What is the primary nursing diagnosis for a 4th to 10th day postoperative liver transplant patient?
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Solution
Risk for Rejection
Risk for rejection is always a possibility, especially during the 4th to 10th day postoperatively.
You are caring for Rona, a 35-year-old female in a hepatic coma. Which evaluation criteria would be the most appropriate?
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Solution
The patient demonstrates an increase in level of consciousness.
Increased level of consciousness indicates resolving of a comatose state. Other options are important evaluation but do not evaluate a patient in a hepatic coma who is responding to external stimuli.
Which phase of hepatitis would the nurse incur strict precautionary measures at?
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Solution
Pre-icteric
Pre-icteric is the infective phase and precautionary measures should be strictly enforced. However, most patients are not always diagnosed during this phase. For Option A and C, precautionary measures should already be in placed. For Option B, there is no non-icteric phase.
A patient with severe cirrhosis of the liver develops hepatorenal syndrome. Which of the following nursing assessment data would support this?
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Solution
oliguria and azotemia
Hepatorenal syndrome is a functional disorder resulting from a redistribution of renal blood flow. Oliguria and azotemia occur abruptly as a result of this complication.
For Option B, excess organic acids are not being excreted by the damaged kidneys, resulting in an elevated concentration of hydrogen ions; decreased pH occurs, causing metabolic acidosis.
For Option C, concentration of the urine is increased with decreased renal function.
For Option D, with renal insufficiency, significant weight gain is expected due to fluid retention.
What assessment finding of a patient with acute pancreatitis would indicate a bluish discoloration around the umbilicus?
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Solution
Cullen’s sign
Cullen’s sign is associated with pancreatitis when a hemorrhage is suspected. Grey-Turner’s sign is ecchymosis in the flank area suggesting retroperitoneal bleed. Homan’s sign is cal pain elicited by the dorsiflexion of the foot and suggests deep vein thrombosis. Rovsing’s sign is associated with appendicitis when pain is felt with pressure at McBurney’s point.
A clinical manifestation of acute pancreatitis is epigastric pain. Your nursing intervention to facilitate relief of pain would place the patient in a:
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Solution
knee-chest position
Flexion of the trunk lessens the pain and decreases restlessness. Other positions do not decrease the pain.
Your patient’s ABG reveal an acidic pH, an acidic CO2 and a normal bicarbonate level. Which of the following indicates this acid-base disturbance?
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Solution
Respiratory acidosis
A pH of 7.35 indicates acidosis, as does an acidic CO2 and bicarbonate. See also: 8-Step Guide to ABG Analysis: Tic-Tac-Toe Method
To inhibit pancreatic secretions, which pharmacologic agent would you anticipate administering to a patient with acute pancreatitis?
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Solution
Somatostatin
Somatostatin, a treatment for acute pancreatitis, inhibits the release of pancreatic enzymes. Nitroglycerin (Option A) is a vasodilator and does not affect pancreatic secretions. Pancrelipase (Option C) is an enzyme that aids in the digestion and absorption of fats and proteins. Pepcid is an H2 blocker and is used to decrease gastric motility.
Which of the following tests can be useful as a diagnostic and therapeutic tool in the biliary system?
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Solution
Endoscopic retrograde cholangiopancreatography (ERCP)
ERCP permits direct visualization of the pancreatic and common bile ducts. Its therapeutic value is in retrieving gallstones from the distal and common bile ducts and dilating strictures. Ultrasonography (Option A) aids in the diagnosis of cholecystitis, gallstones, pancreatitis, and metastatic disease. It also identifies edema, inflammation, and fatty or fibrotic infiltrates or calcifications. MRI (Option B) detects hepatic neoplasms, cysts, abscesses, and hematomas. A CT Scan (Option D) can be done with our without a contrast medium. It can detect tumors, cysts, pseudocysts, abscesses, hematomas, and obstructions of the liver, biliary tract and pancreas.
During initial assessment of a patient post-endoscopy, the nurse notes absent bowel sounds, tachycardia, and abdominal distention. The nurse would anticipate:
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Solution
perforated bowel
Invasive diagnostic testing can cause perforated bowel. Ischemic bowel (Choice A) is usually not related. Peritonitis (Choice B) can be a complication after initial perforation. Hypovolemic shock (Choice C) can occur if peritonitis is allowed to continue.