Question 1

The nurse is providing care for a patient admitted with acute liver failure related to an acetaminophen overdose. Which goal is associated with care for the patient?

Accepted Answer

Maintaining functional ability of the liver is a goal of care for a patient with acute liver failure related to an acetaminophen overdose.

Question 2

The nurse is providing care for a client following an open cholecystectomy involving the removal of large gallstones and placement of a T-tube. Which third day postsurgical manifestation will cause the nurse to report the finding?

Accepted Answer

T-tube drainage of 600 mL over the past 24-hour period is excessive and could indicate a complication such as bile leak or liver dysfunction, necessitating immediate reporting to a healthcare provider.

Question 3

The nurse is obtaining information from a patient who is obese and has diabetes mellitus (DM). Upon physical examination, the nurse notes generalized ecchymosis, an enlarged and tender liver with palpation, and evidence of ascites with percussion. Which possible disease condition does the nurse identify from the findings?

Accepted Answer

The symptoms of generalized ecchymosis, an enlarged and tender liver, and ascites suggest liver dysfunction, possibly due to conditions like cirrhosis or liver disease.

Question 4

A patient with liver failure and esophageal varices is prescribed to receive vasopressin. For which purpose does the nurse recognize the need for this medication?

Accepted Answer

Vasopressin is used in this context to constrict the blood vessels, thereby reducing the risk of bleeding from the esophageal varices. It does not directly promote portal circulation, reduce ammonia buildup, or maintain hypotension; its primary role is to decrease blood flow to the varices by vasoconstriction.

Question 5

A patient with biliary colic is prescribed an anticholinergic medication to help treat the condition. For which medical diagnosis should the nurse question the administration of this medication?

Accepted Answer

Anticholinergic medications can exacerbate urinary retention, which is a concern in patients with prostatic hypertrophy.

Question 6

The nurse is reinforcing teaching provided to a patient with esophageal varices. Which suggestion is the least important?
is the least important?

Accepted Answer

Maintaining low physical activity is the least important suggestion compared to the others. While it's important for patients with esophageal varices to avoid straining and heavy lifting which can increase pressure in the varices and risk of bleeding, suggesting to maintain low physical activity broadly might not be as crucial. Regular, gentle exercise could be beneficial for overall health unless specifically contraindicated. The other options (A, B, C) are directly related to preventing life-threatening complications or ensuring proper management of the condition.

Question 7

The nurse is preparing to reinforce discharge teaching for a patient who underwent a cholecystectomy. Which information does the nurse plan to cover? (Select all that apply.)

Accepted Answer

The answer of The nurse is preparing to reinforce discharge...

Question 8

The nurse is collecting data from a patient with liver failure to detect hepatic encephalopathy. Which instruction does the nurse give to the patient to collect the data?

Accepted Answer

"Hold out your arms and hands" is the instruction given to assess for asterixis, a flapping tremor associated with hepatic encephalopathy. This involves asking the patient to extend their arms and hands to observe for involuntary flapping movements.

Question 9

The nurse is collecting data from a patient with acute pancreatitis. Which symptoms should the nurse anticipate?

Accepted Answer

Acute pancreatitis typically presents with midepigastric pain that can radiate to the back, abdominal distention due to ileus or inflammation, and respiratory distress from diaphragmatic irritation or pleural effusions.

Question 10

A patient recovering from hepatitis is concerned about liver damage from the infection. Which instructions does the nurse provide the patient to prevent long-term liver damage? (Select all that apply.)

Accepted Answer

The answer of A patient recovering from hepatitis is concerned...

Question 11

A patient just receives a diagnosis of pancreatic cancer with metastasis to the liver, gallbladder, and stomach. The nurse is informed that the patient has agreed to palliative care. Which intervention seems unexpected to the nurse?

Accepted Answer

The Whipple procedure is a complex surgery typically aimed at removing a tumor in the pancreas and is not usually part of palliative care, which focuses on relieving symptoms and improving quality of life rather than curative measures.

