Nokea
The nurse is caring for a client who has undergone surgery for a liver disorder and has started shivering. Which intervention would be appropriate?
- A. Provide the client with warm fluids.
- B. Cover the client with a light blanket.
- C. Ensure that the room temperature is below 70?°F.
- D. Place the client on a hypothermia blanket.
Correct Answer: B
Rationale: The nurse should cover the client with a light blanket to prevent shivering. This is because the client who has undergone surgery for liver disorder also faces the risk of hyperthermia related to infection, rejection, or both. Providing the client with warm fluids will not control shivering. The client is covered with a hypothermia blanket if the temperature rises to 105?°F. The room temperature need not be below 70?°F.
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A client with cirrhosis is complaining of severe pruritus related to the accumulation of bile salts. What can be prescribed for the client to relieve the itching?
- A. Cholestyaramine
- B. Kanamyycin
- C. Lactulose
- D. Cyclosporine
Correct Answer: A
Rationale: Cholestyramine may be prescribed to bind bile salts and relieve pruritus. Kanamycin is prescribed to reduce the bacterial count in the intestine. Lactulose is used to decrease the amount of ammonia level in the blood. Cyclosporine is used to prevent rejection of a transplanted organ.
A client is suspected of having cirrhosis of the liver. What diagnostic procedure will the nurse prepare the client for in order to obtain a confirmed diagnosis?
- A. A liver biopsy
- B. A CT scan
- C. A prothrombin time
- D. Platelet count
Correct Answer: A
Rationale: A liver biopsy, which reveals hepatic fibrosis, is the most conclusive diagnostic procedure. It can be performed in the radiology department with ultrasound or CT to identify appropriate placement of the trocar or biopsy needle. A prothrombin time and platelet count will assist with determining if the client is at increased risk for bleeding.
A client is seeing the physician for a suspected tumor of the liver. What laboratory study results would indicate that the client may have a primary malignant liver tumor?
- A. Elevated white blood cell count
- B. Elevated alpha-fetoprotein
- C. Decreased AST levels
- D. Decreased alkaline phosphatase levels
Correct Answer: B
Rationale: Alpha-fetoprotein, a serum protein normally produced during fetal development, is a marker that, if elevated, can induce a primary malignant liver tumor. Total bilirubin and serum enzyme levels may be elevated. White blood cell count elevation would indicate an inflammatory response.
The nurse is caring for a client suspected of having stones that have collected in the common bile duct. What test should the nurse prepare the client for that will locate these stones?
- A. Colonoscopy
- B. Abdominal x-ray
- C. Cholecystectomy
- D. Endoscopic retrograde cholangiopancreatography (ERCP)
Correct Answer: D
Rationale: ERCP locates stones that have collected in the common bile duct. A colonoscopy will not locate gallstones but only allows visualization of the large intestine. Abdominal x-ray is not a reliable locator of gallstones. A cholecystectomy is the surgical removal of the gallbladder.
A client with esophageal varices is scheduled to undergo injection sclerotherapy. Which client statement indicates that the nurse's teaching was successful?
- A. The physician will use a balloon to compress the vessels.
- B. I might need to have this procedure done again.
- C. I seems odd that a rubber band can block off the vessels.
- D. A catheter will be inserted through my belly to fix the vessels.
Correct Answer: B
Rationale: Persistent portal hypertension allows varices to form again, making it necessary to repeat injection sclerotherapy or variceal banding regularly. Injection sclerotherapy involves passing an endoscope orally to locate the varix. Balloon tamponade is used to compress actively bleeding esophageal varices as a temporary measure. Variceal banding involves using a rubber band over the varix to restrict blood flow that eventually leads to sloughing.