Question 1

A telehealth nurse speaks with a client who is recovering from a liver transplant 2 weeks ago.The client states,"I am experiencing right flank pain and have a temperature of 101° F." How should the nurse respond?

Accepted Answer

Fever,right quadrant or flank pain,and jaundice are signs of liver transplant rejection; the client should be admitted to the hospital as soon as possible for intervention.Anti-rejection drugs do make a client more susceptible to infection,but this client has signs of rejection,not infection.The nurse should not advise the client to take an additional dose of cyclosporine or acetaminophen as these medications will not treat the acute rejection.

Question 2

An emergency room nurse assesses a client after a motor vehicle crash.The nurse notices a "steering wheel mark" across the client's chest.Which action should the nurse take?

Accepted Answer

The liver is often injured by a steering wheel in a motor vehicle crash.Because the client's chest was marked by the steering wheel,the nurse should perform an abdominal assessment.Assessing the client's position in the crash is not needed because of the steering wheel imprint.The client may or may not need a blood transfusion.The client does not need to be in reverse Trendelenburg position.

Question 3

A nurse obtains a client's health history at a community health clinic.Which statement alerts the nurse to provide health teaching to this client?

Accepted Answer

Acetaminophen (Tylenol)can cause liver damage if taken in large amounts.Clients should be taught not to exceed 4000 mg/day of acetaminophen.The nurse should teach the client about this limitation and should explore other drug options with the client to manage his or her arthritis pain.Two glasses of wine each week,a cousin with liver cancer,and the hepatitis vaccine do not place the client at risk for a liver disorder,and therefore do not require any health teaching.

Question 4

A nurse cares for a client with hepatitis C.The client's brother states,"I do not want to contract this infection,so I will not go into his hospital room." How should the nurse respond?

Accepted Answer

Although family members may be afraid that they will contract hepatitis C,the nurse should educate the client's family about how the virus is spread.Viral hepatitis,or hepatitis C,is spread via blood-to-blood transmission and is associated with illicit IV drug needle sharing,blood and organ transplantation,accidental needle sticks,unsanitary tattoo equipment,and sharing of intranasal cocaine paraphernalia.Wearing a gown and gloves will not decrease the transmission of this virus.Hepatitis C is not spread through casual contact or a fecal specimen.The nurse would be violating privacy laws by sharing the client's status with the brother.

Question 5

A nurse cares for a client with hepatopulmonary syndrome who is experiencing dyspnea with oxygen saturations at 92%.The client states,"I do not want to wear the oxygen because it causes my nose to bleed.Get out of my room and leave me alone!" Which action should the nurse take?

Accepted Answer

The client with hepatopulmonary syndrome is often dyspneic.Because the oxygen saturation is not significantly low,the nurse should first allow the client to sit upright to see if that helps.If the client remains dyspneic,or if the oxygen saturation drops further,the nurse should investigate adding humidity to the oxygen and seeing whether the client will tolerate that.The other two options may be beneficial,but they are not the best choices.If the client is comfortable,his or her agitation will decrease; this will improve respiratory status.

Question 6

After teaching a client who has plans to travel to a non-industrialized country,the nurse assesses the client's understanding regarding the prevention of viral hepatitis.Which statement made by the client indicates a need for additional teaching?

Accepted Answer

The client should be advised to avoid fresh,raw fruits and vegetables because they can be contaminated by tap water.Drinking bottled water,and not sharing plates,glasses,or eating utensils are good ways to prevent illness,as is careful handwashing.

Question 7

A nurse cares for a client who is hemorrhaging from bleeding esophageal varices and has an esophagogastric tube.Which action should the nurse take first?

Accepted Answer

Maintaining airway patency is the primary nursing intervention for this client.The nurse suctions oral secretions to prevent aspiration and occlusion of the airway.The client usually is intubated and mechanically ventilated during this treatment.The client should be sedated,balloon pressure should be maintained between 15 and 20 mm Hg,and the lumen can be irrigated with saline or tap water.However,these are not a higher priority than airway patency.

Question 8

After teaching a client who has alcohol-induced cirrhosis,a nurse assesses the client's understanding.Which statement made by the client indicates a need for additional teaching?

Accepted Answer

Based on the degree of liver involvement and decreased function,protein intake may have to be decreased.However,some protein is necessary for the synthesis of albumin and normal healing.The other statements indicate accurate understanding of self-care measures for this client.

Question 9

A nurse cares for a client who has cirrhosis of the liver.Which action should the nurse take to decrease the presence of ascites?

Accepted Answer

A low-sodium diet is one means of controlling abdominal fluid collection.Monitoring intake and output does not control fluid accumulation,nor does weighing the client.These interventions merely assess or monitor the situation.Increasing fluid intake would not be helpful.

Question 10

After teaching a client who has been diagnosed with hepatitis A,the nurse assesses the client's understanding.Which statement by the client indicates a correct understanding of the teaching?

Accepted Answer

The route of acquisition of hepatitis A infection is through close personal contact or ingestion of contaminated water or shellfish.Hepatitis A is not transmitted through medications,blood transfusions,or Epstein-Barr virus.Toxic and drug-induced hepatitis is caused from exposure to hepatotoxins,but this is not a form of hepatitis A.Hepatitis B can be spread through blood transfusions.Epstein-Barr virus causes a secondary infection that is not associated with hepatitis A.

