Medical-Surgical Nursing Assessment and Management of Clinical Problems 9e Chapter 44

Chapter 44: Nursing Management: Liver, Pancreas, and Biliary Tract Problems
Test Bank
MULTIPLE CHOICE
1. A 24-year-old female contracts hepatitis from contaminated food. During the acute (icteric)
phase of the patients illness, the nurse would expect serologic testing to reveal
a. antibody to hepatitis D (anti-HDV).
b. hepatitis B surface antigen (HBsAg).
c. anti-hepatitis A virus immunoglobulin G (anti-HAV IgG).
d. anti-hepatitis A virus immunoglobulin M (anti-HAV IgM).
ANS: D
Hepatitis A is transmitted through the oral-fecal route, and antibody to HAV IgM appears
during the acute phase of hepatitis A. The patient would not have antigen for hepatitis B or
antibody for hepatitis D. Anti-HAV IgG would indicate past infection and lifelong immunity.
DIF: Cognitive Level: Apply (application) REF: 1007

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
2. Administration of hepatitis B vaccine to a healthy 18-year-old patient has been effective when
a specimen of the patients blood reveals
a. HBsAg.
b. anti-HBs.
c. anti-HBc IgG.
d. anti-HBc IgM.
ANS: B
The presence of surface antibody to HBV (anti-HBs) is a marker of a positive response to the
vaccine. The other laboratory values indicate current infection with HBV.
DIF: Cognitive Level: Analyze (analysis) REF: 1008

TOP: Nursing Process: Evaluation MSC: NCLEX: Health Promotion and Maintenance
3. A 36-year-old male patient in the outpatient clinic is diagnosed with acute hepatitis C (HCV)
infection. Which action by the nurse is appropriate?
a. Schedule the patient for HCV genotype testing.
b. Administer the HCV vaccine and immune globulin.
c. Teach the patient about ribavirin (Rebetol) treatment.
d. Explain that the infection will resolve over a few months.
ANS: A
Genotyping of HCV has an important role in managing treatment and is done before drug
therapy is initiated. Because most patients with acute HCV infection convert to the chronic
state, the nurse should not teach the patient that the HCV will resolve in a few months.
Immune globulin or vaccine is not available for HCV. Ribavirin is used for chronic HCV
infection.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
4. The nurse will plan to teach the patient diagnosed with acute hepatitis B about
a. side effects of nucleotide analogs.
b. measures for improving the appetite.
c. ways to increase activity and exercise.
d. administering a-interferon (Intron A).
ANS: B
Maintaining adequate nutritional intake is important for regeneration of hepatocytes.
Interferon and antivirals may be used for chronic hepatitis B, but they are not prescribed for
acute hepatitis B infection. Rest is recommended.

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
5. The nurse administering a-interferon and ribavirin (Rebetol) to a patient with chronic
hepatitis C will plan to monitor for
a. leukopenia.
b. hypokalemia.
c. polycythemia.
d. hypoglycemia.
ANS: A
Therapy with ribavirin and a-interferon may cause leukopenia. The other problems are not
associated with this drug therapy.

6. Which information given by a 70-year-old patient during a health history indicates to the
nurse that the patient should be screened for hepatitis C?
a. The patient had a blood transfusion in 2005.
b. The patient used IV drugs about 20 years ago.
c. The patient frequently eats in fast-food restaurants.
d. The patient traveled to a country with poor sanitation.
ANS: B
Any patient with a history of IV drug use should be tested for hepatitis C. Blood transfusions
given after 1992 (when an antibody test for hepatitis C became available) do not pose a risk
for hepatitis C. Hepatitis C is not spread by the oral-fecal route and therefore is not caused by
contaminated food or by traveling in underdeveloped countries.

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance
7. A 55-year-old patient admitted with an abrupt onset of jaundice and nausea has abnormal liver
function studies but serologic testing is negative for viral causes of hepatitis. Which question
by the nurse is most appropriate?
a. Is there any history of IV drug use?
b. Do you use any over-the-counter drugs?
c. Are you taking corticosteroids for any reason?
d. Have you recently traveled to a foreign country?
ANS: B
The patients symptoms, lack of antibodies for hepatitis, and the abrupt onset of symptoms
suggest toxic hepatitis, which can be caused by commonly used over-the-counter drugs such
as acetaminophen (Tylenol). Travel to a foreign country and a history of IV drug use are risk
factors for viral hepatitis. Corticosteroid use does not cause the symptoms listed.

