Test 2- Liver

64. The nurse is preparing a client for a paracentesis. The nurse should: 1. Have the client void immediately before the procedure. 2. Place the client in a side-lying position. 3. Initiate an I.V. line to administer sedatives. 4. Place the client on nothing-by-mouth (NPO) status 6 hours before the procedure.

1. Immediately before a paracentesis, the client should empty the bladder to prevent perforation. The client will be placed in a high Fowler's position or seated on the side of the bed for the procedure. I.V. sedatives are not usually administered. The client does not need to be NPO.

68. The nurse's assignment consists of the following four clients. From highest to lowest priority, in which order should the nurse assess the clients after receiving morning report? 1. The client with cirrhosis who became confused and disoriented during the night. 2. The client with acute pancreatitis who is requesting pain medication. 3. The client who is 1 day postoperative following a cholecystectomy and has a T-tube inserted. 4. The client with hepatitis B who has questions about his discharge instructions.

1. The client with cirrhosis who became confused and disoriented during the night. 2. The client with acute pancreatitis who is requesting pain medication. 3. The client who is 1 day postoperative following a cholecystectomy and has a T-tube inserted. 4. The client with hepatitis B who has questions about his discharge instructions. The nurse should first assess the client with cirrhosis to ensure the client's safety and to assess the client for the onset of hepatic encephalopathy. The nurse should then assess the client with acute pancreatitis who is requesting pain medication and administer the needed medication. The nurse should next assess the client who underwent a cholecystectomy and is 1 day postoperative to make sure that the T-tube is draining and that the client is performing postoperative breathing exercises. This client's safety is not at risk and the client is not indicating that he is in pain, so his care is a lower priority. The nurse can speak last with the client with hepatitis B who has questions about his dis¬charge instructions because this client's issues are not urgent.

63. The nurse is providing discharge instructions for a client with cirrhosis. Which of the following statements best indicates that the client has understood the teaching? 1. "I should eat a high-protein, high-carbohydrate diet to provide energy." 2. "It is safer for me to take acetaminophen (Tylenol) for pain instead of aspirin." 3. "I should avoid constipation to decrease chances of bleeding." 4. "If I get enough rest and follow my diet, it is possible for my cirrhosis to be cured."

3. Clients with cirrhosis should be instructed to avoid constipation and straining at stool to prevent hemorrhage. The client with cirrhosis has bleeding tendencies because of the liver's inability to produce clotting factors. A low-protein and high-carbohydrate diet is recommended. Clients with cirrhosis should not take acetaminophen (Tylenol), which is potentially hepatotoxic. Aspirin also should be avoided if esophageal varices are present. Cirrhosis is a chronic disease.

66. A client with ascites and peripheral edema is at risk for impaired skin integrity. To prevent skin breakdown, the nurse should: 1. Institute range-of-motion (ROM) exercise every 4 hours. 2. Massage the abdomen once a shift. 3. Use an alternating air pressure mattress. 4. Elevate the lower extremities.

3. Edematous tissue is easily traumatized and must receive meticulous care. An alternating air pressure mattress will help decrease pressure on the edematous tissue. ROM exercises are important to maintain joint function, but they do not necessarily prevent skin breakdown. When abdominal skin is stretched taut due to ascites, it must be cleaned very carefully. The abdomen should not be massaged. Elevation of the lower extremities promotes venous return and decreases swelling.

65. Which of the following interventions should the nurse anticipate incorporating into the client's plan of care when hepatic encephalopathy initially develops? 1. Inserting a nasogastric (NG) tube. 2. Restricting fluids to 1,000 mL/day. 3. Administering I.V. salt-poor albumin. 4. Implementing a low-protein diet.

