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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 nurses most recent assessment reveals the presence of dark green fluid in the collection container. What is the nurses best response to this assessment finding?
- A. Document the presence of normal bile output.
- B. Irrigate the drainage system with normal saline as ordered.
- C. Aspirate a sample of the drainage for culture.
- D. Promptly report this assessment finding to the primary care provider.
Correct Answer: A
Rationale: Bile is usually a dark green or brownish-yellow color, so this would constitute an expected assessment finding, with no other action necessary.
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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 nurses most recent assessment reveals the presence of dark green fluid in the collection container. What is the nurses best response to this assessment finding?
- A. Document the presence of normal bile output.
- B. Irrigate the drainage system with normal saline as ordered.
- C. Aspirate a sample of the drainage for culture.
- D. Promptly report this assessment finding to the primary care provider.
Correct Answer: A
Rationale: Bile is usually a dark green or brownish-yellow color, so this would constitute an expected assessment finding, with no other action necessary.
A nurse is participating in the emergency care of a patient who has just developed variceal bleeding. What intervention should the nurse anticipate?
- A. Infusion of intravenous heparin
- B. IV administration of albumin
- C. STAT administration of vitamin K by the intramuscular route
- D. IV administration of octreotide (Sandostatin)
Correct Answer: D
Rationale: Octreotide (Sandostatin) a synthetic analog of the hormone somatostatin is effective in decreasing bleeding from esophageal varices, and lacks the vasoconstrictive effects of vasopressin. Because of this safety and efficacy profile, octreotide is considered the preferred treatment regimen for immediate control of variceal bleeding. Vitamin K and albumin are not administered and heparin would exacerbate, not alleviate, bleeding.
A group of nurses have attended an inservice on the prevention of occupationally acquired diseases that affect healthcare providers. What action has the greatest potential to reduce a nurses risk of acquiring hepatitis C in the workplace?
- A. Disposing of sharps appropriately and not recapping needles
- B. Performing meticulous hand hygiene at the appropriate moments in care
- C. Adhering to the recommended schedule of immunizations
- D. Wearing an N95 mask when providing care for patients on airborne precautions
Correct Answer: A
Rationale: HCV is bloodborne. Consequently, prevention of needlestick injuries is paramount. Hand hygiene, immunizations and appropriate use of masks are important aspects of overall infection control, but these actions do not directly mitigate the risk of HCV.
A nurse is caring for a patient with severe hemolytic jaundice. Laboratory tests show free bilirubin to be 24 mg/dL. For what complication is this patient at risk?
- A. Chronic jaundice
- B. Pigment stones in portal circulation
- C. Central nervous system damage
- D. Hepatomegaly
Correct Answer: C
Rationale: Prolonged jaundice, even if mild, predisposes to the formation of pigment stones in the gallbladder, and extremely severe jaundice (levels of free bilirubin exceeding 20 to 25 mg/dL) poses a risk for CNS damage. There are not specific risks of hepatomegaly or chronic jaundice resulting from high bilirubin.
A participant in a health fair has asked the nurse about the role of drugs in liver disease. What health promotion teaching has the most potential to prevent drug-induced hepatitis?
- A. Finish all prescribed courses of antibiotics, regardless of symptom resolution.
- B. Adhere to dosing recommendations of OTC analgesics.
- C. Ensure that expired medications are disposed of safely.
- D. Ensure that pharmacists regularly review drug regimens for potential interactions.
Correct Answer: B
Rationale: Although any medication can affect liver function, use of acetaminophen (found in many over-the-counter medications used to treat fever and pain) has been identified as the leading cause of acute liver failure. Finishing prescribed antibiotics and avoiding expired medications are unrelated to this disease. Drug interactions are rarely the cause of drug-induced hepatitis.