8. Which data will the nurse monitor in relation to the 4+ pitting edema assessed in a patient
with cirrhosis?
a. Hemoglobin
b. Temperature
c. Activity level
d. Albumin level
ANS: D
The low oncotic pressure caused by hypoalbuminemia is a major pathophysiologic factor in
the development of edema. The other parameters should also be monitored, but they are not
directly associated with the patients current symptoms.

9. Which topic is most important to include in patient teaching for a 41-year-old patient
diagnosed with early alcoholic cirrhosis?
a. Maintaining good nutrition
b. Avoiding alcohol ingestion
c. Taking lactulose (Cephulac)
d. Using vitamin B supplements
ANS: B
The disease progression can be stopped or reversed by alcohol abstinence. The other
interventions may be used when cirrhosis becomes more severe to decrease symptoms or
complications, but the priority for this patient is to stop the progression of the disease.
DIF: Cognitive Level: Apply (application) REF: 1015-1016

10. A serum potassium level of 3.2 mEq/L (3.2 mmol/L) is reported for a patient with cirrhosis
who has scheduled doses of spironolactone (Aldactone) and furosemide (Lasix). due. Which
action should the nurse take?
a. Administer both drugs.
b. Administer the spironolactone.
c. Withhold the spironolactone and administer the furosemide.
d. Withhold both drugs until discussed with the health care provider.
ANS: B
Spironolactone is a potassium-sparing diuretic and will help increase the patients potassium
level. The nurse does not need to talk with the doctor before giving the spironolactone,
although the health care provider should be notified about the low potassium value. The
furosemide will further decrease the patients potassium level and should be held until the
nurse talks with the health care provider.

11. Which action should the nurse take to evaluate treatment effectiveness for a patient who has
hepatic encephalopathy?
a. Request that the patient stand on one foot.
b. Ask the patient to extend both arms forward.
c. Request that the patient walk with eyes closed.
d. Ask the patient to perform the Valsalva maneuver.
ANS: B
Extending the arms allows the nurse to check for asterixis, a classic sign of hepatic
encephalopathy. The other tests might also be done as part of the neurologic assessment but
would not be diagnostic for hepatic encephalopathy.

12. Which finding indicates to the nurse that lactulose (Cephulac) is effective for a 72-year-old
man who has advanced cirrhosis?
a.The patient is alert and oriented.
b.The patient denies nausea or anorexia.
c.The patients bilirubin level decreases.
d.The patient has at least one stool daily.
ANS: A
The purpose of lactulose in the patient with cirrhosis is to lower ammonia levels and prevent
encephalopathy. Although lactulose may be used to treat constipation, that is not the purpose
for this patient. Lactulose will not decrease nausea and vomiting or lower bilirubin levels.

TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
13. A 53-year-old patient is being treated for bleeding esophageal varices with balloon
tamponade. Which nursing action will be included in the plan of care?
a. Instruct the patient to cough every hour.
b. Monitor the patient for shortness of breath.
c. Verify the position of the balloon every 4 hours.
d. Deflate the gastric balloon if the patient reports nausea.
ANS: B
The most common complication of balloon tamponade is aspiration pneumonia. In addition, if
the gastric balloon ruptures, the esophageal balloon may slip upward and occlude the airway.
Coughing increases the pressure on the varices and increases the risk for bleeding. Balloon
position is verified after insertion and does not require further verification. The esophageal
balloon is deflated every 8 to 12 hours to avoid necrosis, but if the gastric balloon is deflated,
the esophageal balloon may occlude the airway.

14. To detect possible complications in a patient with severe cirrhosis who has bleeding
esophageal varices, it is most important for the nurse to monitor
a. bilirubin levels.
b. ammonia levels.
c. potassium levels.
d. prothrombin time.
ANS: B
The protein in the blood in the gastrointestinal (GI) tract will be absorbed and may result in an
increase in the ammonia level because the liver cannot metabolize protein very well. The
prothrombin time, bilirubin, and potassium levels should also be monitored, but they will not
be affected by the bleeding episode.

