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The nurse is caring for a patient with cirrhosis who has scheduled doses of spironolactone and furosemide and has a serum potassium level of 3.2 mmol/L. Which of the following actions should the nurse take?
- A. Give both drugs as scheduled
- B. Administer the spironolactone
- C. Administer the furosemide and withhold the spironolactone
- D. Withhold both drugs until talking with the health care provider.
Correct Answer: B
Rationale: Spironolactone is a potassium-sparing diuretic and will help to increase the patient's potassium level. The nurse does not need to talk with the doctor before giving the spironolactone, although the health care provider should be notified about the low potassium value. The furosemide will further decrease the patient's potassium level and should be held until the nurse talks with the health care provider.
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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.
Which of the following actions should the nurse implement to evaluate the effectiveness of treatment for a patient who has hepatic encephalopathy?
- A. Request that the patient stand on one foot.
- B. Ask the patient to extend both arms to the front.
- C. Instruct the patient to perform the Valsalva manoeuvre.
- D. Have the patient walk a few steps with the eyes closed.
Correct Answer: B
Rationale: Extending the arms allows the nurse to check for asterixis, a classic sign of hepatic encephalopathy. The other tests also might be done as part of the neurological assessment but would not be diagnostic for hepatic encephalopathy.
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.
Which of the following nursing actions should be included in the plan of care for a patient with cirrhosis who has ascites and 4+ edema of the feet and legs?
- A. Weekly weight of patient.
- B. Reposition the patient every 4 hours.
- C. Restrict sodium intake.
- D. Perform passive range-of-motion QID.
Correct Answer: C
Rationale: To maintain skin integrity, restrict sodium intake as ordered to prevent additional fluid retention. The patient should be weighed daily, not weekly. Repositioning the patient every 4 hours will not be adequate to maintain skin integrity, patients should be repositioned at least every two hours. Passive range of motion will not take pressure off areas like the sacrum that are vulnerable to breakdown.
The nurse is caring for a patient who is diagnosed with acute hepatitis B. Which of the following information should the nurse include in the teaching plan?
- A. Ways to increase exercise and activity level
- B. Self-administration of ?±-interferon
- C. Adverse effects of nucleoside and nucleotide analogs
- D. Measures that will be helpful in improving appetite
Correct Answer: D
Rationale: Maintaining adequate nutritional intake is important for regeneration of hepatocytes. Interferon and antivirals may be used for persistent hepatitis B, but they are not prescribed for acute hepatitis B infection. Rest is recommended.