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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.
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The health care provider plans a paracentesis for a patient with ascites caused by liver cancer. Which of the following actions should the nurse implement to prepare the patient for the procedure?
- A. Place the patient on NPO status
- B. Assist the patient to lie flat in bed.
- C. Ask the patient to empty the bladder.
- D. Position the patient on the right side.
Correct Answer: C
Rationale: The patient should empty the bladder to decrease the risk of bladder perforation during the procedure. The patient would be positioned in Fowler's position and would not be able to lie flat without compromising breathing. Since no sedation is required for paracentesis, the patient does not need to be NPO.
The nurse is obtaining a health history from a patient with acute pancreatitis. Which of the following information should the nurse specifically assess when conducting a health history?
- A. Alcohol use
- B. Diabetes mellitus
- C. High-protein diet
- D. Cigarette smoking
Correct Answer: A
Rationale: Alcohol use is one of the most common risk factors for pancreatitis in Canada. In Canada, the most common cause is gallbladder disease (gallstones) followed by alcoholism. Cigarette smoking, diabetes, and high-protein diets are not risk factors.
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 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.
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.