15. A 38-year-old patient with cirrhosis has ascites and 4+ edema of the feet and legs. Which
nursing action will be included in the plan of care?
a. Restrict daily dietary protein intake.
b. Reposition the patient every 4 hours.
c. Place the patient on a pressure-relieving mattress.
d. Perform passive range of motion daily.
ANS: C
The pressure-relieving mattress will decrease the risk for skin breakdown for this patient.
Adequate dietary protein intake is necessary in patients with ascites to improve oncotic
pressure. Repositioning the patient every 4 hours will not be adequate to maintain skin
integrity. Passive range of motion will not take the pressure off areas such as the sacrum that
are vulnerable to breakdown.

16. Which finding indicates to the nurse that a patients transjugular intrahepatic portosystemic
shunt (TIPS) placed 3 months ago has been effective?
a. Increased serum albumin level
b. Decreased indirect bilirubin level
c. Improved alertness and orientation
d. Fewer episodes of bleeding varices
ANS: D
TIPS is used to lower pressure in the portal venous system and decrease the risk of bleeding
from esophageal varices. Indirect bilirubin level and serum albumin levels are not affected by
shunting procedures. TIPS will increase the risk for hepatic encephalopathy.

17. To prepare a 56-year-old male patient with ascites for paracentesis, the nurse
a. places the patient on NPO status.
b. assists the patient to lie flat in bed.
c. asks the patient to empty the bladder.
d. positions the patient on the right side.
ANS: C
The patient should empty the bladder to decrease the risk of bladder perforation during the
procedure. The patient would be positioned in Fowlers position and would not be able to lie
flat without compromising breathing. Because no sedation is required for paracentesis, the
patient does not need to be NPO.

18. Which finding is most important for the nurse to communicate to the health care provider
about a patient who received a liver transplant 1 week ago?
a. Dry palpebral and oral mucosa
b. Crackles at bilateral lung bases
c. Temperature 100.8 F (38.2 C)
d. No bowel movement for 4 days
ANS: C
The risk of infection is high in the first few months after liver transplant and fever is
frequently the only sign of infection. The other patient data indicate the need for further
assessment or nursing actions and might be communicated to the health care provider, but
they do not indicate a need for urgent action.

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity
19. Which laboratory test result will the nurse monitor when evaluating the effects of therapy for
a 62-year-old female patient who has acute pancreatitis?
a. Calcium
b. Bilirubin
c. Amylase
d. Potassium
ANS: C
Amylase is elevated in acute pancreatitis. Although changes in the other values may occur,
they would not be useful in evaluating whether the prescribed therapies have been effective.

20. Which assessment finding would the nurse need to report most quickly to the health care
provider regarding a patient with acute pancreatitis?
a. Nausea and vomiting
b. Hypotonic bowel sounds
c. Abdominal tenderness and guarding
d. Muscle twitching and finger numbness
ANS: D
Muscle twitching and finger numbness indicate hypocalcemia, which may lead to tetany
unless calcium gluconate is administered. Although the other findings should also be reported
to the health care provider, they do not indicate complications that require rapid action.

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
21. The nurse will ask a 64-year-old patient being admitted with acute pancreatitis specifically
about a history of
a. diabetes mellitus.
b. high-protein diet.
c. cigarette smoking.
d. alcohol consumption.
ANS: D
Alcohol use is one of the most common risk factors for pancreatitis in the United States.
Cigarette smoking, diabetes, and high-protein diets are not risk factors.
DIF: Cognitive Level: Understand (comprehension) REF: 1030

22. The nurse will teach a patient with chronic pancreatitis to take the prescribed pancrelipase
(Viokase)
a. at bedtime.
b. in the morning.
c. with each meal.
d. for abdominal pain.
ANS: C
Pancreatic enzymes are used to help with digestion of nutrients and should be taken with
every meal.

23. The nurse recognizes that teaching a 44-year-old woman following a laparoscopic
cholecystectomy has been effective when the patient states which of the following?
a. I can expect yellow-green drainage from the incision for a few days.
b. I can remove the bandages on my incisions tomorrow and take a shower.
c. I should plan to limit my activities and not return to work for 4 to 6 weeks.
d. I will always need to maintain a low-fat diet since I no longer have a
gallbladder.
ANS: B
After a laparoscopic cholecystectomy, the patient will have Band-Aids in place over the
incisions. Patients are discharged the same (or next) day and have few restrictions on activities
of daily living. Drainage from the incisions would be abnormal, and the patient should be
instructed to call the health care provider if this occurs. A low-fat diet may be recommended
for a few weeks after surgery but will not be a life-long requirement.