4. When hepatic encephalopathy develops, measures are taken to reduce ammonia formation. Protein is restricted in the diet. An NG tube is not inserted initially but may be necessary as the disease progresses. Fluid restriction and salt-poor albumin are incorporated into the treatment of ascites, but not hepatic encephalopathy.

ascites causes

Ascites results from high pressure in the blood vessels of the liver (portal hypertension) and low levels of a protein called albumin. Diseases that can cause severe liver damage can lead to ascites. These include long-term hepatitis C or B infection and alcohol abuse over many years. People with certain cancers in the abdomen may develop ascites. These include cancer of the appendix, colon, ovaries, uterus, pancreas, and liver. Other conditions that can cause this problem include: Clots in the veins of the liver (portal vein thrombosis) Congestive heart failure Pancreatitis Thickening and scarring of the sac-like covering of the heart Kidney dialysis may also be linked to ascites.

Thyroidectomy concerns

• Airway-swelling may occlude airways, suction set up and tubes to open up airway, trach at bedside, Respiratory distress-stridor, ability to speak however in this case your do not want them to, O2, calcium gluconate at bedside, ca signs, bleeding-pooling in back of neck, HOB up

67. The nurse is planning a staff development program on how to care for clients with hepatitis A. Which of the following precautions should the nurse indicate as essential when caring for clients with hepatitis A? 1. Gowning when entering a client's room. 2. Wearing a mask when providing care. 3. Assigning the client to a private room. 4. Wearing gloves when giving direct care.

4. Contact precautions are recommended for clients with hepatitis A. This includes wearing gloves for direct care. These recommendations are made by the Centers for Disease Control and Prevention. A gown is not required unless substantial contact with the client is anticipated. It is not necessary to wear a mask. The client does not need a private room unless incontinent of stool.

ascites

Ascites is the build-up of fluid in the space between the lining of the abdomen and abdominal organs.

A client is admitted with acute necrotizing pancreatitis. Lab results have been obtained and a peripheral IV has been inserted. Which of the following orders from a health care provider should the nurse question?

Clients with acute necrotizing pancreatitis should remain NPO with early enteral feeding via the jejunum to maintain bowel integrity and immune function. TPN is considered if enteral feedings are contraindicated. Access is also needed for TPN, preferably via a central line.

A client has had a nasogastric tube connected to low intermittent suction. The client is at risk for:

Muscle cramping is a sign of hypokalemia.

portal hypertension

Portal hypertension is an increase in the blood pressure within a system of veins called the portal venous system. Veins coming from the stomach, intestine, spleen, and pancreas merge into the portal vein, which then branches into smaller vessels and travels through the liver. If the vessels in the liver are blocked due to liver damage, blood cannot flow properly through the liver. As a result, high pressure in the portal system develops. This increased pressure in the portal vein may lead to the development of large, swollen veins (varices) within the esophagus, stomach, rectum, or umbilical area (belly button). Varices can rupture and bleed, resulting in potentially life-threatening complications.

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. The client's morning ammonia level is 110 mcg/dl. The nurse should suspect which situation?

The decreased level of consciousness caused by an increased serum ammonia level indicates hepatic disfunction.

59. The nurse monitors a client with cirrhosis for the development of hepatic encephalopathy. Which of the following would be an indication that hepatic encephalopathy is developing? 1. Decreased mental status. 2. Elevated blood pressure. 3. Decreased urine output. 4. Labored respirations.

1. The client should be monitored closely for changes in mental status. Ammonia has a toxic effect on central nervous system tissue and produces an altered level of consciousness, marked by drowsiness and irritability. If this process is unchecked, the client may lapse into coma. Increasing ammonia levels are not detected by changes in blood pressure, urine output, or respirations.

69. The nurse should institute which of the following measures to prevent transmission of the hepatitis C virus to health care personnel? 1. Administering hepatitis C vaccine to all health care personnel. 2. Decreasing contact with blood and blood-contaminated fluids. 3. Wearing gloves when emptying the bedpan. 4. Wearing a gown and mask when providing direct care.

