PREPU chapter 43

A client has undergone a liver biopsy. Which postprocedure position is appropriate?

On the right side

What initial measure can the nurse implement to reduce risk of injury for a client with liver disease?

Pad the side rails on the bed

A client was admitted to a critical care unit with esophageal varices and a precarious physical condition. What predisposes the client to have bleeding varices? Select all that apply.

Rough food Chemical irritation Straining at stool Little protective tissue to protect fragile veins

The nurse is administering medications to a client that has elevated ammonia due to cirrhosis of the liver. What medication will the nurse give to detoxify ammonium and to act as an osmotic agent?

Lactulose

During assessment, a patient with chronic liver dysfunction tells the nurse that he is experiencing spontaneous episodes of bleeding and has noticed increased areas of bruising on his chest and arms. The nurse suspects a deficiency in

Vitamin K

A patient who had a recent myocardial infarction was brought to the emergency department with bleeding esophageal varices and is presently receiving fluid resuscitation. What first-line pharmacologic therapy does the nurse anticipate administering to control the bleeding from the varices?

Octreotide (Sandostatin)

A physician orders spironolactone (Aldactone), 50 mg by mouth four times daily, for a client with fluid retention caused by cirrhosis. Which finding indicates that the drug is producing a therapeutic effect?

Loss of 2.2 lb (1 kg) in 24 hours

A client is scheduled to have a laparoscopic cholecystectomy as an outpatient. The client asks the nurse when the client will be able to resume normal activities. What information should the nurse provide?

Normal activities may be resumed in 1 week.

The nurse is caring for a client suspected of having stones that have collected in the common bile duct. What test should the nurse prepare the client for that will locate these stones?

Endoscopic retrograde cholangiopancreatography (ERCP)

Which type of deficiency results in macrocytic anemia?

Folic acid

A client with liver cirrhosis develops ascites. Which medication will the nurse prepare teaching for this client?

Spironolactone

The nurse is completing a morning assessment of a client with cirrhosis. Which information obtained by the nurse will be of most concern?

The client's hands flap back and forth when the arms are extended.

Which of the following diagnostic studies definitely confirms the presence of ascites?

Ultrasound of liver and abdomen

The nurse is preparing to interview a client with cirrhosis. Based on an understanding of this disorder, which question would be most important to include?

"How often do you drink alcohol?"

Alcohol, which is toxic to the liver, is a common cause of hepatic disorders. As part of health teaching, the nurse advises a group of women that the amount of daily alcohol use should generally be limited to the equivalent of:

1 drink/12floz

The nurse is assisting the physician with a procedure to remove ascitic fluid from a client with cirrhosis. What procedure does the nurse ensure the client understands will be performed?

Abdominal paracentesis

A client reporting shortness of breath is admitted with a diagnosis of cirrhosis. A nursing assessment reveals an enlarged abdomen with striae, an umbilical hernia, and 4+ pitting edema of the feet and legs. What is the most important data for the nurse to monitor?

Albumin

The nurse is assessing a client with hepatic cirrhosis for mental deterioration. For what clinical manifestations will the nurse monitor? Select all that apply.

Alterations in mood Agitation Insomnia

Which term is used to describe a chronic liver disease in which scar tissue surrounds the portal areas?

Alcoholic cirrhosis

Which of the following would the nurse expect to assess in a conscious client with hepatic encephalopathy?

Asterixis

A nurse is caring for a client with cholelithiasis. Which sign indicates obstructive jaundice?

Clay-colored stools

Which nursing assessment is most important in a client diagnosed with ascites?

Daily measurement of weight and abdominal girth

A nurse is caring for a patient with cancer of the liver whose condition has required the insertion of a percutaneous biliary drainage system. The nurse's most recent assessment reveals the presence of dark green fluid in the collection container. What is the nurse's best response to this assessment finding?

Document the presence of normal bile output.

A client is receiving vasopressin for the urgent management of active bleeding due to esophageal varices. What most serious complication should the nurse assess the client for after the administration?

Electrocardiogram changes

The nurse identifies which type of jaundice in an adult experiencing a transfusion reaction?

Hemolytic

A client has an elevated serum ammonia concentration and is exhibiting changes in mental status. The nurse should suspect which condition?

Hepatic encephalopathy

Clients diagnosed with esophageal varices are at risk for hemorrhagic shock. Which is a sign of potential hypovolemia?

Hypotension

The assessment of a client admitted with increased ascites related to cirrhosis reveals the following: pulse 86 beats per minute and weak, respirations 28 breaths per minute, blood pressure 130/88 mm Hg, and pulse oximetry 90%. Which nursing diagnosis should receive top priority?

Ineffective breathing pattern

A client is being prepared to undergo laboratory and diagnostic testing to confirm the diagnosis of cirrhosis. Which test would the nurse expect to be used to provide definitive confirmation of the disorder?

