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The nurse is preparing a teaching plan for a young adult patient who is diagnosed with early alcoholic cirrhosis. Which of the following topics is most important to include in patient teaching?
- A. Need to abstain from alcohol
- B. Use of vitamin B supplements
- C. Maintenance of a nutritious diet
- D. Treatment with lactulose
Correct Answer: A
Rationale: The disease progression can be stopped or reversed by alcohol abstinence. The other interventions may be used when cirrhosis becomes more severe to decrease symptoms or complications, but the priority for this patient is to stop the progression of the disease.
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The nurse is assessing a patient who had a liver transplant a week previously and obtains the following data. Which of the following findings is most important to communicate to the health care provider?
- A. Dry lips and oral mucosa
- B. Crackles at both lung bases
- C. Temperature 38.2°C (100.8°F)
- D. Pain at the incision site
Correct Answer: B
Rationale: Crackles at both lung bases may indicate pulmonary edema or infection, which are serious complications post-liver transplant requiring immediate attention. Dry lips, fever, and incisional pain are also concerning but less urgent unless accompanied by other critical symptoms.
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.
After receiving change-of-shift report, which of the following patients should the nurse assess first?
- A. 50-year-old with persistent pancreatitis who has gnawing abdominal pain
- B. 48-year-old who has compensated cirrhosis and is complaining of anorexia
- C. 45-year-old with cirrhosis and severe ascites who has an oral temperature of 38.8°C (101.8°F)
- D. 36-year-old who is recovering from a laparoscopic cholecystectomy and has severe shoulder pain
Correct Answer: C
Rationale: This patient's history and fever suggest spontaneous bacterial peritonitis, which would require rapid assessment and interventions such as antibiotic therapy. The clinical manifestations for the other patients are consistent with their diagnoses and do not indicate complications are occurring.
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 caring for a patient with acute pancreatitis who has a nasogastric (NG) tube to suction and is NPO. Which of the following information obtained by the nurse indicates that these therapies have been effective?
- A. Bowel sounds are present.
- B. Grey Turner sign resolves.
- C. Electrolyte levels are normal.
- D. Abdominal pain is decreased.
Correct Answer: D
Rationale: NG suction and NPO status will decrease the release of pancreatic enzymes into the pancreas and decrease pain. Although bowel sounds may be hypotonic with acute pancreatitis, the presence of bowel sounds does not indicate that treatment with NG suction and NPO status have been effective. Electrolyte levels will be abnormal with NG suction and must be replaced by appropriate IV infusion. Although Grey Turner sign will eventually resolve, it would not be appropriate to wait for this to occur to determine whether treatment was effective.