24. The nurse is caring for a 73-year-old man who has cirrhosis. Which data obtained by the nurse
during the assessment will be of most concern?
a. The patient complains of right upper-quadrant pain with palpation.
b. The patients hands flap back and forth when the arms are extended.
c. The patient has ascites and a 2-kg weight gain from the previous day.
d. The patients skin has multiple spider-shaped blood vessels on the abdomen.
ANS: B
Asterixis indicates that the patient has hepatic encephalopathy, and hepatic coma may occur.
The spider angiomas and right upper quadrant abdominal pain are not unusual for the patient
with cirrhosis and do not require a change in treatment. The ascites and weight gain indicate
the need for treatment but not as urgently as the changes in neurologic status.

25. A 49-year-old female patient with cirrhosis and esophageal varices has a new prescription for
propranolol (Inderal). Which finding is the best indicator that the medication has been
effective?
a. The patient reports no chest pain.
b. Blood pressure is 140/90 mm Hg.
c. Stools test negative for occult blood.
d. The apical pulse rate is 68 beats/minute.
ANS: C
Because the purpose of b-blocker therapy for patients with esophageal varices is to decrease
the risk for bleeding from esophageal varices, the best indicator of the effectiveness for
propranolol is the lack of blood in the stools. Although propranolol is used to treat
hypertension, angina, and tachycardia, the purpose for use in this patient is to decrease the risk
for bleeding from esophageal varices.

26. Which response by the nurse best explains the purpose of ranitidine (Zantac) for a patient
admitted with bleeding esophageal varices?
a.The medication will reduce the risk for aspiration.
b.The medication will inhibit development of gastric ulcers.
c.The medication will prevent irritation of the enlarged veins.
d.The medication will decrease nausea and improve the appetite.
ANS: C
Esophageal varices are dilated submucosal veins. The therapeutic action of H2-receptor
blockers in patients with esophageal varices is to prevent irritation and bleeding from the
varices caused by reflux of acid gastric contents. Although ranitidine does decrease the risk
for peptic ulcers, reduce nausea, and help prevent aspiration pneumonia, these are not the
primary purposes for H2-receptor blockade in this patient.

27. When taking the blood pressure (BP) on the right arm of a patient with severe acute
pancreatitis, the nurse notices carpal spasms of the patients right hand. Which action should
the nurse take next?
a. Ask the patient about any arm pain.
b. Retake the patients blood pressure.
c. Check the calcium level in the chart.
d. Notify the health care provider immediately.
ANS: C
The patient with acute pancreatitis is at risk for hypocalcemia, and the assessment data
indicate a positive Trousseaus sign. The health care provider should be notified after the
nurse checks the patients calcium level. There is no indication that the patient needs to have
the BP rechecked or that there is any arm pain.

28. A 67-year-old male patient with acute pancreatitis has a nasogastric (NG) tube to suction and
is NPO. Which information obtained by the nurse indicates that these therapies have been
effective?
a. Bowel sounds are present.
b. Grey Turner sign resolves.
c. Electrolyte levels are normal.
d. Abdominal pain is decreased.
ANS: D
NG suction and NPO status will decrease the release of pancreatic enzymes into the pancreas
and decrease pain. Although bowel sounds may be hypotonic with acute pancreatitis, the
presence of bowel sounds does not indicate that treatment with NG suction and NPO status
has been effective. Electrolyte levels may be abnormal with NG suction and must be replaced
by appropriate IV infusion. Although Grey Turner sign will eventually resolve, it would not be
appropriate to wait for this to occur to determine whether treatment was effective.

29. Which assessment finding is of most concern for a 46-year-old woman with acute
pancreatitis?
a. Absent bowel sounds
b. Abdominal tenderness
c. Left upper quadrant pain
d. Palpable abdominal mass
ANS: D
A palpable abdominal mass may indicate the presence of a pancreatic abscess, which will
require rapid surgical drainage to prevent sepsis. Absent bowel sounds, abdominal tenderness,
and left upper quadrant pain are common in acute pancreatitis and do not require rapid action
to prevent further complications.

