Nokea
A client had an open cholecystectomy with a T-tube insertion, and the nurse is measuring the bile drainage every 8 hours. When should the nurse notify the health care provider?
- A. If more than 17 oz (500 mL) of bile drainage is present in 24 hours
- B. If the bile drainage tubing is slack
- C. If there is 34 oz (100 mL) in the drainage pouch after 8 hours
- D. If there is 34 oz (10 mL) per hour of drainage in 24 hours
Correct Answer: A
Rationale: The nurse measures bile drainage every 8 hours or according to agency policy. If more than 17 oz (500 mL) of bile drains within 24 hours or if drainage is significantly reduced, the nurse notifies the health care provider. The nurse should ensure that there is no tension on the bile drainage tubing; slack drainage tubing is an expected finding. About 34 oz (100 mL) in the drainage pouch after 8 hours, and 34 oz (10 mL) per hour of drainage in 24 hours are less than 17 oz (100 mL) in 24 hours and are therefore not findings that require health care provider notification.
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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?
- A. Paracentesis
- B. Liver transplantation
- C. High-dose corticosteroids
- D. Azathioprine
Correct Answer: C
Rationale: Drug-induced hepatitis occurs when a drug reaction damages the liver. This form of hepatitis can be severe and fatal. High-dose corticosteroids usually administered first to treat the reaction. Liver transplantation may be necessary. Paracentesis should be used to withdraw fluid for the treatment of ascites. Azathioprine (Imuran) may be used for autoimmune hepatitis.
The nurse is assessing a client with suspected cholelithiasis. What can the nurse expect to observe?
- A. Stools that contain blood and mucus
- B. Bowel sounds that are absent
- C. Stools that appear small and dry
- D. Urine that appears dark brown
Correct Answer: D
Rationale: When a client is being assessed for cholelithiasis, the urine appears dark brown, whereas the stools may be light-colored. Bowel sounds are present because cholelithiasis does not cause lack of bowel motility. The stool does not contain blood or mucus.
The nurse is caring for a client with cirrhosis of the liver. What symptom(s) would indicate to the nurse that the client is experiencing central nervous system effects of the disease? Select all that apply.
- A. Asterixis
- B. Joint stiffness
- C. Positive Babinski reflex
- D. Cough
- E. Fetor hepaticus
Correct Answer: A,C,E
Rationale: Hepatic encephalopathy is a CNS manifestation of liver failure that is a complication of cirrhosis. Indications of CNS effects include disorientation, confusion, personality changes, memory loss, a flapping tremor called asterixis, a positive Babinski reflex, sulfurous breath odor (fetor hepaticus), and lethargy to deep coma. Cough and joint stiffness are not indicators of CNS effects of cirrhosis.
The nurse is caring for a client with chronic pancreatitis. Which symptom would indicate the client has developed secondary diabetes?
- A. Increased appetite and thirst
- B. Vomiting and diarrhea
- C. Low blood pressure and pulse
- D. Decreased urination and constipation
Correct Answer: A
Rationale: When secondary diabetes develops in a client with chronic pancreatitis, the client experiences increased appetite, thirst, and urination. Vomiting, diarrhea, low blood pressure and pulse, and constipation do not indicate the development of secondary diabetes.
A client is about to undergo a liver biopsy. Which should the nurse administer to the client before the procedure?
- A. Potassium
- B. Vitamin K
- C. Vitamin B
- D. Oral bile acids
Correct Answer: B
Rationale: Clients about to undergo a liver biopsy may require vitamin K before the procedure to reduce the risk of bleeding. Potassium would be given only if the client's serum potassium levels were low. Oral bile acids are not prescribed for a client about to undergo a liver biopsy, they are given to dissolve gallstones. Vitamin B has no implications in the procedure.