2. Hepatitis C is usually transmitted through blood exposure or needlesticks. A hepatitis C vaccine is currently under development, but it is not available for use. The first line of defense against hepatitis B is the hepatitis B vaccine. Hepatitis C is not transmitted through feces or urine. Wearing a gown and mask will not prevent transmission of the hepatitis C virus if the caregiver comes in contact with infected blood or needles.

ascites s/s

Symptoms may develop slowly or suddenly depending on the cause of ascites. You may have no symptoms if there is only a small amount of fluid in the belly. As more fluid collects, you may have abdominal pain and bloating. Large amounts of fluid can cause shortness of breath. Many other symptoms of liver failure may also be present.

ascites interventions

Your doctor will do a physical exam to determine the amount of swelling in your belly. You may also have the following tests to assess your liver and kidneys: 24-hour urine collection Electrolyte levels Kidney function tests Liver function tests Tests to measure the risk of bleeding and protein levels in the blood Urinalysis Abdominal ultrasound Your doctor may also use a thin needle to withdraw ascites fluid from your belly. The fluid is tested to look for the cause of ascites.

Transjugular intrahepatic portosystemic shunt (TIPS):

procedure involves placing a stent (a tubular device) in the middle of the liver. The stent connects the hepatic vein with the portal vein, which reroutes blood flow in the liver and helps relieve pressure in abnormal veins.

portal hypertension tx

tx is based on managing liver failure Medications. Nonselective beta-blockers (nadolol or propranolol) may be prescribed alone or in combination with endoscopic therapy to reduce the pressure in varices and further reduce the risk of bleeding. Nonselective beta blockers are also prescribed to prevent a first variceal hemorrhage in a patient with varices that are felt to be at risk for bleeding. Esophageal variceal banding has also been used for that purpose, especially in patients who can't take beta blockers. The drug lactulose can help treat confusion and other mental changes associated with encephalopathy.

Distal splenorenal shunt (DSRS):

This procedure connects the vein from your spleen to the vein from the left kidney in order to reduce pressure in the varices and control bleeding.

portal hypertension causes

The most common cause of portal hypertension is cirrhosis of the liver. Cirrhosis is scarring which accompanies the healing of liver injury caused by hepatitis, alcohol, or other less common causes of liver damage. In cirrhosis, the scar tissue blocks the flow of blood through the liver.

ascites treatement

Treatments for fluid build-up may include lifestyle changes: Avoiding alcohol Lowering salt in your diet (no more than 1,500 mg/day of sodium) Limiting fluid intake You may also get medicines from your doctor, including: "Water pills" (diuretics) to get rid of extra fluid Antibiotics for infections Other things you can do to help take care of your liver disease are: Get vaccinated for diseases such as influenza, hepatitis A and hepatitis B, and pneumococcal pneumonia Talk to your doctor about all medicines you take, including herbs and supplements and over-the-counter medicines Procedures that you may have are: Inserting a needle into the belly to remove large volumes of fluid (called a paracentesis) Placing a special tube or shunt inside your liver (TIPS) to repair blood flow to the liver People with end-stage liver disease may need a liver transplant.

portal hypertension s/s

The onset of portal hypertension may not always be associated with specific symptoms that identify what is happening in the liver. But if you have liver disease that leads to cirrhosis, the chance of developing portal hypertension is high. The main symptoms and complications of portal hypertension include: Gastrointestinal bleeding marked by black, tarry stools or blood in the stools, or vomiting of blood due to the spontaneous rupture and hemorrhage from varices Ascites (an accumulation of fluid in the abdomen) Encephalopathy or confusion and forgetfulness caused by poor liver function Reduced levels of platelets, blood cells that help form blood clots, or white blood cells, the cells that fight infection

When planning care for a client with hepatitis A, the nurse should review labororatory reports for which laboratory value?

The prothrombin time may be prolonged because of decreased absorption of vitamin K and decreased production of prothrombin by the liver. The client should be assessed carefully for bleeding tendencies.