30. Which action will be included in the care for a patient who has recently been diagnosed with
asymptomatic nonalcoholic fatty liver disease (NAFLD)?
a. Teach symptoms of variceal bleeding.
b. Draw blood for hepatitis serology testing.
c. Discuss the need to increase caloric intake.
d. Review the patients current medication list.
ANS: D
Some medications can increase the risk for NAFLD, and they should be eliminated. NAFLD
is not associated with hepatitis, weight loss is usually indicated, and variceal bleeding would
not be a concern in a patient with asymptomatic NAFLD.

31. A 34-year old patient with chronic hepatitis C infection has several medications prescribed.
Which medication requires further discussion with the health care provider before
administration?
a. Ribavirin (Rebetol, Copegus) 600 mg PO bid
b. Pegylated a-interferon (PEG-Intron, Pegasys) SQ daily
c. Diphenhydramine (Benadryl) 25 mg PO every 4 hours PRN itching
d. Dimenhydrinate (Dramamine) 50 mg PO every 6 hours PRN nausea
ANS: B
Pegylated a-interferon is administered weekly. The other medications are appropriate for a
patient with chronic hepatitis C infection.

32. During change-of-shift report, the nurse learns about the following four patients. Which
patient requires assessment first?
a. 40-year-old with chronic pancreatitis who has gnawing abdominal pain
b. 58-year-old who has compensated cirrhosis and is complaining of anorexia
c. 55-year-old with cirrhosis and ascites who has an oral temperature of 102 F
(38.8 C)
d. 36-year-old recovering from a laparoscopic cholecystectomy who has severe
shoulder pain
ANS: C
This patients history and fever suggest possible spontaneous bacterial peritonitis, which
would require rapid assessment and interventions such as antibiotic therapy. The clinical
manifestations for the other patients are consistent with their diagnoses and do not indicate
complications are occurring.

OBJ: Special Questions: Multiple Patients
TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment
33. Which goal has the highest priority in the plan of care for a 26-year-old homeless patient
admitted with viral hepatitis who has severe anorexia and fatigue?
a. Increase activity level.
b. Maintain adequate nutrition.
c. Establish a stable environment.
d. Identify sources of hepatitis exposure.
ANS: B
The highest priority outcome is to maintain nutrition because adequate nutrition is needed for
hepatocyte regeneration. Finding a home for the patient and identifying the source of the
infection would be appropriate activities, but they do not have as high a priority as ensuring
adequate nutrition. Although the patients activity level will be gradually increased, rest is
indicated during the acute phase of hepatitis.

OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning
34. Which action should the nurse in the emergency department take first for a new patient who is
vomiting blood?
a. Insert a large-gauge IV catheter.
b. Draw blood for coagulation studies.
c. Check blood pressure (BP), heart rate, and respirations.
d. Place the patient in the supine position.
ANS: C
The nurses first action should be to determine the patients hemodynamic status by assessing
vital signs. Drawing blood for coagulation studies and inserting an IV catheter are also
appropriate. However, the vital signs may indicate the need for more urgent actions. Because
aspiration is a concern for this patient, the nurse will need to assess the patients vital signs
and neurologic status before placing the patient in a supine position.
DIF: Cognitive Level: Apply (application) REF: 1032-1033 | 1040

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation
35. The nurse is planning care for a 48-year-old woman with acute severe pancreatitis. The
highest priority patient outcome is
a. maintaining normal respiratory function.
b. expressing satisfaction with pain control.
c. developing no ongoing pancreatic disease.
d. having adequate fluid and electrolyte balance.
ANS: A
Respiratory failure can occur as a complication of acute pancreatitis, and maintenance of
adequate respiratory function is the priority goal. The other outcomes would also be
appropriate for the patient.

36. The nurse is caring for a 36-year-old patient with pancreatic cancer. Which nursing action is
the highest priority?
a. Offer psychologic support for depression.
b. Offer high-calorie, high-protein dietary choices.
c. Administer prescribed opioids to relieve pain as needed.
d. Teach about the need to avoid scratching any pruritic areas.
ANS: C
Effective pain management will be necessary in order for the patient to improve nutrition, be
receptive to teaching, or manage anxiety or depression.

37. Which assessment information will be most important for the nurse to report to the health care
provider about a patient with acute cholecystitis?
a. The patients urine is bright yellow.
b. The patients stools are tan colored.
c. The patient has increased pain after eating.
d. The patient complains of chronic heartburn.
ANS: B
Tan or grey stools indicate biliary obstruction, which requires rapid intervention to resolve.
The other data are not unusual for a patient with this diagnosis, although the nurse would also
report the other assessment information to the health care provider.