Liver biopsy

A client has a blockage of the passage of bile from a stone in the common bile duct. What type of jaundice does the nurse suspect this client has?

Obstructive jaundice

A client is actively bleeding from esophageal varices. Which medication would the nurse most expect to be administered to this client?

Octreotide

Which is the most common cause of esophageal varices?

Portal hypertension

The nurse is concerned about potassium loss when a diuretic is prescribed for a patient with ascites and edema. What diuretic may be ordered that spares potassium and prevents hypokalemia?

Spironolactone (Aldactone)

Ammonia, the major etiologic factor in the development of encephalopathy, inhibits neurotransmission. Increased levels of ammonia are damaging to the body. The largest source of ammonia is from:

The digestion of dietary and blood proteins.

The nurse is administering Cephulac (lactulose) to decrease the ammonia level in a patient who has hepatic encephalopathy. What should the nurse carefully monitor for that may indicate a medication overdose?

Watery diarrhea

A client has just been diagnosed with hepatitis A. On assessment, the nurse expects to note:

anorexia, nausea, and vomiting.

A client with acute liver failure exhibits confusion, a declining level of consciousness, and slowed respirations. The nurse finds him very difficult to arouse. The diagnostic information which best explains the client's behavior is:

subnormal serum glucose and elevated serum ammonia levels.

A nurse is assessing a postoperative client for hemorrhage. What responses associated with the compensatory stage of shock should be reported to the healthcare provider?

tachycardia and tachypnea

A client with liver and renal failure has severe ascites. On initial shift rounds, his primary nurse finds his indwelling urinary catheter collection bag too full to store more urine. The nurse empties more than 2,000 ml from the collection bag. One hour later, she finds the collection bag full again. The nurse notifies the physician, who suspects that a bladder rupture is allowing the drainage of peritoneal fluid. The physician orders a urinalysis to be obtained immediately. The presence of which substance is considered abnormal?

Albumin

A client has developed drug-induced hepatitis from a drug reaction to antidepressants. What treatment does the nurse anticipate the client will receive to treat the reaction?

High-dose corticosteroids

After undergoing a liver biopsy, a client should be placed in which position?

Right lateral decubitus position

A patient with severe chronic liver dysfunction comes to the clinic with bleeding of the gums and blood in the stool. What vitamin deficiency does the nurse suspect the patient may be experiencing?

Vitamin K deficiency

The mode of transmission of hepatitis A virus (HAV) includes which of the following?

fecal-oral

A client with viral hepatitis A is being treated in an acute care facility. Because the client requires enteric precautions, the nurse should:

wash her hands after touching the client.

Which liver function study is used to show the size of the liver and hepatic blood flow and obstruction?

Radioisotope liver scan

A client with cirrhosis has portal hypertension, which is causing esophageal varices. What is the goal of the interventions that the nurse will provide?

Reduce fluid accumulation and venous pressure.

When performing a physical examination on a client with cirrhosis, a nurse notices that the client's abdomen is enlarged. Which of the following interventions should the nurse consider?

Measure abdominal girth according to a set routine.

A client is admitted to the hospital with acute hemorrhage from esophageal varices. What medication should the nurse anticipate administering that will reduce pressure in the portal venous system and control esophageal bleeding?

Octreotide

A nurse is caring for a client with cirrhosis. The nurse assesses the client at noon and discovers that the client is difficult to arouse and has an elevated serum ammonia level. The nurse should suspect which situation?

The client's hepatic function is decreasing.

A patient is scheduled for a diagnostic paracentesis, but when coagulation studies were reviewed, the nurse observed they were abnormal. How does the nurse anticipate the physician will proceed with the paracentesis?

The physician will use an ultrasound guided paracentesis

Which of the following is the most effective strategy to prevent hepatitis B infection?

Vaccine

Which medication is used to decrease portal pressure, halting bleeding of esophageal varices?

Vasopressin

A client with severe and chronic liver disease is showing manifestations related to inadequate vitamin intake and metabolism. He reports difficulty driving at night because he cannot see well. Which of the following vitamins is most likely deficient for this client?

Vitamin A

A client with carcinoma of the head of the pancreas is scheduled for surgery. Which of the following should a nurse administer to the client before surgery?

Vitamin K

A client is admitted for suspected GI disease. Assessment data reveal muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendency. The nurse suspects the client has:

cirrhosis/muscle wasting

A physician has ordered a liver biopsy for a client with cirrhosis whose condition has recently deteriorated. The nurse reviews the client's recent laboratory findings and recognizes that the client is at risk for complications due to:

low platelet count.

What is the recommended dietary treatment for a client with chronic cholecystitis?

low-fat diet