the color. d. No. The color will change to freckles.
b. No. The color will fade gradually as liver inflammation decreases. Jaundice causes patients to be self-conscious and reclusive because of the change in physical appearance. Patients can be reassured that the color improves as liver function improves, usually in 2 to 4 weeks.
When assessing a client's pain level the nurse concludes the client is experiencing acute pancreatitis. What did the nurse assess? select all that apply a Over-the-counter pain relievers take the pain away b Pain is relieved with the passing of flatus c Pain is sharp, like a knife, occurs without warning d Pain is less when the client leans forward e Pain settles in the right shoulder f Pain is relieved with coughing
c, d Pain is the most consistent complaint associated with acute pancreatitis and is a high-priority assessment. Pain is sudden onset, sharp, knifelike, twisting, deep, and radiates to the flank, chest, abdomen. Pain may be relieved by leaning forward or assuming the fetal position.
A client is found to have a malfunction in his ability to manufacture and secrete secretin. The nurse realizes this hormone: select all that apply a Tells the pancreas to release elastase. b Raises the pH of the stomach. c Tells the pancreas to release bicarbonate and water. d Tells the pancreas to release trypsin. e Regulates intestinal pH. f Keeps intestinal mucosa acidic.
c, e This is the mechanism to maintain the intestinal pH. Secretin is essential in the regulation of intestinal pH.
What should a nurse often find in the medical history of a patient diagnosed with pancreatic disease? a. Liver disorders b. Drug abuse c. Alcohol abuse d. Excessive sugar intake
c. Alcohol abuse Pancreatic disease is often related to alcohol abuse.
A patient was positive for hepatitis B virus, although she had the disease 4 years ago and now is symptom free. What is the nurse aware is true regarding this patient? a. Is likely to have hepatitis B again b. Now has noninfectious hepatitis c. Is an infectious carrier and always will be d. Is at risk for hepatitis E
c. Is an infectious carrier and always will be A certain percentage of persons who have had hepatitis B convert to carriers. They have the live virus, which causes no symptoms in them, but they are able to transmit the disease and always will be infectious.
An LPN is caring for a patient who is scheduled to undergo magnetic resonance imaging (MRI). What is the MOST important instruction to give the patient? a. She may feel claustrophobic. b. MRI is painless and noninvasive. c. She must lie still on the narrow surface. d. She must remove all metal before the procedure.
d. She must remove all metal before the procedure. Because the risk of significant injury to the patient exists, asking the patient to remove all metal before the procedure is the most important instructional point. After the nurse has impressed upon the patient the importance of removing all metal before the procedure, the nurse should also inform the patient that she may feel claustrophobic, she must lie still on the narrow surface, and that the MRI is painless and noninvasive. REF: p. 854
An LPN is caring for a patient who is scheduled to undergo ultrasonography. What is the HIGHEST priority preprocedural instruction that the nurse should give to this the patient? The patient will: a. be lying on a table during the procedure. b. feel a technician apply gel to the abdomen. c. see images projected onto a screen during the test. d. take nothing by mouth for 8 to 12 hours before the test.
d. take nothing by mouth for 8 to 12 hours before the test. Asking the patient to avoid taking anything by mouth for 8 to 12 hours before the test is the most important preprocedural instruction for the patient. If this status is not maintained, the test cannot take place. After this instruction is given, the nurse can inform the patient that he or she will be lying on a table during the procedure, feel a technician apply gel to the abdomen, and see images projected onto a screen during the test. REF: p. 854
