Nokea
The nurse is caring for a patient who has advanced cirrhosis and is receiving lactulose. Which of the following findings by the nurse indicates that the medication is effective?
- A. The patient is alert and oriented.
- B. The patient denies nausea or anorexia.
- C. The patient's bilirubin level decreases.
- D. The patient has at least one stool daily.
Correct Answer: A
Rationale: The purpose for lactulose in the patient with cirrhosis is to lower ammonia levels and prevent encephalopathy. Although lactulose may be used to treat constipation, that is not the purpose for this patient. Lactulose will not decrease nausea and vomiting or lower bilirubin levels.
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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.
The nurse is caring for a patient following an incisional cholecystectomy for cholelithiasis. Which of the following actions is priority for the nurse to implement?
- A. Patient education about low-fat food choices.
- B. Perform leg exercises hourly while awake.
- C. Ambulate the evening of the operative day.
- D. Turn, cough, and deep breathe every 2 hours.
Correct Answer: D
Rationale: Postoperative nursing care for incisional cholecystectomy is the same as general postoperative nursing care. Postoperative nursing care after a cholecystectomy focuses on prevention of respiratory complications because the surgical incision is high in the abdomen and impairs coughing and deep breathing. The other nursing actions also are important to implement but are not as high a priority as ensuring adequate ventilation.
Which of the following findings in a blood specimen indicates that the administration of hepatitis B vaccine to a patient has been effective?
- A. HBsAg
- B. Anti-HBs
- C. Anti-HBc IgG
- D. Anti-HBc IgM
Correct Answer: B
Rationale: The presence of surface antibody to HBV (anti-HBs) is a marker of a positive response to the vaccine. The other laboratory values indicate current infection with HBV.
Which of the following actions should be included in the plan of care for a patient who has recently been diagnosed with asymptomatic non-alcoholic fatty liver disease (NAFLD)?
- 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 essential to identify potential hepatotoxic drugs and manage risk factors like diabetes or hyperlipidemia, which are associated with NAFLD progression. Teaching about variceal bleeding is irrelevant for asymptomatic NAFLD, as varices are a complication of advanced liver disease. Hepatitis serology is not indicated unless viral hepatitis is suspected.
The nurse is caring for a patient with severe cirrhosis who has an episode of bleeding esophageal varices. Which of the following laboratory tests should the nurse monitor to detect possible complications of the bleeding episode?
- A. Bilirubin
- B. Ammonia
- C. Potassium
- D. Prothrombin time
Correct Answer: B
Rationale: The blood in the gastrointestinal (GI) tract will be absorbed as protein and may result in an increase in ammonia level because the liver cannot metabolize protein well. The prothrombin time, bilirubin, and potassium levels also should be monitored, but these will not be affected by the bleeding episode.