Nokea
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.
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A patient with liver disease has developed jaundice; the nurse is collaborating with the patient to develop a nutritional plan. The nurse should prioritize which of the following in the patients plan?
- A. Increased potassium intake
- B. Fluid restriction to 2 L per day
- C. Reduction in sodium intake
- D. High-protein, low-fat diet
Correct Answer: C
Rationale: Patients with ascites require a sharp reduction in sodium intake. Potassium intake should not be correspondingly increased. There is no need for fluid restriction or increased protein intake.
A previously healthy adults sudden and precipitous decline in health has been attributed to fulminant hepatic failure, and the patient has been admitted to the intensive care unit. The nurse should be aware that the treatment of choice for this patient is what?
- A. IV administration of immune globulins
- B. Transfusion of packed red blood cells and fresh-frozen plasma (FFP)
- C. Liver transplantation
- D. Lobectomy
Correct Answer: C
Rationale: Liver transplantation carries the highest potential for the resolution of fulminant hepatic failure. This is preferred over other interventions, such as pharmacologic treatments, transfusions, and surgery.
A patient with a diagnosis of cirrhosis has developed variceal bleeding and will imminently undergo variceal banding. What psychosocial nursing diagnosis should the nurse most likely prioritize during this phase of the patients treatment?
- A. Decisional Conflict
- B. Deficient Knowledge
- C. Death Anxiety
- D. Disturbed Thought Processes
Correct Answer: C
Rationale: The sudden hemorrhage that accompanies variceal bleeding is intensely anxiety-provoking. The nurse must address the patients likely fear of death, which is a realistic possibility. For most patients, anxiety is likely to be a more acute concern than lack of knowledge or decisional conflict. The patient may or may not experience disturbances in thought processes.
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 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.