Lewis Chapter 43: Liver, Pancreas, and Biliary Tract Problems

c. Alcohol abuse

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.

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

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.

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. "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.

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. 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.

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

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 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. Milk thistle may affect liver enzymes and thus alter drug metabolism.

There is good scientific evidence that there is no real benefit from using milk thistle to protect the liver cells from toxic damage in the treatment of cirrhosis. Milk thistle does affect liver enzymes and thus could alter drug metabolism. Therefore patients will need to be monitored for drug interactions. It is noted to be safe for up to 6 years, not 10 years, and it may lower, not elevate, blood glucose levels.

A patient with type 2 diabetes and cirrhosis asks the nurse if it would be okay to take silymarin (milk thistle) to help minimize liver damage. The nurse responds based on what knowledge?

a. Milk thistle may affect liver enzymes and thus alter drug metabolism.

b. Milk thistle is generally safe in recommended doses for up to 10 years.

c. There is unclear scientific evidence for the use of milk thistle in treating cirrhosis.

d. Milk thistle may elevate the serum glucose levels and is thus contraindicated in diabetes.

Vitamin A, D, E, and 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.

When caring for a patient with a biliary obstruction, the nurse will anticipate administering which vitamin supplements (select all that apply)?

Vitamin A

Vitamin D

Vitamin E

Vitamin K

Vitamin B

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.

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)

c. Hepatic structure ultrasound

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.

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

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 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.

c. activated partial thromboplastin time (aPTT) of 54 seconds

Normal aPPT: 25-35 seconds

Multiple obstructions in the cystic and common bile duct.

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 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. "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.

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."

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.

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. "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 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."

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.

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.

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 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.

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.

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 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.

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

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; this is used to treat hepatic encephalopathy, not ascites and peripheral edema.

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)."

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).

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 102 F (38.9 C)

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 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."

a. pruritus us a common problem with jaundice in this phase

Jaundice results when bilirubin diffuses into the tissues. Pruritus sometimes accompanies jaundice as a result of an accumulation of bile salts beneath the skin. The patient with hepatitis A is most likely to transmit the disease two weeks before the onset of symptoms. Gastrointestinal symptoms (clay colored stools, nausea, vomiting, anorexia) are equally severe in hepatitis A and hepatitis B. Glomerulonephritis may occur with acute hepatitis infection as result of immune complex activation, but are not common.

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.

b. use a condom during sexual intercourse.

Hepatitis B virus may be transmitted by mucosal exposure to infected blood, blood products, or other body fluids (e.g., semen, vaginal secretions, saliva). Condom use should be taught to patients to prevent transmission of hepatitis B. The patient recovering from acute hepatitis B should avoid alcohol for 3-6 months. Family members receiving an injection of immunoglobulin is appropriate for hepatitis A.

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: 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.

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. (Lewis 1042)

a, e

Biliary sludge associated with acute pancreatitis results in hypocalcemia, so the patient should be monitored for signs such as Chvostek's sign, Trousseau's sign, tetany, and cardiac arrhythmias. NPO status is common to allow for pancreatic rest, so a low carb diet would not be appropriate. Insulin may be used to treat diabetes developed from chronic pancreatitis, but not for acute pancreatitis. Steatorrhea is an expected finding of chronic pancreatitis, not acute pancreatitis. The patient with acute pancreatitis is at increased risk for developing respiratory infections due to respiratory complications such as ineffective breathing pattern and pleural effusions.

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.

d. Laparoscopic cholecystectomy is the treatment of choice for symptomatic cholelithiasis.

see Lewis pg 1007

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.

b. reporting any bile-colored drainage or pus from any incision.

Bandages may be removed from puncture sites after 24 hours. Bile colored drainage or pus from the incision is not normal and should be reported immediately. OTC antiemetics are appropriate for controlling nausea and vomiting. A T tube may be inserted during an incisional cholecystectomy, but not a laparoscopic procedure.

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.T

ANS: D

Hepatitis A is transmitted through the oral-fecal route, and antibody to HAV IgM appears during the acute phase of hepatitis A. The patient would not have antigen for hepatitis B or antibody for hepatitis D. Anti-HAV IgG would indicate past infection and lifelong immunity.