38. A 51-year-old woman had an incisional cholecystectomy 6 hours ago. The nurse will place the
highest priority on assisting the patient to
a. choose low-fat foods from the menu.
b. perform leg exercises hourly while awake.
c. ambulate the evening of the operative day.
d. turn, cough, and deep breathe every 2 hours.
ANS: D
Postoperative nursing care after a cholecystectomy focuses on prevention of respiratory
complications because the surgical incision is high in the abdomen and impairs coughing and
deep breathing. The other nursing actions are also important to implement but are not as high
a priority as ensuring adequate ventilation.
39. For a patient with cirrhosis, which of the following nursing actions can the registered nurse
(RN) delegate to unlicensed assistive personnel (UAP)?
a.Assessing the patient for jaundice
b.Providing oral hygiene after a meal
c.Palpating the abdomen for distention
d.Assisting the patient to choose the diet
ANS: B
Providing oral hygiene is within the scope of UAP. Assessments and assisting patients to
choose therapeutic diets are nursing actions that require higher-level nursing education and
scope of practice and would be delegated to licensed practical/vocational nurses (LPNs/LVNs)
or RNs.

OBJ: Special Questions: Delegation TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
40. Which action will the nurse include in the plan of care for a patient who has been diagnosed
with chronic hepatitis B?
a. Advise limiting alcohol intake to 1 drink daily.
b. Schedule for liver cancer screening every 6 months.
c. Initiate administration of the hepatitis C vaccine series.
d. Monitor anti-hepatitis B surface antigen (anti-HBs) levels annually.
ANS: B
Patients with chronic hepatitis are at higher risk for development of liver cancer, and should
be screened for liver cancer every 6 to 12 months. Patients with chronic hepatitis are advised
to completely avoid alcohol. There is no hepatitis C vaccine. Because anti-HBs is present
whenever there has been a past hepatitis B infection or vaccination, there is no need to
regularly monitor for this antibody.

41. A patient born in 1955 had hepatitis A infection 1 year ago. According to Centers for Disease
Control and Prevention (CDC) guidelines, which action should the nurse include in care when
the patient is seen for a routine annual physical exam?
a. Start the hepatitis B immunization series.
b. Teach the patient about hepatitis A immune globulin.
c. Ask whether the patient has been screened for hepatitis C.
d. Test for anti-hepatitis-A virus immune globulin M (anti-HAV-IgM).
ANS: C
Current CDC guidelines indicate that all patients who were born between 1945 and 1965
should be screened for hepatitis C because many individuals who are positive have not been
diagnosed. Although routine hepatitis B immunization is recommended for infants, children,
and adolescents, vaccination for hepatitis B is recommended only for adults at risk for blood-
borne infections. Because the patient has already had hepatitis A, immunization and anti-HAV
IgM levels will not be needed.

TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance
42. A 23-year-old has been admitted with acute liver failure. Which assessment data are most
important for the nurse to communicate to the health care provider?
a. Asterixis and lethargy
b. Jaundiced sclera and skin
c. Elevated total bilirubin level
d. Liver 3 cm below costal margin
ANS: A
The patients findings of asterixis and lethargy are consistent with grade 2 hepatic
encephalopathy. Patients with acute liver failure can deteriorate rapidly from grade 1 or 2 to
grade 3 or 4 hepatic encephalopathy and need early transfer to a transplant center. The other
findings are typical of patients with hepatic failure and would be reported but would not
indicate a need for an immediate change in the therapeutic plan.

43. A 36-year-old female patient is receiving treatment for chronic hepatitis C with pegylated
interferon (PEG-Intron, Pegasys), ribavirin (Rebetol), and telaprevir (Incivek). Which finding
is most important to communicate to the health care provider?
a. Weight loss of 2 lb (1 kg)
b. Positive urine pregnancy test
c. Hemoglobin level of 10.4 g/dL
d. Complaints of nausea and anorexia
ANS: B
Because ribavirin is teratogenic, the medication will need to be discontinued immediately.
Anemia, weight loss, and nausea are common adverse effects of the prescribed regimen and
may require actions such as patient teaching, but they would not require immediate cessation
of the therapy.

