ATI LPN
Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
Chapter 49 : Assessment and Management of Patients with Hepatic Disorders Questions
Question 1 of 5
A nurse is performing an admission assessment of a patient with a diagnosis of cirrhosis. What technique should the nurse use to palpate the patients liver?
Correct Answer: C
Rationale:
To palpate the liver, the examiner places one hand under the right lower rib cage and presses downward with light pressure with the other hand. The liver is not on the left side or in the right lower abdominal quadrant.
Question 2 of 5
A patient with portal hypertension has been admitted to the medical floor. The nurse should prioritize which of the following assessments related to the manifestations of this health problem?
Correct Answer: C
Rationale: Obstruction to blood flow through the damaged liver results in increased blood pressure (portal hypertension) throughout the portal venous system. This can result in varices and ascites in the abdominal cavity. Assessments related to ascites are daily weights and abdominal girths. Portal hypertension is not synonymous with cardiovascular hypertension and does not create a risk for unstable blood glucose or VTE.
Question 3 of 5
A nurse educator is teaching a group of recent nursing graduates about their occupational risks for contracting hepatitis B. What preventative measures should the educator promote? Select all that apply.
Correct Answer: A,B
Rationale: People who are at high risk, including nurses and other health care personnel exposed to blood or blood products, should receive active immunization. The consistent use of standard precautions is also highly beneficial. Vitamin supplementation is unrelated to an individuals risk of HBV.
Question 4 of 5
A nurse is caring for a patient with cancer of the liver whose condition has required the insertion of a percutaneous biliary drainage system. The nurses most recent assessment reveals the presence of dark green fluid in the collection container. What is the nurses best response to this assessment finding?
Correct Answer: A
Rationale: Bile is usually a dark green or brownish-yellow color, so this would constitute an expected assessment finding, with no other action necessary.
Question 5 of 5
A patient who has undergone liver transplantation is ready to be discharged home. Which outcome of health education should the nurse prioritize?
Correct Answer: C
Rationale: The patient is given written and verbal instructions about immunosuppressive agent doses and dosing schedules. The patient is also instructed on steps to follow to ensure that an adequate supply of medication is available so that there is no chance of running out of the medication or skipping a dose. Failure to take medications as instructed may precipitate rejection. The nurse would not teach the patient to measure drainage from a T-tube as the patient wouldn't go home with a T-tube. The nurse may teach the patient about the need to exercise or what the signs of liver dysfunction are, but the nurse would not stress these topics over the immunosuppressive drug regimen.