A 24-year-old female contracts hepatitis from contaminated food. During the acute (icteric) phase of the patient's illness, the nurse would expect serologic testing to reveal

a. antibody to hepatitis D (anti-HDV).

b. hepatitis B surface antigen (HBsAg).

c. anti-hepatitis A virus immunoglobulin G (anti-HAV IgG).

d. anti-hepatitis A virus immunoglobulin M (anti-HAV IgM).

ANS: B

The presence of surface antibody to HBV (anti-HBs) is a marker of a positive response to the vaccine. The other laboratory values indicate current infection with HBV.

2. Administration of hepatitis B vaccine to a healthy 18-year-old patient has been effective when a specimen of the patient's blood reveals

a. HBsAg.

b. anti-HBs.

c. anti-HBc IgG.

d. anti-HBc IgM.

ANS: A

Genotyping of HCV has an important role in managing treatment and is done before drug therapy is initiated. Because most patients with acute HCV infection convert to the chronic state, the nurse should not teach the patient that the HCV will resolve in a few months. Immune globulin or vaccine is not available for HCV. Ribavirin is used for chronic HCV infection rather than acute.

3. A 36-year-old male patient in the outpatient clinic is diagnosed with acute hepatitis C (HCV) infection. Which action by the nurse is appropriate?

a. Schedule the patient for HCV genotype testing.

b. Administer the HCV vaccine and immune globulin.

c. Teach the patient about ribavirin (Rebetol) treatment.

d. Explain that the infection will resolve over a few months.

ANS: B

Maintaining adequate nutritional intake is important for regeneration of hepatocytes. Interferon and antivirals may be used for chronic hepatitis B, but they are not prescribed for acute hepatitis B infection. Rest is recommended.

4. The nurse will plan to teach the patient diagnosed with acute hepatitis B about

a. side effects of nucleotide analogs.

b. measures for improving the appetite.

c. ways to increase activity and exercise.

d. administering α-interferon (Intron A).

ANS: A

Therapy with ribavirin and α-interferon may cause leukopenia. The other problems are not associated with this drug therapy.

5. The nurse administering α-interferon and ribavirin (Rebetol) to a patient with chronic hepatitis C will plan to monitor for

a. leukopenia.

b. hypokalemia.

c. polycythemia.

d. hypoglycemia.

ANS: B

Any patient with a history of IV drug use should be tested for hepatitis C. Blood transfusions given after 1992 (when an antibody test for hepatitis C became available) do not pose a risk for hepatitis C. Hepatitis C is not spread by the oral-fecal route and therefore is not caused by contaminated food or by traveling in underdeveloped countries.

6. Which information given by a 70-year-old patient during a health history indicates to the nurse that the patient should be screened for hepatitis C?

a. The patient had a blood transfusion in 2005.

b. The patient used IV drugs about 20 years ago.

c. The patient frequently eats in fast-food restaurants.

d. The patient traveled to a country with poor sanitation.

ANS: B

The patient's symptoms, lack of antibodies for hepatitis, and the abrupt onset of symptoms suggest toxic hepatitis, which can be caused by commonly used over-the-counter drugs such as acetaminophen (Tylenol). Travel to a foreign country and a history of IV drug use are risk factors for viral hepatitis. Corticosteroid use does not cause the symptoms listed.

7. 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?"

ANS: D

The low oncotic pressure caused by hypoalbuminemia is a major pathophysiologic factor in the development of edema. The other parameters should also be monitored, but they are not directly associated with the patient's current symptoms.

8. 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

ANS: B

The disease progression can be stopped or reversed by alcohol abstinence. The other interventions may be used when cirrhosis becomes more severe to decrease symptoms or complications, but the priority for this patient is to stop the progression of the disease.

9. 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

ANS: B

Spironolactone is a potassium-sparing diuretic and will help increase the patient's potassium level. The nurse does not need to talk with the doctor before giving the spironolactone, although the health care provider should be notified about the low potassium value. The furosemide will further decrease the patient's potassium level and should be held until the nurse talks with the health care provider.

