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A nurse is performing an admission assessment of a patient with a diagnosis of cirrhosis. What technique should the nurse use to palpate the patients liver?
- A. Place hand under the right lower abdominal quadrant and press down lightly with the other hand.
- B. Place the left hand over the abdomen and behind the left side at the 11th rib.
- C. Place hand under right lower rib cage and press down lightly with the other hand.
- D. Hold hand 90 degrees to right side of the abdomen and push down firmly.
Correct Answer: C
Rationale: To palpate the liver, the examiner places one hand under the right lower rib cage and presses downward with light pressure with the other hand. The liver is not on the left side or in the right lower abdominal quadrant.
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A patient with portal hypertension has been admitted to the medical floor. The nurse should prioritize which of the following assessments related to the manifestations of this health problem?
- A. Assessment of blood pressure and assessment for headaches and visual changes
- B. Assessments for signs and symptoms of venous thromboembolism
- C. Daily weights and abdominal girth measurement
- D. Blood glucose monitoring q4h
Correct Answer: C
Rationale: Obstruction to blood flow through the damaged liver results in increased blood pressure (portal hypertension) throughout the portal venous system. This can result in varices and ascites in the abdominal cavity. Assessments related to ascites are daily weights and abdominal girths. Portal hypertension is not synonymous with cardiovascular hypertension and does not create a risk for unstable blood glucose or VTE.
A nurse educator is teaching a group of recent nursing graduates about their occupational risks for contracting hepatitis B. What preventative measures should the educator promote? Select all that apply.
- A. Immunization
- B. Use of standard precautions
- C. Consumption of a vitamin-rich diet
- D. Annual vitamin K injections
- E. Annual vitamin B12 injections
Correct Answer: A,B
Rationale: People who are at high risk, including nurses and other health care personnel exposed to blood or blood products, should receive active immunization. The consistent use of standard precautions is also highly beneficial. Vitamin supplementation is unrelated to an individuals risk of HBV.
A nurse is caring for a patient with a blocked bile duct from a tumor. What manifestation of obstructive jaundice should the nurse anticipate?
- A. Watery, blood-streaked diarrhea
- B. Orange and foamy urine
- C. Increased abdominal girth
- D. Decreased cognition
Correct Answer: B
Rationale: If the bile duct is obstructed, the bile will be reabsorbed into the blood and carried throughout the entire body. It is excreted in the urine, which becomes deep orange and foamy. Bloody diarrhea, ascites, and cognitive changes are not associated with obstructive jaundice.
A patient has developed hepatic encephalopathy secondary to cirrhosis and is receiving care on the medical unit. The patients current medication regimen includes lactulose (Cephulac) four times daily. What desired outcome should the nurse relate to this pharmacologic intervention?
- A. Two to 3 soft bowel movements daily
- B. Significant increase in appetite and food intake
- C. Absence of nausea and vomiting
- D. Absence of blood or mucus in stool
Correct Answer: A
Rationale: Lactulose (Cephulac) is administered to reduce serum ammonia levels. Two or three soft stools per day are desirable; this indicates that lactulose is performing as intended. Lactulose does not address the patients appetite, symptoms of nausea and vomiting, or the development of blood and mucus in the stool.
A patient with liver cancer is being discharged home with a biliary drainage system in place. The nurse should teach the patients family how to safely perform which of the following actions?
- A. Aspirating bile from the catheter using a syringe
- B. Removing the catheter when output is 15 mL in 24 hours
- C. Instilling antibiotics into the catheter
- D. Assessing the patency of the drainage catheter
Correct Answer: D
Rationale: Families should be taught to provide basic catheter care, including assessment of patency. Antibiotics are not instilled into the catheter and aspiration using a syringe is contraindicated. The family would not independently remove the catheter; this would be done by a member of the care team when deemed necessary.