44. A nurse is considering which patient to admit to the same room as a patient who had a liver
transplant 3 weeks ago and is now hospitalized with acute rejection. Which patient would be
the best choice?
a. Patient who is receiving chemotherapy for liver cancer
b. Patient who is receiving treatment for acute hepatitis C
c. Patient who has a wound infection after cholecystectomy
d. Patient who requires pain management for chronic pancreatitis
ANS: D
The patient with chronic pancreatitis does not present an infection risk to the
immunosuppressed patient who had a liver transplant. The other patients either are at risk for
infection or currently have an infection, which will place the immunosuppressed patient at
risk for infection.

OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
45. In reviewing the medical record shown in the accompanying figure for a patient admitted with
acute pancreatitis, the nurse sees that the patient has a positive Cullens sign. Indicate the area
where the nurse will assess for this change.
a. 1
b. 2
c. 3
d. 4
ANS: C
The area around the umbilicus should be indicated. Cullens sign consists of ecchymosis
around the umbilicus. Cullens sign occurs because of seepage of bloody exudates from the
inflamed pancreas and indicates severe acute pancreatitis.
DIF: Cognitive Level: Understand (comprehension) REF: 1031

MULTIPLE RESPONSE
1. After an unimmunized individual is exposed to hepatitis B through a needle-stick injury,

which actions will the nurse plan to take (select all that apply)?
a.Administer hepatitis B vaccine.
b.Test for antibodies to hepatitis B.
c.Teach about a-interferon therapy.
d.Give hepatitis B immune globulin.
e. Teach about choices for oral antiviral therapy.
ANS: A, B, D
The recommendations for hepatitis B exposure include both vaccination and immune globulin
administration. In addition, baseline testing for hepatitis B antibodies will be needed.
Interferon and oral antivirals are not used for hepatitis B prophylaxis.

TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment

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Chapter 44: Nursing Management: Liver, Pancreas, and Biliary Tract Problems

DIF: Cognitive Level: Apply (application) REF: 1007

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DIF: Cognitive Level: Apply (application) REF: 1023

DIF: Cognitive Level: Apply (application) REF: 1025-1026

DIF: Cognitive Level: Apply (application) REF: 1021

DIF: Cognitive Level: Apply (application) REF: 1025

DIF: Cognitive Level: Apply (application) REF: 1022-1023

DIF: Cognitive Level: Apply (application) REF: 1025

DIF: Cognitive Level: Apply (application) REF: 1029

DIF: Cognitive Level: Apply (application) REF: 1031

DIF: Cognitive Level: Apply (application) REF: 1033

DIF: Cognitive Level: Understand (comprehension) REF: 1030

DIF: Cognitive Level: Apply (application) REF: 1032

DIF: Cognitive Level: Apply (application) REF: 1041

DIF: Cognitive Level: Apply (application) REF: 1021

DIF: Cognitive Level: Apply (application) REF: 1022

DIF: Cognitive Level: Apply (application) REF: 1019

DIF: Cognitive Level: Apply (application) REF: 1033

DIF: Cognitive Level: Apply (application) REF: 1032

DIF: Cognitive Level: Apply (application) REF: 1031

DIF: Cognitive Level: Apply (application) REF: 1016-1017

DIF: Cognitive Level: Apply (application) REF: 1013

DIF: Cognitive Level: Analyze (analysis) REF: 1021

DIF: Cognitive Level: Apply (application) REF: 1015

DIF: Cognitive Level: Apply (application) REF: 1032-1033 | 1040

DIF: Cognitive Level: Apply (application) REF: 1031

DIF: Cognitive Level: Apply (application) REF: 1035-1036

DIF: Cognitive Level: Apply (application) REF: 1037

DIF: Cognitive Level: Apply (application) REF: 15-16

DIF: Cognitive Level: Apply (application) REF: 1028

DIF: Cognitive Level: Analyze (analysis) REF: 1015

DIF: Cognitive Level: Apply (application) REF: 1021

DIF: Cognitive Level: Apply (application) REF: 1013

DIF: Cognitive Level: Analyze (analysis) REF: 1029

DIF: Cognitive Level: Understand (comprehension) REF: 1031

1. After an unimmunized individual is exposed to hepatitis B through a needle-stick injury,

DIF: Cognitive Level: Apply (application) REF: 1014-1015

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