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Medical Surgical Nursing Assessment and Management of Clinical Problems (Chapter-44)
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Medical Surgical Nursing Assessment and Management of Clinical Problems (Chapter-44)
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Chapter 44: Nursing Management: Liver, Pancreas, and Biliary Tract ProblemsTest Bank
MULTIPLE CHOICE
1. A 24-year-old female contracts hepatitis from contaminated food. During the acute (icteric)
phase of the patient’s 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 patient’s 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.
, DIF: Cognitive Level: Apply (application) REF: 1010
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.
DIF: Cognitive Level: Apply (application) REF: 1015
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.
DIF: Cognitive Level: Apply (application) REF: 1013
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
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.
DIF: Cognitive Level: Apply (application) REF: 1009 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 patient’s 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.
DIF: Cognitive Level: Apply (application) REF: 1027 TOP: Nursing
Process: Assessment MSC: NCLEX: Physiological Integrity
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 patient’s current symptoms.
DIF: Cognitive Level: Apply (application) REF: 1019 TOP: Nursing
Process: Assessment MSC: NCLEX: Physiological Integrity
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
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
,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 patient’s 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 patient’s potassium level and should be held until the
nurse talks with the health care provider.
DIF: Cognitive Level: Apply (application) REF: 1022 TOP: Nursing
Process: Implementation MSC: NCLEX: Physiological Integrity
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.
DIF: Cognitive Level: Apply (application) REF: 1021 TOP: Nursing
Process: Assessment MSC: NCLEX: Physiological Integrity
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 patient’s 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.
DIF: Cognitive Level: Apply (application) REF: 1023 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.
DIF: Cognitive Level: Apply (application) REF: 1025-1026 TOP: Nursing
Process: Implementation MSC: NCLEX: Physiological Integrity
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.
DIF: Cognitive Level: Apply (application) REF: 1021 TOP: Nursing
Process: Assessment MSC: NCLEX: Physiological Integrity
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.
, DIF: Cognitive Level: Apply (application) REF: 1025 TOP: Nursing
Process: Implementation MSC: NCLEX: Physiological Integrity
16. Which finding indicates to the nurse that a patient’s 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.
DIF: Cognitive Level: Apply (application) REF: 1022-1023
TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
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 Fowler’s 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.
DIF: Cognitive Level: Apply (application) REF: 1025 TOP: Nursing
Process: Implementation MSC: NCLEX: Physiological Integrity
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.
DIF: Cognitive Level: Apply (application) REF: 1029
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.
DIF: Cognitive Level: Apply (application) REF: 1031
TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
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.
DIF: Cognitive Level: Apply (application) REF: 1033
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC:
NCLEX: Physiological Integrity
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
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
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.
DIF: Cognitive Level: Apply (application) REF: 1032 TOP: Nursing
Process: Implementation MSC: NCLEX: Physiological Integrity
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.
DIF: Cognitive Level: Apply (application) REF: 1041 TOP: Nursing
Process: Evaluation MSC: NCLEX: Physiological Integrity
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 patient’s 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 patient’s 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.
DIF: Cognitive Level: Apply (application) REF: 1021
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC:
NCLEX: Physiological Integrity
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.
DIF: Cognitive Level: Apply (application) REF: 1022 TOP: Nursing
Process: Evaluation MSC: NCLEX: Physiological Integrity
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.
DIF: Cognitive Level: Apply (application) REF: 1019 TOP: Nursing
Process: Implementation MSC: NCLEX: Physiological Integrity
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 patient’s right hand. Which action should
the nurse take next?
a. Ask the patient about any arm pain.
b. Retake the patient’s 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 Trousseau’s sign. The health care provider should be notified after the nurse checks
the patient’s calcium level. There is no indication that the patient needs to have the BP
rechecked or that there is any arm pain.
DIF: Cognitive Level: Apply (application) REF: 1033 TOP: Nursing
Process: Assessment MSC: NCLEX: Physiological Integrity
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.
DIF: Cognitive Level: Apply (application) REF: 1032 TOP: Nursing
Process: Evaluation MSC: NCLEX: Physiological Integrity
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.
DIF: Cognitive Level: Apply (application) REF: 1031
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC:
NCLEX: Physiological Integrity
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 patient’s 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.
DIF: Cognitive Level: Apply (application) REF: 1016-1017 TOP: Nursing
Process: Planning MSC: NCLEX: Physiological Integrity
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