1. A nurse is caring for a patient with liver failure and is performing an assessment in the knowledge of the
patients increased risk of bleeding. The nurse recognizes that this risk is related to the patients inability
to synthesize prothrombin in the liver. What factor most likely contributes t...
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 922
Chapter 49: Assessment and Management of Patients with Hepatic
Disorders
1. A nurse is caring for a patient with liver failure and is performing an assessment in the knowledge of the
patients increased risk of bleeding. The nurse recognizes that this risk is related to the patients inability
to synthesize prothrombin in the liver. What factor most likely contributes to this loss of function?
A) Alterations in glucose metabolism
B) Retention of bile salts
C) Inadequate production of albumin by hepatocytes
D) Inability of the liver to use vitamin K
Ans: D
Feedback:
Decreased production of several clotting factors may be partially due to deficient absorption of vitamin
K from the GI tract. This probably is caused by the inability of liver cells to use vitamin K to make
prothrombin. This bleeding risk is unrelated to the roles of glucose, bile salts, or albumin.
2. 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?
A) Place hand under the right lower abdominal quadrant and press down lightly with the other hand.
B) Place the left hand over the abdomen and behind the left side at the 11th rib.
C) Place hand under right lower rib cage and press down lightly with the other hand.
D) Hold hand 90 degrees to right side of the abdomen and push down firmly.
Ans: C
Feedback:
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.
3. A patient with portal hypertension has been admitted to the medical floor. The nurse should prioritize
,Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 923
which of the following assessments related to the manifestations of this health problem?
A) Assessment of blood pressure and assessment for headaches and visual changes
B) Assessments for signs and symptoms of venous thromboembolism
C) Daily weights and abdominal girth measurement
D) Blood glucose monitoring q4h
Ans: C
Feedback:
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.
4. 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.
A) Immunization
B) Use of standard precautions
C) Consumption of a vitamin-rich diet
D) Annual vitamin K injections
E) Annual vitamin B12 injections
Ans: A, B
Feedback:
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.
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?
,Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 924
A) Document the presence of normal bile output.
B) Irrigate the drainage system with normal saline as ordered.
C) Aspirate a sample of the drainage for culture.
D) Promptly report this assessment finding to the primary care provider.
Ans: A
Feedback:
Bile is usually a dark green or brownish-yellow color, so this would constitute an expected assessment
finding, with no other action necessary.
6. A patient who has undergone liver transplantation is ready to be discharged home. Which outcome of
health education should the nurse prioritize?
A) The patient will obtain measurement of drainage from the T-tube.
B) The patient will exercise three times a week.
C) The patient will take immunosuppressive agents as required.
D) The patient will monitor for signs of liver dysfunction.
Ans: C
Feedback:
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 wouldnt 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.
7. A triage nurse in the emergency department is assessing a patient who presented with complaints of
general malaise. Assessment reveals the presence of jaundice and increased abdominal girth. What
assessment question best addresses the possible etiology of this patients presentation?
A) How many alcoholic drinks do you typically consume in a week?
B) To the best of your knowledge, are your immunizations up to date?
C) Have you ever worked in an occupation where you might have been exposed to toxins?
, Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 925
D) Has anyone in your family ever experienced symptoms similar to yours?
Ans: A
Feedback:
Signs or symptoms of hepatic dysfunction indicate a need to assess for alcohol use. Immunization status,
occupational risks, and family history are also relevant considerations, but alcohol use is a more
common etiologic factor in liver disease.
8. A nurse is participating in the emergency care of a patient who has just developed variceal bleeding.
What intervention should the nurse anticipate?
A) Infusion of intravenous heparin
B) IV administration of albumin
C) STAT administration of vitamin K by the intramuscular route
D) IV administration of octreotide (Sandostatin)
Ans: D
Feedback:
Octreotide (Sandostatin)a synthetic analog of the hormone somatostatinis effective in decreasing
bleeding from esophageal varices, and lacks the vasoconstrictive effects of vasopressin. Because of this
safety and efficacy profile, octreotide is considered the preferred treatment regimen for immediate
control of variceal bleeding. Vitamin K and albumin are not administered and heparin would exacerbate,
not alleviate, bleeding.
9. A nurse is caring for a patient with hepatic encephalopathy. While making the initial shift assessment,
the nurse notes that the patient has a flapping tremor of the hands. The nurse should document the
presence of what sign of liver disease?
A) Asterixis
B) Constructional apraxia
C) Fetor hepaticus
D) Palmar erythema
Ans: A
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