Chapter 6: Care of the Patient with a Gallbladder, Liver, Biliary Tract, or Exocrine Pancreatic Disorder
MULTIPLE CHOICE
- The nurse clarifies that unconjugated bilirubin, which is made up of broken-down red cells, is:
| a. | stored in the gallbladder to make bile. |
| b. | water insoluble bilirubin that must be converted by the liver. |
| c. | a by-product which is excreted directly into the bowel for excretion. |
| d. | necessary for digestion of fats. |
ANS: B
Unconjugated bilirubin is a water-insoluble product that must be converted in the liver to conjugated bilirubin (water soluble) so that it may be excreted through the bowel.
DIF: Cognitive Level: Analysis REF: Page 233 OBJ: 1
TOP: Bilirubin KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- The patient with cirrhosis has an albumin of 2.8 g/dL. The nurse is aware that normal is 3.5 g/dL to 5 g/dL. Based on these findings, what would the nurse expect the patient to exhibit?
| a. | Jaundice |
| b. | Edema |
| c. | Copious urine output |
| d. | Pallor |
ANS: B
Low serum albumin levels result also from excessive loss of albumin into urine or into third-space volumes, causing ascites or edema.
DIF: Cognitive Level: Analysis REF: Page 234 OBJ: 1
TOP: Cirrhosis KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
- What is an essential nursing measure to prevent injury to the patient who is to receive a paracentesis?
| a. | Have patient sign a permit |
| b. | Pad side rails |
| c. | Check for allergy to contrast media or to shellfish |
| d. | Have patient void immediately before procedure |
ANS: D
To prevent the puncturing of the bladder, the patient must void immediately before the procedure. A permit is required but it is not a safety precaution for the patient. There is no contrast media used in a paracentesis.
DIF: Cognitive Level: Application REF: Page 242 OBJ: 2
TOP: Paracentesis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- What should the nurse expect of a patient with a malabsorption of vitamin K?
| a. | Lowered hemoglobin |
| b. | Elevated hematocrit |
| c. | Increased prothrombin time |
| d. | Diminished white blood cell count |
ANS: C
Prothrombin times are increased because malabsorption of vitamin K or inability to produce the clotting factors VII, IX, and X cause the patient to have bleeding tendencies.
DIF: Cognitive Level: Analysis REF: Page 240 OBJ: 3
TOP: Cirrhosis KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
- A patient was scheduled for a laparoscopic cholecystectomy, but complications developed and he underwent an open cholecystectomy with a T-tube inserted into the common bile duct. What is the purpose of the T-tube?
| a. | To decompress the duct and relieve pain caused by stimulation of the sphincter of Oddi. |
| b. | To improve diaphragmatic expansion and prevention of atelectasis. |
| c. | To shorten postoperative recovery and hasten the healing process. |
| d. | To keep the duct open and allow drainage of the bile until edema resolves. |
ANS: D
If the stones are in the common bile duct and edema is present, a biliary drainage tube, or T-tube, will be inserted to keep the duct open and allow drainage of the bile until the edema resolves.
DIF: Cognitive Level: Comprehension REF: Page 254, Figure 6-7
OBJ: 8 TOP: Cholecystectomy
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- The nurse caring for a patient who has had an open cholecystectomy with a T-Tube will:
| a. | open the T-tube to the air so that it will drain freely. |
| b. | position and secure the drainage bag at the chest level. |
| c. | Place the collection bag so the tube is not kinked. |
| d. | Irrigate the T-tube with normal saline to ensure the free flow of bile. |
ANS: B
The T-tube is placed below the level of the common bile duct to prevent the reflux of bile. The bag must be positioned so the tube is not kinked, or bile cannot drain from the liver. Normally T-tubes are not irrigated.
DIF: Cognitive Level: Application REF: Page 255 OBJ: 8
TOP: Cholecystectomy KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- Which nursing intervention should be completed immediately after the physician has performed a needle liver biopsy?
| a. | Assisting to ambulate for the bathroom |
| b. | Keeping the patient on the right side for a minimum of 2 hours |
| c. | Taking vital signs every 4 hours |
| d. | Keeping the patient on the left side for a minimum of 4 hours |
ANS: B
Keep the patient lying on the right side for minimum of 2 hours to splint the puncture site. It compresses the liver capsule against the chest wall to decrease the risk of hemorrhage or bile leak. Vital signs are taken every 15 minutes for 30 minutes, then every 30 minutes for 2 hours.
DIF: Cognitive Level: Application REF: Page 236 OBJ: 2
TOP: Liver biopsy KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- Immediately following a liver biopsy, the patient becomes dyspneic, the pulse increases to 100, and no breath sounds can be heard on the affected side. What should the nurse suspect?
| a. | Peritonitis |
| b. | Pneumothorax |
| c. | Hemorrhage of the liver |
| d. | Pleural effusion |
ANS: B
Pneumothorax is a possible complication of paracentesis. The patient’s head of the bed should be raised slightly, but kept on the right side. Oxygen should be administered and the assessment reported to the charge nurse and documented.