Question 11

A nurse assesses a client who is recovering from a paracentesis 1 hour ago.Which assessment finding requires action by the nurse?

Accepted Answer

Rapid removal of ascetic fluid causes decreased abdominal pressure,which can contribute to hypovolemia.This can be manifested by a decrease in urine output to below 30 mL/hr.A slight increase in systolic blood pressure is insignificant.A decrease in respiratory rate indicates that breathing has been made easier by the procedure.The nurse would expect the client's weight to drop as fluid is removed.Six kilograms is less than 3 pounds and is expected.

Question 12

A nurse assesses a client who is prescribed an infusion of vasopressin (Pitressin)for bleeding esophageal varices.Which clinical manifestation should alert the nurse to a serious adverse effect?

Accepted Answer

Mid-sternal chest pain is indicative of acute angina or myocardial infarction,which can be precipitated by vasopressin.Nausea and vomiting,headache,and vertigo and syncope are not side effects of vasopressin.

Question 13

A nurse assesses clients at a community health fair.Which client is at greatest risk for the development of hepatitis B?

Accepted Answer

Hepatitis B can be spread through sexual contact,needle sharing,needle sticks,blood transfusions,hemodialysis,acupuncture,and the maternal-fetal route.A person with multiple sexual partners has more opportunities to contract the infection.Hepatitis B is not transmitted through medications,casual contact with other travelers,or raw shellfish.Although an overdose of acetaminophen can cause liver cirrhosis,this is not associated with hepatitis B.Hepatitis E is found most frequently in international travelers.Hepatitis A is spread through ingestion of contaminated shellfish.

Question 14

A nurse cares for a client who has chronic cirrhosis from substance abuse.The client states,"All of my family hates me." How should the nurse respond?

Accepted Answer

Clients who have chronic cirrhosis may have alienated relatives over the years because of substance abuse.The nurse should assist the client to identify a friend,neighbor,or person in his or her recovery group for support.The nurse should not minimize the client's concerns by brushing off the client's comment.Attending AA may be appropriate,but this response doesn't address the client's concern.Making peace with the client's family may not be possible.This statement is not client-centered.

Question 15

A nurse cares for a client who is scheduled for a paracentesis.Which intervention should the nurse delegate to an unlicensed assistive personnel (UAP)?

Accepted Answer

For safety,the client should void just before a paracentesis.The nurse or the provider should have the client sign the consent form.The proper position for a paracentesis is sitting upright in bed or,alternatively,sitting on the side of the bed and leaning over the bedside table.The client will be on bedrest after the procedure.

Question 16

A nurse assesses clients on the medical-surgical unit.Which client is at greatest risk for the development of carcinoma of the liver?

Accepted Answer

The risk of contracting a primary carcinoma of the liver is higher in clients with cirrhosis from any cause.Blunt liver trauma,diabetes mellitus,and chronic malnutrition do not increase a person's risk for developing liver cancer.

Question 17

An infection control nurse develops a plan to decrease the number of health care professionals who contract viral hepatitis at work.Which ideas should the nurse include in this plan? (Select all that apply.)

Accepted Answer

Nurses should always use Standard Precautions for client care,and policies should reflect this.Needleless systems and reduction of sharps can help prevent hepatitis.Postexposure prophylaxis should be provided immediately.All health care workers should receive the hepatitis vaccinations that are available.

Question 18

A nurse cares for a client who is prescribed lactulose (Heptalac).The client states,"I do not want to take this medication because it causes diarrhea." How should the nurse respond?

Accepted Answer

The purpose of administering lactulose to this client is to help ammonia leave the circulatory system through the colon.Lactulose draws water into the bowel with its high osmotic gradient,thereby producing a laxative effect and subsequently evacuating ammonia from the bowel.The client must understand that this is an expected and therapeutic effect for him or her to remain compliant.The nurse should not suggest administering anything that would decrease the excretion of ammonia or holding the medication.There is no need to send a stool specimen to the laboratory because diarrhea is the therapeutic response to this medication.

Question 19

A nurse cares for a client with hepatic portal-systemic encephalopathy (PSE).The client is thin and cachectic in appearance,and the family expresses distress that the client is receiving little dietary protein.How should the nurse respond?

Accepted Answer

A low-protein diet is ordered when serum ammonia levels increase and/or the client shows signs of PSE.A low-protein diet helps reduce excessive breakdown of protein into ammonia by intestinal bacteria.Encephalopathy is caused by excess ammonia.A low-protein diet has no impact on restoring liver function.Increasing the client's dietary protein will cause complications of liver failure and should not be suggested.Increased intravascular protein will help prevent ascites,but clients with liver failure are not able to effectively synthesize dietary protein.

Question 20

A nurse teaches a client with hepatitis C who is prescribed ribavirin (Copegus).Which statement should the nurse include in this client's discharge education?

Accepted Answer

Treatment of hepatitis C with ribavirin takes up to 48 weeks,making compliance a serious issue.The nurse should work with the client on a strategy to remain compliant for this length of time.Muscle aching is not a common side effect.The client will be on this medication for many weeks and does not need a blood toxicity examination.There is no need for the client to assess his or her radial pulse prior to taking the medication.

Quiz 58: Care of Patients with Liver Problems