10. A serum potassium level of 3.2 mEq/L (3.2 mmol/L) is reported for a patient with cirrhosis who has scheduled doses of spironolactone (Aldactone) and furosemide (Lasix). due. Which action should the nurse take?

a. Administer both drugs.

b. Administer the spironolactone.

c. Withhold the spironolactone and administer the furosemide.

d. Withhold both drugs until discussed with the health care provider.

ANS: B

Extending the arms allows the nurse to check for asterixis (tremors of the hand when the wrist is extended), a classic sign of hepatic encephalopathy. The other tests might also be done as part of the neurologic assessment but would not be diagnostic for hepatic encephalopathy.

11. 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.

ANS: A

The purpose of lactulose in the patient with cirrhosis is to lower ammonia levels and prevent encephalopathy. Although lactulose may be used to treat constipation, that is not the purpose for this patient. Lactulose will not decrease nausea and vomiting or lower bilirubin levels.

12. 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.

ANS: B

The most common complication of balloon tamponade is aspiration pneumonia. In addition, if the gastric balloon ruptures, the esophageal balloon may slip upward and occlude the airway. Coughing increases the pressure on the varices and increases the risk for bleeding. Balloon position is verified after insertion and does not require further verification. The esophageal balloon is deflated every 8 to 12 hours to avoid necrosis, but if the gastric balloon is deflated, the esophageal balloon may occlude the airway.

13. 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.

ANS: 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 prothrombin time, bilirubin, and potassium levels should also be monitored, but they will not be affected by the bleeding episode.

14. 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.

ANS: C

The pressure-relieving mattress will decrease the risk for skin breakdown for this patient. Adequate dietary protein intake is necessary in patients with ascites to improve oncotic pressure. Repositioning the patient every 4 hours will not be adequate to maintain skin integrity. Passive range of motion will not take the pressure off areas such as the sacrum that are vulnerable to breakdown.

15. 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.

ANS: D

TIPS is used to lower pressure in the portal venous system and decrease the risk of bleeding from esophageal varices. Indirect bilirubin level and serum albumin levels are not affected by shunting procedures. TIPS will increase the risk for hepatic encephalopathy.

16. 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

ANS: C

The patient should empty the bladder to decrease the risk of bladder perforation during the procedure. The patient would be positioned in Fowler's position and would not be able to lie flat without compromising breathing. Because no sedation is required for paracentesis, the patient does not need to be NPO.

17. 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.

ANS: C

The risk of infection is high in the first few months after liver transplant and fever is frequently the only sign of infection. The other patient data indicate the need for further assessment or nursing actions and might be communicated to the health care provider, but they do not indicate a need for urgent action.

18. Which finding is most important for the nurse to communicate to the health care provider about a patient who received a liver transplant 1 week ago?

a. Dry palpebral and oral mucosa

b. Crackles at bilateral lung bases

c. Temperature 100.8° F (38.2° C)

d. No bowel movement for 4 days

ANS: C

Amylase is elevated in acute pancreatitis. Although changes in the other values may occur, they would not be useful in evaluating whether the prescribed therapies have been effective.

19. 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

ANS: D

Muscle twitching and finger numbness indicate hypocalcemia, which may lead to tetany unless calcium gluconate is administered. Although the other findings should also be reported to the health care provider, they do not indicate complications that require rapid action.

20. 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

ANS: D

Alcohol use is one of the most common risk factors for pancreatitis in the United States. Cigarette smoking, diabetes, and high-protein diets are not risk factors.

21. 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.

ANS: C

Pancreatic enzymes are used to help with digestion of nutrients and should be taken with every meal.

22. 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.

ANS: B

After a laparoscopic cholecystectomy, the patient will have Band-Aids in place over the incisions. Patients are discharged the same (or next) day and have few restrictions on activities of daily living. Drainage from the incisions would be abnormal, and the patient should be instructed to call the health care provider if this occurs. A low-fat diet may be recommended for a few weeks after surgery but will not be a life-long requirement.