Question 12

The nurse is providing care for an older adult patient with a diagnosis of small noncalcified gallstones. The HCP prefers to avoid surgery on the patient due to age and a medical history of cardiac disorders. Which medical treatment does the nurse most likely expect the HCP to prescribe?

Accepted Answer

Long-term treatment with a dissolution drug, such as ursodeoxycholic acid, is often prescribed for patients with small, noncalcified gallstones, especially when surgery is not an option due to other health concerns. This medication can help dissolve gallstones over time.

Question 13

A patient presents at the HCP's office with epigastric pain. The patient's temperature and pulse and respiration rates are all elevated. Which additional symptom will the nurse associate as a possible sign of cholelithiasis?

Accepted Answer

Jaundice can occur with cholelithiasis (gallstones) when a stone blocks the common bile duct, leading to a buildup of bilirubin in the blood.

Question 14

A patient reports that a family member is diagnosed with hepatitis and asks the nurse the best way to prevent becoming infected. Which is the best information for the nurse to provide?

Accepted Answer

The best way to prevent hepatitis infection is through frequent hand washing and not sharing personal items. Hepatitis viruses are primarily spread through contact with infected bodily fluids, not through the environment, making personal hygiene and avoiding sharing personal items crucial in prevention. Antibiotics are ineffective against viruses, and while cleaning with bleach and using ultraviolet light can disinfect surfaces, these measures are not the primary means of preventing hepatitis transmission.

Question 15

A patient is being treated for acute cholecystitis. The patient is instructed on dietary measures to reduce the possibility of recurrent episodes. Which patient comment indicates a need to reinforce teaching?

Accepted Answer

Rapid weight loss can increase the risk of gallstone formation, which can exacerbate or contribute to issues related to cholecystitis. Proper weight management should be gradual to avoid such complications. Choices A, B, and C reflect appropriate understanding of dietary management in the context of cholecystitis.

Question 16

The nurse is gathering information about a new patient in an adult clinic. The patient states, "I have severe arthritis, but I control the pain with two 650-mg acetaminophen tablets four times a day." Which condition does the nurse associate with the patient's medication regimen?

Accepted Answer

The patient is consuming 5200 mg of acetaminophen daily (650 mg x 2 tablets x 4 times a day), which exceeds the recommended maximum daily dose of 3000-4000 mg for adults. Chronic overuse of acetaminophen can lead to liver damage or failure.

Question 17

The nurse is reinforcing patient teaching regarding the causes of gallbladder disorders. Which condition does the nurse present as being a common cause?

Accepted Answer

Gallstones and inflammations are common causes of gallbladder disorders, as they can block the bile ducts and lead to conditions such as cholecystitis.

Question 18

The nurse is providing care for a patient diagnosed with chronic pancreatitis. The patient's vital signs are blood pressure 130/78 mm Hg, respirations 28 breaths/min and labored with O₂saturation rate of 90%, pulse 102 beats/min, and pain level of 7 on a 0-to-10 scale. Which immediate nursing action is appropriate?

Accepted Answer

Placing the patient in an upright or slightly leaning forward position can help improve breathing and oxygenation, which is crucial given the patient's labored respirations and low oxygen saturation.

Question 19

The nurse is assisting with the care of a patient following a liver transplant for cirrhosis. Which finding will the nurse report immediately to the RN or HCP?

Accepted Answer

A decrease in the amount of bile in the T-tube may indicate a blockage or complication with the bile duct, which is a critical concern following a liver transplant and requires immediate attention.

Question 20

The nurse is providing care for a patient admitted with serious acute pancreatitis. The patient is in guarded condition and exhibits multiple manifestations of pancreatitis complications. The nurse is aware that which body system is unlikely to lead to patient death?

Accepted Answer

Neurologic complications, while possible in acute pancreatitis, are less directly associated with mortality compared to complications in the cardiovascular, respiratory, and renal systems, which can lead to more immediate life-threatening conditions.

Quiz 35: Nursing Care of Patients With Liver, Pancreatic, and Gallbladder Disorders