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After teaching a client who has alcohol-induced cirrhosis, a nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching?
- A. I cannot drink any alcohol at all anymore.
- B. I need to avoid protein in my diet.
- C. I should not take over-the-counter medications.
- D. I should not take any prescription medications.
Correct Answer: B
Rationale: Based on the degree of liver involvement and decreased function, protein intake may have to be decreased. However, some protein is necessary for the synthesis of albumin and normal healing. The other statements indicate accurate understanding of self-care measures for this client.
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A nurse assesses clients at a community health fair. Which client is at greatest risk for the development of hepatitis B?
- A. A 20-year-old college student who has had several sexual partners
- B. A 46-year-old woman who takes acetaminophen daily for headaches
- C. A 63-year-old businessman who travels frequently across the country
- D. An 18-year-old woman who recently ate raw shellfish for dinner
Correct Answer: A
Rationale: Hepatitis B can be spread through sexual contact, needle sharing, needle sticks, blood transfusions, hemodialysis, acupuncture, and the maternal-fetal route. A person with multiple sexual partners has more opportunities to contract the infection. Hepatitis B is not transmitted through medications, casual contact with other travelers, or raw shellfish. Although an overdose of acetaminophen can cause liver cirrhosis, this is not associated with hepatitis B. Hepatitis A is spread through ingestion of contaminated shellfish.
A nurse cares for a client with hepatopulmonary syndrome who is experiencing dyspnea with oxygen saturations at 92%. The client states, 'I do not want to wear the oxygen because it causes my nose to bleed. Get out of my room and leave me alone!' Which action should the nurse take?
- A. Ensure the client is in as upright a position as possible.
- B. Add humidity to the oxygen and encourage the client to wear it.
- C. Document the client's refusal, and call the health care provider.
- D. Contact the provider to request an extra dose of the client's diuretic.
Correct Answer: A
Rationale: The client with hepatopulmonary syndrome is often dyspneic. Because the oxygen saturation is not significantly low, the nurse should first allow the client to sit upright to see if that helps. If the client remains dyspneic, or if the oxygen saturation drops further, the nurse should investigate adding humidity to the oxygen and using a face mask to deliver the oxygen. The other two options may be beneficial, but they are not the best choices. If the client is comfortable, his or her agitation will decrease; this will improve respiratory status.
An infection control nurse develops a plan to decrease the number of health care professionals who contract viral hepatitis at work. Which ideas should the nurse include in this plan? (Select all that apply.)
- A. Policies related to consistent use of Standard Precautions
- B. Hepatitis vaccination mandate for workers in high-risk areas
- C. Implementation of a needleless system for intravenous therapy
- D. Hepatitis B immunity in clients at risk for hepatitis B
- E. Postexposure prophylaxis provided in a timely manner
Correct Answer: A,C,D,E
Rationale: Nurses should always use Standard Precautions for client care, and policies should reflect this. Needleless systems and reduction of sharps can help prevent hepatitis. Postexposure prophylaxis should be provided in a timely manner. Hepatitis B immunity in clients does not protect healthcare workers, but ensuring worker immunity through vaccination is critical.
A nurse assesses a client who has liver disease. Which laboratory findings should the nurse recognize as potentially limiting complications of this disorder? (Select all that apply.)
- A. Elevated aspartate transaminase
- B. Elevated international normalized ratio (INR)
- C. Elevated serum albumin
- D. Decreased serum alkaline phosphatase
- E. Elevated serum ammonia
- F. Elevated serum ALT (AST) (PT)
Correct Answer: B,E,F
Rationale: Because INR and PT are indications of clotting disturbances and alert the nurse to the increased possibility of hemorrhage, and elevated ammonia levels increase the client's confusion, these are critical findings. The other values are abnormal and associated with liver disease but do not necessarily place the client at increased risk for complications.
A nurse assesses a client who is recovering from a paracentesis 1 hour ago. Which assessment finding requires action by the nurse?
- A. Urine output via indwelling urinary catheter is 20 mL/hr.
- B. Blood pressure increases from 120/80 mm Hg to 140/90 mm Hg.
- C. Respiratory rate decreases from 18 to 14 breaths/min.
- D. A decrease in the clients weight by 6 kg
Correct Answer: A
Rationale: Rapid removal of ascitic fluid causes decreased abdominal pressure, which can contribute to hypovolemia. This can be manifested by a decrease in urine output to below 30 mL/hr. A slight increase in systolic blood pressure is insignificant. A decrease in respiratory rate indicates that breathing has been made easier by the procedure. The nurse would expect the clients weight to drop as fluid is removed. Six kilograms is less than 3 pounds and is expected.