23. The nurse recognizes that teaching a 44-year-old woman following a laparoscopic cholecystectomy has been effective when the patient states which of the following?

a. "I can expect yellow-green drainage from the incision for a few days."

b. "I can remove the bandages on my incisions tomorrow and take a shower."

c. "I should plan to limit my activities and not return to work for 4 to 6 weeks."

d. "I will always need to maintain a low-fat diet since I no longer have a gallbladder."

ANS: B

Asterixis indicates that the patient has hepatic encephalopathy, and hepatic coma may occur. The spider angiomas and right upper quadrant abdominal pain are not unusual for the patient with cirrhosis and do not require a change in treatment. The ascites and weight gain indicate the need for treatment but not as urgently as the changes in neurologic status.

24. 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.

ANS: C

Because the purpose of β-blocker therapy for patients with esophageal varices is to decrease the risk for bleeding from esophageal varices, the best indicator of the effectiveness for propranolol is the lack of blood in the stools. Although propranolol is used to treat hypertension, angina, and tachycardia, the purpose for use in this patient is to decrease the risk for bleeding from esophageal varices.

25. 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.

ANS: 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. Although ranitidine does decrease the risk for peptic ulcers, reduce nausea, and help prevent aspiration pneumonia, these are not the primary purposes for H2-receptor blockade in this patient.

26. 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.

ANS: C

The patient with acute pancreatitis is at risk for hypocalcemia, and the assessment data indicate a positive Trousseau's sign. The health care provider should be notified after the nurse checks the patient's calcium level. There is no indication that the patient needs to have the BP rechecked or that there is any arm pain.

27. 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.

ANS: D

NG suction and NPO status will decrease the release of pancreatic enzymes into the pancreas and decrease pain. Although bowel sounds may be hypotonic with acute pancreatitis, the presence of bowel sounds does not indicate that treatment with NG suction and NPO status has been effective. Electrolyte levels may be abnormal with NG suction and must be replaced by appropriate IV infusion. Although Grey Turner sign will eventually resolve, it would not be appropriate to wait for this to occur to determine whether treatment was effective.

28. 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.

ANS: D

A palpable abdominal mass may indicate the presence of a pancreatic abscess, which will require rapid surgical drainage to prevent sepsis. Absent bowel sounds, abdominal tenderness, and left upper quadrant pain are common in acute pancreatitis and do not require rapid action to prevent further complications.

29. Which assessment finding is of most concern for a 46-year-old woman with acute pancreatitis?

a. Absent bowel sounds

b. Abdominal tenderness

c. Left upper quadrant pain

d. Palpable abdominal mass

ANS: D

Some medications can increase the risk for NAFLD, and they should be eliminated. NAFLD is not associated with hepatitis, weight loss is usually indicated, and variceal bleeding would not be a concern in a patient with asymptomatic NAFLD.

30. Which action will be included in the care for a patient who has recently been diagnosed with asymptomatic nonalcoholic fatty liver disease (NAFLD)?

a. Teach symptoms of variceal bleeding.

b. Draw blood for hepatitis serology testing.

c. Discuss the need to increase caloric intake.

d. Review the patient's current medication list.

ANS: B

Pegylated α-interferon is administered weekly. The other medications are appropriate for a patient with chronic hepatitis C infection.

31. A 34-year old patient with chronic hepatitis C infection has several medications prescribed. Which medication requires further discussion with the health care provider before administration?

a. Ribavirin (Rebetol, Copegus) 600 mg PO bid

b. Pegylated α-interferon (PEG-Intron, Pegasys) SQ daily

c. Diphenhydramine (Benadryl) 25 mg PO every 4 hours PRN itching

d. Dimenhydrinate (Dramamine) 50 mg PO every 6 hours PRN nausea

ANS: C

This patient's history and fever suggest possible spontaneous bacterial peritonitis, which would require rapid assessment and interventions such as antibiotic therapy. The clinical manifestations for the other patients are consistent with their diagnoses and do not indicate complications are occurring.

