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A nurse on a solid organ transplant unit is planning the care of a patient who will soon be admitted upon immediate recovery following liver transplantation. What aspect of nursing care is the nurses priority?
- A. Implementation of infection-control measures
- B. Close monitoring of skin integrity and color
- C. Frequent assessment of the patients psychosocial status
- D. Administration of antiretroviral medications
Correct Answer: A
Rationale: Infection control is paramount following liver transplantation. This is a priority over skin integrity and psychosocial status, even though these are valid areas of assessment and intervention. Antiretrovirals are not indicated.
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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.
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.
A patient with liver cancer is being discharged home with a hepatic artery catheter in place. The nurse should be aware that this catheter will facilitate which of the following?
- A. Continuous monitoring for portal hypertension
- B. Administration of immunosuppressive drugs during the first weeks after transplantation
- C. Real-time monitoring of vascular changes in the hepatic system
- D. Delivery of a continuous chemotherapeutic dose
Correct Answer: D
Rationale: In most cases, the hepatic artery catheter has been inserted surgically and has a prefilled infusion pump that delivers a continuous chemotherapeutic dose until completed. The hepatic artery catheter does not monitor portal hypertension, deliver immunosuppressive drugs, or monitor vascular changes in the hepatic system.
A local public health nurse is informed that a cook in a local restaurant has been diagnosed with hepatitis A. What should the nurse advise individuals to obtain who ate at this restaurant and have never received the hepatitis A vaccine?
- A. The hepatitis A vaccine
- B. Albumin infusion
- C. The hepatitis A and B vaccines
- D. An immune globulin injection
Correct Answer: D
Rationale: For people who have not been previously vaccinated, hepatitis A can be prevented by the intramuscular administration of immune globulin during the incubation period, if given within 2 weeks of exposure. Administration of the hepatitis A vaccine will not protect the patient exposed to hepatitis A, as protection will take a few weeks to develop after the first dose of the vaccine. The hepatitis B vaccine provides protection again the hepatitis B virus, but plays no role in protection for the patient exposed to hepatitis A. Albumin confers no therapeutic benefit.
A triage nurse in the emergency department is assessing a patient who presented with complaints of general malaise. Assessment reveals the presence of jaundice and increased abdominal girth. What assessment question best addresses the possible etiology of this patients presentation?
- A. How many alcoholic drinks do you typically consume in a week?
- B. To the best of your knowledge, are your immunizations up to date?
- C. Have you ever worked in an occupation where you might have been exposed to toxins?
- D. Has anyone in your family ever experienced symptoms similar to yours?
Correct Answer: A
Rationale: Signs or symptoms of hepatic dysfunction indicate a need to assess for alcohol use. Immunization status, occupational risks, and family history are also relevant considerations, but alcohol use is a more common etiologic factor in liver disease.