ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 47 : Caring for Clients With Disorders of the Liver, Gallbladder, or Pancreas Questions
Question 1 of 5
A client had an open cholecystectomy with a T-tube insertion, and the nurse is measuring the bile drainage every 8 hours. When should the nurse notify the health care provider?
Correct Answer: A
Rationale: The nurse measures bile drainage every 8 hours or according to agency policy. If more than 17 oz (500 mL) of bile drains within 24 hours or if drainage is significantly reduced, the nurse notifies the health care provider. The nurse should ensure that there is no tension on the bile drainage tubing; slack drainage tubing is an expected finding. About 34 oz (100 mL) in the drainage pouch after 8 hours, and 34 oz (10 mL) per hour of drainage in 24 hours are less than 17 oz (100 mL) in 24 hours and are therefore not findings that require health care provider notification.
Question 2 of 5
The nurse is caring for a client with severe acute pancreatitis with a glucose level of 750 mg/dL. What does the nurse understand is the cause of this level of hyperglycemia?
Correct Answer: D
Rationale: Complications from severe acute pancreatitis are serious and sometimes fatal. Hyperglycemia results from an imbalance of glucagon, insulin, and somatostatin. Increase in circulating calcium does not result in an increase in glucose levels. The nurse cannot assume that the client has diabetes and is noncompliant.
Question 3 of 5
The nurse is caring for a client with cirrhosis of the liver. What symptom(s) would indicate to the nurse that the client is experiencing central nervous system effects of the disease? Select all that apply.
Correct Answer: A,C,E
Rationale: Hepatic encephalopathy is a CNS manifestation of liver failure that is a complication of cirrhosis. Indications of CNS effects include disorientation, confusion, personality changes, memory loss, a flapping tremor called asterixis, a positive Babinski reflex, sulfurous breath odor (fetor hepaticus), and lethargy to deep coma. Cough and joint stiffness are not indicators of CNS effects of cirrhosis.
Question 4 of 5
When inspecting the abdomen of a client with cirrhosis, the nurse observes that the veins over the abdomen are dilated. How does the nurse document this finding?
Correct Answer: C
Rationale: Caput medus is a term used to denote the appearance of dilated veins over the client's abdomen. Gynecomastia refers to enlarged breasts in a male, which may occur because the dysfunctional liver is unable to metabolize estrogen. Palmer erythema refers to the bright pink appearance of the palms and cutaneous spider angioma refers to tiny, spider-like blood vessels that may be apparent in a client with cirrhosis due to the liver's inability to inactivate estrogen.
Question 5 of 5
A nurse is preparing a presentation for a local community group about hepatitis. Which information would the nurse include?
Correct Answer: C
Rationale: Infection with hepatitis C increases the risk of a person developing hepatic (liver) cancer. Hepatitis A is transmitted primarily by the oral-fecal route, hepatitis B is frequently spread by sexual contact and infected blood. Hepatitis E is similar to hepatitis A whereas hepatitis G is similar to hepatitis C.