32. During change-of-shift report, the nurse learns about the following four patients. Which patient requires assessment first?

a. 40-year-old with chronic pancreatitis who has gnawing abdominal pain

b. 58-year-old who has compensated cirrhosis and is complaining of anorexia

c. 55-year-old with cirrhosis and ascites who has an oral temperature of 102° F (38.8° C)

d. 36-year-old recovering from a laparoscopic cholecystectomy who has severe shoulder pain

ANS: B

The highest priority outcome is to maintain nutrition because adequate nutrition is needed for hepatocyte regeneration. Finding a home for the patient and identifying the source of the infection would be appropriate activities, but they do not have as high a priority as ensuring adequate nutrition. Although the patient's activity level will be gradually increased, rest is indicated during the acute phase of hepatitis.

33. Which goal has the highest priority in the plan of care for a 26-year-old homeless patient admitted with viral hepatitis who has severe anorexia and fatigue?

a. Increase activity level.

b. Maintain adequate nutrition.

c. Establish a stable environment.

d. Identify sources of hepatitis exposure.

ANS: C

The nurse's first action should be to determine the patient's hemodynamic status by assessing vital signs. Drawing blood for coagulation studies and inserting an IV catheter are also appropriate. However, the vital signs may indicate the need for more urgent actions. Because aspiration is a concern for this patient, the nurse will need to assess the patient's vital signs and neurologic status before placing the patient in a supine position.

34. Which action should the nurse in the emergency department take first for a new patient who is vomiting blood?

a. Insert a large-gauge IV catheter.

b. Draw blood for coagulation studies.

c. Check blood pressure (BP), heart rate, and respirations.

d. Place the patient in the supine position.

ANS: A

Respiratory failure can occur as a complication of acute pancreatitis, and maintenance of adequate respiratory function is the priority goal. The other outcomes would also be appropriate for the patient.

35. The nurse is planning care for a 48-year-old woman with acute severe pancreatitis. The highest priority patient outcome is

a. maintaining normal respiratory function.

b. expressing satisfaction with pain control.

c. developing no ongoing pancreatic disease.

d. having adequate fluid and electrolyte balance.

ANS: C

Effective pain management will be necessary in order for the patient to improve nutrition, be receptive to teaching, or manage anxiety or depression.

36. The nurse is caring for a 36-year-old patient with pancreatic cancer. Which nursing action is the highest priority?

a. Offer psychologic support for depression.

b. Offer high-calorie, high-protein dietary choices.

c. Administer prescribed opioids to relieve pain as needed.

d. Teach about the need to avoid scratching any pruritic areas.

ANS: B

Tan or grey stools indicate biliary obstruction, which requires rapid intervention to resolve. The other data are not unusual for a patient with this diagnosis, although the nurse would also report the other assessment information to the health care provider.

37. Which assessment information will be most important for the nurse to report to the health care provider about a patient with acute cholecystitis?

a. The patient's urine is bright yellow.

b. The patient's stools are tan colored.

c. The patient has increased pain after eating.

d. The patient complains of chronic heartburn.

ANS: D

Postoperative nursing care after a cholecystectomy focuses on prevention of respiratory complications because the surgical incision is high in the abdomen and impairs coughing and deep breathing. The other nursing actions are also important to implement but are not as high a priority as ensuring adequate ventilation.

38. A 51-year-old woman had an incisional cholecystectomy 6 hours ago. The nurse will place the highest priority on assisting the patient to

a. choose low-fat foods from the menu.

b. perform leg exercises hourly while awake.

c. ambulate the evening of the operative day.

d. turn, cough, and deep breathe every 2 hours.

ANS: B

Providing oral hygiene is within the scope of UAP. Assessments and assisting patients to choose therapeutic diets are nursing actions that require higher-level nursing education and scope of practice and would be delegated to licensed practical/vocational nurses (LPNs/LVNs) or RNs.

39. For a patient with cirrhosis, which of the following nursing actions can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP)?

a. Assessing the patient for jaundice

b. Providing oral hygiene after a meal

c. Palpating the abdomen for distention

d. Assisting the patient to choose the diet

ANS: B

Patients with chronic hepatitis are at higher risk for development of liver cancer, and should be screened for liver cancer every 6 to 12 months. Patients with chronic hepatitis are advised to completely avoid alcohol. There is no hepatitis C vaccine. Because anti-HBs is present whenever there has been a past hepatitis B infection or vaccination, there is no need to regularly monitor for this antibody.