DIF: Cognitive Level: Comprehension REF: Page 236 OBJ: 1
TOP: Pneumothorax KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- Which patient statement indicates that the patient requires additional teaching about an endoscopic retrograde cholangiopancreatography?
| a. | “Right after the test, I want breakfast with black coffee.” |
| b. | “The instrument will be put down my throat.” |
| c. | “I haven’t had anything to eat or drink since 9 PM last night.” |
| d. | “My doctor said I could have medicine to relax me before the test.” |
ANS: A
After the procedure, keep the patient NPO until the gag reflex returns.
DIF: Cognitive Level: Analysis REF: Page 239 OBJ: 1
TOP: Diagnostic procedures KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity
- The nurse assisting in the treatment of a patient with ruptured esophageal varices who has received vasopressin IV will carefully assess for:
| a. | Muscular twitching/spasm |
| b. | Hematuria |
| c. | Macular rash on trunk and arms |
| d. | Evidence of cardiac ischemia |
ANS: D
Vasopressin is a strong vasoconstrictor given to try to stop the hemorrhage of the varices. Unfortunately it also constricts all vessels and may cause cardiac ischemia.
DIF: Cognitive Level: Application REF: Page 242 OBJ: 3
TOP: Vasopressin KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
- What should the nurse point out as a significant advantage of the laparoscopic cholecystectomy?
| a. | Slightly more invasive, but there is less pain |
| b. | Can be performed on all patients of any age |
| c. | Can be performed even when there are large stones present in the bile duct |
| d. | Less invasive procedure |
ANS: D
The laparoscopic cholecystectomy is less invasive and causes less pain and a quick recovery. If there are large stones present a sphincterotomy is done before the laparoscopic cholecystectomy. Persons with bleeding tendencies, pathologic conditions of the abdomen, stones in the bile duct, and extensive adhesions are not good candidates.
DIF: Cognitive Level: Application REF: Page 254 OBJ: 2
TOP: Laparoscopic cholecystectomy KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- What should the nurse explain is the major purpose of the Sengstaken-Blakemore tube (S/B tube)?
| a. | Decompress the stomach |
| b. | Control esophageal varices bleeding |
| c. | A route for tube feedings |
| d. | Obtain specimen for gastric analysis |
ANS: B
The major purpose of the S/B tube is to control bleeding by pressure against the vessels in the esophagus. The two balloons of the tube are inflated to put direct pressure on the esophagus and are anchored by the inflated balloon in the stomach. The tube can suction blood from the stomach as well.
DIF: Cognitive Level: Analysis REF: Pages 242-243, Figure 6-4
OBJ: 2 TOP: SB tube KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- The patient’s cirrhosis of the liver has also caused a dilation of the veins of the lower esophagus secondary to portal hypertension, resulting in the development of the complication of:
| a. | esophageal varices. |
| b. | diverticulosis. |
| c. | Crohn disease. |
| d. | esophageal reflux (GERD). |
ANS: A
Esophageal varices (a complex of longitudinal, tortuous veins at the lower end of the esophagus) enlarge and become edematous as the result of portal hypertension.
DIF: Cognitive Level: Analysis REF: Page 242 OBJ: 3
TOP: Cirrhosis KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
- The patient with cirrhosis has a rising ammonia level and is becoming disoriented. The patient waves to the nurse as she enters the room. How should the nurse interpret this?
| a. | As an attempt to get the nurse’s attention |
| b. | As asterixis |
| c. | As an indication of respiratory obstruction from varices |
| d. | As spasticity |
ANS: B
Asterixis is the “flapping tremor” seen as the patient deteriorates into ammonia intoxication or hepatic encephalopathy.
DIF: Cognitive Level: Application REF: Page 244 OBJ: 3
TOP: Encephalopathy KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
- How does the administration of neomycin (Mycifradin) reduce the production of ammonia?
| a. | By assisting the hepatic cells to regenerate |
| b. | By reducing ascites |
| c. | By decreasing the bacteria in the gut |
| d. | By helping to digest fats and proteins |
ANS: C
The buildup of ammonia can be prevented with the use of lactulose (Chronulac) and neomycin. Ammonia is produced in the gut by bacterial action. By reducing the bacteria, less ammonia is produced.
DIF: Cognitive Level: Application REF: Page 243| Page 239, Table 6-1
OBJ: 3 TOP: Encephalopathy
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- What is the most common procedure for the removal of the gallbladder?
| a. | Laparoscopic cholecystectomy |
| b. | Cholangiography |
| c. | Open cholecystectomy |
| d. | Choledochostomy |
ANS: A
The most recently developed operative procedure, which is now the most common treatment for cholecystitis and cholelithiasis, is done by way of endoscopy. It is called laparoscopic cholecystectomy and uses laser cautery to remove the gallbladder.
DIF: Cognitive Level: Knowledge REF: Page 254 OBJ: 8
TOP: Laparoscopic cholecystectomy KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity
- What should the nurse do to prepare a patient for an oral cholecystography?
| a. | Ensure that the patient drinks 500 mL of water before testing |
| b. | Give 4 Oragrafin (ipodate) 5 minutes apart starting at 6 AM |
| c. | Administer 6 Telepaque (iopanoic acid) tablets 5 minutes apart after the evening meal |
| d. | Give a fatty meal hour before the test is started |
ANS: C