Question 1

A client is hemorrhaging from bleeding esophageal varices and has an esophagogastric tube.Which nursing intervention is the priority?

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 procedure.The other interventions are not a priority over airway.

Question 2

Which laboratory findings does the nurse recognize as potentially causing complications of liver disease?

Accepted Answer

Elevated prothrombin time and INR are indications of clotting disturbances and alert the nurse to the increased possibility of hemorrhage.The other values do not necessarily place the client at increased risk for complications.

Question 3

A client has cirrhosis.Which nursing intervention would be most effective in controlling 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 4

The nurse is assessing a client for asterixis.Which instruction to the client is most appropriate?

Accepted Answer

Asterixis,or liver flap,is a tremor in the client's wrists and fingers.The correct technique for assessing the presence of asterixis is to extend the arm,dorsiflex the wrist,and extend the fingers.The other directions are not related to asterixis.

Question 5

A client is admitted with cirrhosis and hepatopulmonary syndrome.Which clinical manifestation does the nurse monitor for progression or resolution of this problem?

Accepted Answer

An increase in intra-abdominal pressure from ascites can lead to hepatopulmonary syndrome.This is manifested by dyspnea and crackles on auscultation.The other symptoms are consistent with liver disease but are not specific to respiratory involvement.

Question 6

The nurse correlates which data in the client's history as a predisposing factor for Laënnec's cirrhosis?

Accepted Answer

Laënnec's cirrhosis,also known as alcoholic cirrhosis,is caused by the toxic effect of alcohol on the liver.The nurse should ask the client about a history of alcohol use.The other factors are not related to this type of cirrhosis.

Question 7

The client with end-stage cirrhosis presents with GI bleeding,combativeness,and confusion.The nurse anticipates an order to administer which medication?

Accepted Answer

Lactulose helps rid the body of ammonia.Excess ammonia leads to encephalopathy,which this client is manifesting.Omeprazole is a proton pump inhibitor used for reflux and ulcer disease.Somatostatin is given to treat bleeding from esophageal varices.Inderal is given to prevent bleeding from esophageal varices.

Question 8

The nurse recognizes that fetor hepaticus is consistent with which assessment finding?

Accepted Answer

Fetor hepaticus is a distinctive breath odor that presents with chronic liver disease.The client's breath has a fruity or musty odor.The other statements do not apply to fetor hepaticus.

Question 9

A client just had a paracentesis.Which nursing intervention is a priority for this client?

Accepted Answer

After a paracentesis,the client should remain on bedrest with the head of the bed elevated.A client with liver dysfunction is at risk for bleeding,and bedrest decreases this risk.Clients with liver dysfunction must have intake and output monitored,but this is not the priority after this procedure.A drain may be placed for short-term therapy in some clients.

Question 10

A client is bleeding from esophageal varices.The health care provider is arranging sclerotherapy for the client.Before the client goes to interventional radiology,the nurse prepares to administer which medication?

Accepted Answer

Terlipressin is a vasoactive drug that works by reducing portal pressure,which decreases bleeding.These drugs are often given in conjunction with sclerotherapies.Enoxaparin is a low-molecular-weight heparin,which would be contraindicated in a client with bleeding problems.Lactulose helps rid the body of ammonia.Aldactone is a diuretic.

Question 11

The nursing care plan specifies obtaining abdominal girth measurements each shift.The nurse takes the measurement,but when compared with the previous measurement,the new finding is several millimeters off.Which action by the nurse is best?

Accepted Answer

Abdominal girth is measured at the end of exhalation,at the level of the umbilicus,while the client lies flat.To ensure that measurements are taken in the same place each time,the nurse should mark the client's abdomen and flanks with pen.Findings do need to be documented,but this is not the best action when such inconsistency is noted between measurements.Use of a diuretic might decrease ascites,but the best action remains ensuring that measurements are taken in a consistent manner.

Question 12

A client with an esophagogastric tube suddenly experiences acute respiratory distress.Which is the nurse's first action?

Accepted Answer

When respiratory compromise is noted in a client with an esophagogastric tube,the nurse should immediately cut both ports with a pair of scissors that is kept at the bedside and remove the tube.The nurse would not call the health care provider until the client was out of immediate danger.Once the tube has been removed,the nurse can reposition the client and apply oxygen.

Question 13

A client is admitted with end-stage cirrhosis and severe vomiting.Which problem should the nurse monitor the client most carefully for?

Accepted Answer

The portal hypertension that accompanies end-stage cirrhosis predisposes the client to esophageal varices.These varices can rupture from increased pressure in the esophagus caused by coughing or vomiting.Bleeding varices can be life threatening.None of the other assessments take priority over monitoring for bleeding from esophageal varices.

Question 14

The nurse is assessing a client with mild liver disease.Which assessment does the nurse perform to detect the presence of ascites in this client?

Accepted Answer

Mild ascites may be difficult to detect and can be assessed by percussion.Shifting dullness and a fluid wave alert the nurse to the presence of ascites.The other findings are inconsistent with ascites.

Question 15

The nurse is reviewing a client's history.Which statement by the client indicates a need for health teaching?

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.The other statements do not necessarily require health teaching by the nurse.

Question 16

A client just returned to the nursing unit after having a trans-jugular intrahepatic portal-systemic shunt (TIPS)procedure.Which clinical finding does the nurse expect to observe in this client?

Accepted Answer

With TIPS placement,ascitic fluid is routed into the venous system,resulting in vascular volume expansion.An increase in blood pressure is reflective of increased circulating volume.The client should not have the other findings.

Question 17

A client had a paracentesis 1 hour ago.Which assessment finding requires action by the nurse?

Accepted Answer

Rapid removal of ascitic 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.The nurse would expect the client's weight to drop as fluid is removed.A decrease in respiratory rate indicates that breathing has been made easier by the procedure.A slight increase in systolic blood pressure is insignificant.

Question 18

The nurse monitors for which clinical manifestation in a client with a decreased fecal urobilinogen concentration?

Accepted Answer

When fecal urobilinogen levels are decreased as a result of biliary cirrhosis,the stools become lighter or clay-colored.

Question 19

Which laboratory data does the nurse correlate with advanced disease in a client with cirrhosis?

Accepted Answer

The serum ammonia level is elevated in the presence of advanced disease because conversion of ammonia to urea for excretion is decreased.The other laboratory values do not correlate with advanced disease.

Question 20

A client has cirrhosis and has developed ascites and edema.Which laboratory value does the nurse correlate with this condition?

Accepted Answer

Ascites occurs as a result of the inability of the liver to synthesize albumin.Loss of albumin leads to edema.This client's albumin level is low,which correlates with the condition.Sodium and blood urea nitrogen (BUN)levels are normal.The glucose level is slightly high,but this is not directly related to edema.

Quiz 61: Care of Patients With Liver Problems