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After receiving change-of-shift report, which of the following patients should the nurse assess first?
- A. 50-year-old with persistent pancreatitis who has gnawing abdominal pain
- B. 48-year-old who has compensated cirrhosis and is complaining of anorexia
- C. 45-year-old with cirrhosis and severe ascites who has an oral temperature of 38.8°C (101.8°F)
- D. 36-year-old who is recovering from a laparoscopic cholecystectomy and has severe shoulder pain
Correct Answer: C
Rationale: This patient's history and fever suggest spontaneous bacterial peritonitis, which would require rapid assessment and interventions such as antibiotic therapy. The clinical manifestations for the other patients are consistent with their diagnoses and do not indicate complications are occurring.
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The nurse is caring for a patient with cirrhosis who has 4+ pitting edema of the feet and legs. Which of the following assessments is priority for the nurse to monitor?
- A. Hemoglobin
- B. Temperature
- C. Activity level
- D. Albumin
Correct Answer: D
Rationale: The low oncotic pressure caused by hypoalbuminemia is a major pathophysiological factor in the development of edema. The other parameters also should be monitored, but they are not directly associated with the patient's current symptoms.
A patient contracts hepatitis from contaminated food. During the acute (icteric) phase of the patient's illness, which of the following serological findings should the nurse expect?
- A. Antibody to hepatitis D virus (anti-HDV)
- B. Hepatitis B surface antigen (HBsAg)
- C. Anti-hepatitis A virus immunoglobulin G (anti-HAV IgG)
- D. Anti-hepatitis A virus immunoglobulin M (anti-HAV IgM)
Correct Answer: D
Rationale: Hepatitis A is transmitted through the oral-fecal route, and antibody to HAV IgM appears during the acute phase of hepatitis A. The patient would not have antigen for hepatitis B or antibody for hepatitis D. Anti-HAV IgG would indicate past infection and lifelong immunity.
The nurse is caring for a patient who has had a transjugular intrahepatic portosystemic shunt (TIPS) placement. Which of the following indicate that the procedure has been effective?
- A. Lower indirect bilirubin level
- B. Increase in serum albumin level
- C. Decrease in episodes of variceal bleeding
- D. Improvement in alertness and orientation
Correct Answer: C
Rationale: TIPS is used to lower pressure in the portal venous system and decrease the risk of bleeding from esophageal varices. Indirect bilirubin level and serum albumin levels are not affected by shunting procedures. TIPS will increase the risk for hepatic encephalopathy.
The nurse is planning care for a patient with acute severe pancreatitis. Which of the following patient outcomes is priority?
- A. Expressing satisfaction with pain control
- B. Developing no ongoing pancreatic problems
- C. Maintaining normal respiratory function
- D. Having adequate fluid and electrolyte balance
Correct Answer: C
Rationale: Respiratory failure can occur as a complication of acute pancreatitis, and maintenance of adequate respiratory function is the priority goal. The other outcomes also would be appropriate for the patient.
The nurse is caring for a patient with persistent hepatitis C infection who has these
- A. Teach symptoms of variceal bleeding
- B. Review the patient's current medication list.
- C. Draw blood for hepatitis serology testing.
Correct Answer: C
Rationale: Reviewing the patient's current medication list is critical to identify drugs that may exacerbate liver damage or interact with hepatitis C treatments. Teaching about variceal bleeding is not relevant unless the patient has advanced liver disease with portal hypertension. Hepatitis serology is unnecessary since the diagnosis of persistent hepatitis C is already established.