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?
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
A patient with severe cirrhosis of the liver develops hepatorenal syndrome. Which of the following nursing assessment data would support this?
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.
What assessment finding of a patient with acute pancreatitis would indicate a bluish discoloration around the umbilicus?
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:
Flexion of the trunk lessens the pain and decreases restlessness. Other positions do not decrease the pain.
You are caring for Rona, a 35-year-old female in a hepatic coma. Which evaluation criteria would be the most appropriate?
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.
What is the primary nursing diagnosis for a 4th to 10th day postoperative liver transplant patient?
Risk for rejection is always a possibility, especially during the 4th to 10th day postoperatively.
Which phase of hepatitis would the nurse incur strict precautionary measures at?
Pre-icteric is the infective phase and precautionary measures should be strictly enforced. However, most patients are not always diagnosed during this phase.
During initial assessment of a patient post-endoscopy, the nurse notes absent bowel sounds, tachycardia, and abdominal distention. The nurse would anticipate:
Invasive diagnostic testing can cause perforated bowel. Ischemic bowel is usually not related. Peritonitis can be a complication after initial perforation. Hypovolemic shock can occur if peritonitis is allowed to continue.
Which of the following tests can be useful as a diagnostic and therapeutic tool in the biliary system?
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 aids in the diagnosis of cholecystitis, gallstones, pancreatitis, and metastatic disease. It also identifies edema, inflammation, and fatty or fibrotic infiltrates or calcifications. MRI detects hepatic neoplasms, cysts, abscesses, and hematomas. A CT Scan 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.
To inhibit pancreatic secretions, which pharmacologic agent would you anticipate administering to a patient with acute pancreatitis?
Somatostatin, a treatment for acute pancreatitis, inhibits the release of pancreatic enzymes. Nitroglycerin is a vasodilator and does not affect pancreatic secretions. Pancrelipase 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.
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