Nokea
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.
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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.
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 diagnoses is often a misdiagnosis for older-adult patients with liver disease?
- A. Fulminant hepatic failure
- B. Cirrhosis
- C. Dementia
- D. Epstein-Barr virus
Correct Answer: C
Rationale: In older persons with liver disease, hepatic encephalopathy may be misdiagnosed as dementia.
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 admitting a patient who is homeless and has viral hepatitis with symptoms of severe anorexia and fatigue. Which of the following patient goals should have the highest priority when the nurse is developing the plan of care?
- A. Increase activity level.
- B. Maintain adequate nutrition.
- C. Establish a stable home environment.
- D. Identify the source of exposure to hepatitis.
Correct Answer: B
Rationale: The highest priority outcome is to maintain nutrition because adequate nutrition is needed for hepatocyte regeneration. Finding a home for the patient and identifying the source of the infection would be appropriate activities, but they do not have as high a priority as ensuring adequate nutrition. Although the patient's activity level will be gradually increased, rest is indicated during the acute phase of hepatitis.