40. Which action will the nurse include in the plan of care for a patient who has been diagnosed with chronic hepatitis B?

a. Advise limiting alcohol intake to 1 drink daily.

b. Schedule for liver cancer screening every 6 months.

c. Initiate administration of the hepatitis C vaccine series.

d. Monitor anti-hepatitis B surface antigen (anti-HBs) levels annually.

ANS: C

Current CDC guidelines indicate that all patients who were born between 1945 and 1965 should be screened for hepatitis C because many individuals who are positive have not been diagnosed. Although routine hepatitis B immunization is recommended for infants, children, and adolescents, vaccination for hepatitis B is recommended only for adults at risk for blood-borne infections. Because the patient has already had hepatitis A, immunization and anti-HAV IgM levels will not be needed.

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

a. Start the hepatitis B immunization series.

b. Teach the patient about hepatitis A immune globulin.

c. Ask whether the patient has been screened for hepatitis C.

d. Test for anti-hepatitis-A virus immune globulin M (anti-HAV-IgM).

ANS: A

The patient's findings of asterixis and lethargy are consistent with grade 2 hepatic encephalopathy. Patients with acute liver failure can deteriorate rapidly from grade 1 or 2 to grade 3 or 4 hepatic encephalopathy and need early transfer to a transplant center. The other findings are typical of patients with hepatic failure and would be reported but would not indicate a need for an immediate change in the therapeutic plan.

42. A 23-year-old has been admitted with acute liver failure. Which assessment data are most important for the nurse to communicate to the health care provider?

a. Asterixis and lethargy

b. Jaundiced sclera and skin

c. Elevated total bilirubin level

d. Liver 3 cm below costal margin

ANS: B

Because ribavirin is teratogenic, the medication will need to be discontinued immediately. Anemia, weight loss, and nausea are common adverse effects of the prescribed regimen and may require actions such as patient teaching, but they would not require immediate cessation of the therapy.

43. A 36-year-old female patient is receiving treatment for chronic hepatitis C with pegylated interferon (PEG-Intron, Pegasys), ribavirin (Rebetol), and telaprevir (Incivek). Which finding is most important to communicate to the health care provider?

a. Weight loss of 2 lb (1 kg)

b. Positive urine pregnancy test

c. Hemoglobin level of 10.4 g/dL

d. Complaints of nausea and anorexia

ANS: D

The patient with chronic pancreatitis does not present an infection risk to the immunosuppressed patient who had a liver transplant. The other patients either are at risk for infection or currently have an infection, which will place the immunosuppressed patient at risk for infection.

44. A nurse is considering which patient to admit to the same room as a patient who had a liver transplant 3 weeks ago and is now hospitalized with acute rejection. Which patient would be the best choice?

a. Patient who is receiving chemotherapy for liver cancer

b. Patient who is receiving treatment for acute hepatitis C

c. Patient who has a wound infection after cholecystectomy

d. Patient who requires pain management for chronic pancreatitis

ANS: C

The area around the umbilicus should be indicated. Cullen's sign consists of ecchymosis around the umbilicus. Cullen's sign occurs because of seepage of bloody exudates from the inflamed pancreas and indicates severe acute pancreatitis.

45. In reviewing the medical record shown in the accompanying figure for a patient admitted with acute pancreatitis, the nurse sees that the patient has a positive Cullen's sign. Indicate the area where the nurse will assess for this change.

a. 1

b. 2

c. 3

d. 4

ANS: A, B, D

The recommendations for hepatitis B exposure include both vaccination and immune globulin administration. In addition, baseline testing for hepatitis B antibodies will be needed. Interferon and oral antivirals are not used for hepatitis B prophylaxis.

46. After an unimmunized individual is exposed to hepatitis B through a needle-stick injury, which actions will the nurse plan to take (select all that apply)?

a. Administer hepatitis B vaccine.

b. Test for antibodies to hepatitis B.

c. Teach about α-interferon therapy.

d. Give hepatitis B immune globulin.

e. Teach about choices for oral antiviral therapy.