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A nurse cares for a client who has cirrhosis of the liver. Which action should the nurse take to decrease the presence of ascites?
- A. Monitor intake and output.
- B. Monitor vital signs and diet.
- C. Increase oral fluid intake.
- D. Weigh the client daily.
Correct Answer: B
Rationale: A low-sodium diet is one means of controlling abdominal fluid collection. Monitoring intake and output does not control fluid accumulation, nor does weighing the client. These interventions merely assess or monitor the situation. Increasing fluid intake would not be helpful.
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A nurse assesses a male client who has symptoms of cirrhosis. Which questions should the nurse ask to identify potential factors contributing to this disorder? (Select all that apply.)
- A. How frequently do you drink alcohol?
- B. Have you ever had sex with a man?
- C. Do you have a family history of cancer?
- D. Have you ever worked as a plumber?
- E. Were you previously incarcerated?
Correct Answer: A,B,E
Rationale: Alcohol consumption is a major cause of cirrhosis. Sexual practices, particularly unprotected sex with men, increase the risk of hepatitis B or C, which can lead to cirrhosis. Incarceration is a risk factor due to potential exposure to hepatitis C through shared needles or unsanitary conditions. Family history of cancer and working as a plumber are not directly associated with cirrhosis.
An infection control nurse develops a plan to decrease the number of health care professionals who contract viral hepatitis at work. Which ideas should the nurse include in this plan? (Select all that apply.)
- A. Policies related to consistent use of Standard Precautions
- B. Hepatitis vaccination mandate for workers in high-risk areas
- C. Implementation of a needleless system for intravenous therapy
- D. Hepatitis B immunity in clients at risk for hepatitis B
- E. Postexposure prophylaxis provided in a timely manner
Correct Answer: A,C,D,E
Rationale: Nurses should always use Standard Precautions for client care, and policies should reflect this. Needleless systems and reduction of sharps can help prevent hepatitis. Postexposure prophylaxis should be provided in a timely manner. Hepatitis B immunity in clients does not protect healthcare workers, but ensuring worker immunity through vaccination is critical.
A nurse obtains a clients health history at a community health clinic. Which statement alerts the nurse to a possible health threat to the client?
- A. I drink two glasses of red wine each week.
- B. I take a lot of Tylenol for my arthritis pain.
- C. I have a cousin who died of liver cancer.
- D. I got a hepatitis vaccine before traveling.
Correct Answer: B
Rationale: Acetaminophen (Tylenol) can cause liver damage if taken in large amounts. Clients should be taught not to exceed 4000 mg/day of acetaminophen. The nurse should teach the client about this limitation and should explain other drug options with the client to manage his or her arthritis pain. Two glasses of wine each week, a cousin with liver cancer, and the hepatitis vaccine do not place the client at risk for a liver disorder, and therefore do not require any health teaching.
A nurse teaches a client with hepatitis C who is prescribed ribavirin (Copegus). Which statement should the nurse include in this client's discharge education?
- A. Use a pill organizer to ensure you take this medication as prescribed.
- B. Transient muscle aching is a common side effect of this medication.
- C. Follow up with your provider in 1 week to test your blood for toxicity.
- D. Take your radial pulse for 1 minute prior to taking this medication.
Correct Answer: A
Rationale: Treatment of hepatitis C with ribavirin takes up to 48 weeks, making compliance a serious issue. The nurse should work with the client on a strategy to remain compliant for this length of time. Muscle aching is not a common side effect. The client will be on this medication for many weeks and does not need a blood toxicity examination. There is no need for the client to assess his or her radial pulse prior to taking the medication.
A telehealth nurse speaks with a client who is recovering from a liver transplant 2 weeks ago. The client states, 'I am experiencing right flank pain and have a temperature of 101 F.' How should the nurse respond?
- A. Report the client's symptoms to the responsible health care provider.
- B. You should go to the hospital immediately to have your new liver checked out.
- C. You should take an additional dose of cyclosporine today.
- D. Take acetaminophen (Tylenol) every 4 hours until you feel better.
Correct Answer: B
Rationale: Fever, right quadrant or flank pain, and jaundice are signs of liver transplant rejection; the client should be admitted to the hospital as soon as possible for intervention. Anti-rejection drugs do make a client more susceptible to infection, but this client has signs of rejection, not infection. The nurse should not advise the client to take an additional dose of cyclosporine or acetaminophen as these medications will not treat the acute rejection.