Nokea
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.
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A nurse is caring for a patient with hepatic encephalopathy. While making the initial shift assessment, the nurse notes that the patient has a flapping tremor of the hands. The nurse should document the presence of what sign of liver disease?
- A. Asterixis
- B. Constructional apraxia
- C. Fetor hepaticus
- D. Palmar erythema
Correct Answer: A
Rationale: The nurse will document that a patient exhibiting a flapping tremor of the hands is demonstrating asterixis. While constructional apraxia is a motor disturbance, it is the inability to reproduce a simple figure. Fetor hepaticus is a sweet, slightly fecal odor to the breath and not associated with a motor disturbance. Skin changes associated with liver dysfunction may include palmar erythema, which is a reddening of the palms, but is not a flapping tremor.
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.
A patient with esophageal varices is being cared for in the ICU. The varices have begun to bleed and the patient is at risk for hypovolemia. The patient has Ringers lactate at 150 cc/hr infusing. What else might the nurse expect to have ordered to maintain volume for this patient?
- A. Arterial line
- B. Diuretics
- C. Foley catheter
- D. Volume expanders
Correct Answer: D
Rationale: Because patients with bleeding esophageal varices have intravascular volume depletion and are subject to electrolyte imbalance, IV fluids with electrolytes and volume expanders are provided to restore fluid volume and replace electrolytes. Diuretics would reduce vascular volume. An arterial line and Foley catheter are likely to be ordered, but neither actively maintains the patients volume.
A patient is being discharged after a liver transplant and the nurse is performing discharge education. When planning this patients continuing care, the nurse should prioritize which of the following risk diagnoses?
- A. Risk for Infection Related to Immunosuppressant Use
- B. Risk for Injury Related to Decreased Hemostasis
- C. Risk for Unstable Blood Glucose Related to Impaired Gluconeogenesis
- D. Risk for Contamination Related to Accumulation of Ammonia
Correct Answer: A
Rationale: Infection is the leading cause of death after liver transplantation. Pulmonary and fungal infections are common; susceptibility to infection is increased by the immunosuppressive therapy that is needed to prevent rejection. This risk exceeds the threats of injury and unstable blood glucose. The diagnosis of Risk for Contamination relates to environmental toxin exposure.
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.