1. A nurse is caring for a patient with liver failure and is
performing an assessment in the knowledge of the patient’s increased
risk of bleeding. The nurse recognizes that this risk is related to
the patient’s inability to synthesize prothrombin in the liver. What
factor most likely contributes to this loss of function?
Alterations in glucose metabolism
B) Retention of bile
C) Inadequate production of albumin by hepatocytes
Inability of the liver to use vitamin K
Decreased production of several clotting
factors may be partially due to deficient absorption of vitamin K from
the GI tract. This probably is caused by the inability of liver cells
to use vitamin K to make prothrombin. This bleeding risk is unrelated
to the roles of glucose, bile salts, or albumin.
2. A nurse is performing an admission assessment of a patient with a
diagnosis of cirrhosis. What technique should the nurse use to palpate
the patient’s liver?
A) Place hand under the right lower
abdominal quadrant and press down lightly with the other hand.
Place the left hand over the abdomen and behind the left side at the
C) Place hand under right lower rib cage and press down
lightly with the other hand.
D) Hold hand 90 degrees to right
side of the abdomen and push down firmly.
To palpate the liver, the examiner
places one hand under the right lower rib cage and presses downward
with light pressure with the other hand. The liver is not on the left
side or in the right lower abdominal quadrant.
3. A patient with portal hypertension has been admitted to the
medical floor. The nurse should prioritize which of the following
assessments related to the manifestations of this health
A) Assessment of blood pressure and assessment for
headaches and visual changes
B) Assessments for signs and
symptoms of venous thromboembolism
C) Daily weights and abdominal
D) Blood glucose monitoring q4h
Obstruction to blood flow through the
damaged liver results in increased blood pressure (portal
hypertension) throughout the portal venous system. This can result in
varices and ascites in the abdominal cavity. Assessments related to
ascites are daily weights and abdominal girths. Portal hypertension is
not synonymous with cardiovascular hypertension and does not create a
risk for unstable blood glucose or VTE.
4. A nurse educator is teaching a group of recent nursing graduates
about their occupational risks for contracting hepatitis B. What
preventative measures should the educator promote? Select all that
B) Use of standard
C) Consumption of a vitamin-rich diet
vitamin K injections
E) Annual vitamin B12 injections
Ans: A, B
People who are at high risk,
including nurses and other health care personnel exposed to blood or
blood products, should receive active immunization. The consistent use
of standard precautions is also highly beneficial. Vitamin
supplementation is unrelated to an individual’s risk of HBV.
5. A nurse is caring for a patient with cancer of the liver whose
condition has required the insertion of a percutaneous biliary
drainage system. The nurse’s most recent assessment reveals the
presence of dark green fluid in the collection container. What is the
nurse’s best response to this assessment finding?
A) Document the
presence of normal bile output.
B) Irrigate the drainage system
with normal saline as ordered.
C) Aspirate a sample of the
drainage for culture.
D) Promptly report this assessment finding
to the primary care provider.
Bile is usually a dark green or
brownish-yellow color, so this would constitute an expected assessment
finding, with no other action necessary.
6. A patient who has undergone liver transplantation is ready to be
discharged home. Which outcome of health education should the nurse
A) The patient will obtain measurement of drainage
from the T-tube.
B) The patient will exercise three times a
C) The patient will take immunosuppressive agents as
D) The patient will monitor for signs of liver dysfunction.
The patient is given written and verbal
instructions about immunosuppressive agent doses and dosing schedules.
The patient is also instructed on steps to follow to ensure that an
adequate supply of medication is available so that there is no chance
of running out of the medication or skipping a dose. Failure to take
medications as instructed may precipitate rejection. The nurse would
not teach the patient to measure drainage from a T-tube as the patient
wouldn’t go home with a T-tube. The nurse may teach the patient about
the need to exercise or what the signs of liver dysfunction are, but
the nurse would not stress these topics over the immunosuppressive
7. A triage nurse in the emergency department is assessing a patient
who presented with complaints of general malaise. Assessment reveals
the presence of jaundice and increased abdominal girth. What
assessment question best addresses the possible etiology of this
A) “How many alcoholic drinks do you
typically consume in a week?”
B) “To the best of your knowledge,
are your immunizations up to date?”
C) “Have you ever worked in
an occupation where you might have been exposed to toxins?”
“Has anyone in your family ever experienced symptoms similar to yours?”
Signs or symptoms of hepatic dysfunction
indicate a need to assess for alcohol use. Immunization status,
occupational risks, and family history are also relevant
considerations, but alcohol use is a more common etiologic factor in
8. A nurse is participating in the emergency care of a patient who
has just developed variceal bleeding. What intervention should the
A) Infusion of intravenous heparin
administration of albumin
C) STAT administration of vitamin K by
the intramuscular route
D) IV administration of octreotide (Sandostatin)
Octreotide (Sandostatin)—a synthetic
analog of the hormone somatostatin—is effective in decreasing bleeding
from esophageal varices, and lacks the vasoconstrictive effects of
vasopressin. Because of this safety and efficacy profile, octreotide
is considered the preferred treatment regimen for immediate control of
variceal bleeding. Vitamin K and albumin are not administered and
heparin would exacerbate, not alleviate, bleeding.
9. A nurse is caring for a patient with hepatic encephalopathy. While
making the initial shift assessment, the nurse notes that the patient
has a flapping tremor of the hands. The nurse should document the
presence of what sign of liver disease?
C) Fetor hepaticus
D) Palmar erythema
The nurse will document that a patient
exhibiting a flapping tremor of the hands is demonstrating asterixis.
While constructional apraxia is a motor disturbance, it is the
inability to reproduce a simple figure. Fetor hepaticus is a sweet,
slightly fecal odor to the breath and not associated with a motor
disturbance. Skin changes associated with liver dysfunction may
include palmar erythema, which is a reddening of the palms, but is not
a flapping tremor.
10. A local public health nurse is informed that a cook in a local
restaurant has been diagnosed with hepatitis A. What should the nurse
advise individuals to obtain who ate at this restaurant and have never
received the hepatitis A vaccine?
A) The hepatitis A
B) Albumin infusion
C) The hepatitis A and B
D) An immune globulin injection
For people who have not been previously
vaccinated, hepatitis A can be prevented by the intramuscular
administration of immune globulin during the incubation period, if
given within 2 weeks of exposure. Administration of the hepatitis A
vaccine will not protect the patient exposed to hepatitis A, as
protection will take a few weeks to develop after the first dose of
the vaccine. The hepatitis B vaccine provides protection again the
hepatitis B virus, but plays no role in protection for the patient
exposed to hepatitis A. Albumin confers no therapeutic benefit.
11. A participant in a health fair has asked the nurse about the role
of drugs in liver disease. What health promotion teaching has the most
potential to prevent drug-induced hepatitis?
A) Finish all
prescribed courses of antibiotics, regardless of symptom
B) Adhere to dosing recommendations of OTC
C) Ensure that expired medications are disposed of
D) Ensure that pharmacists regularly review drug regimens
for potential interactions.
Although any medication can affect liver
function, use of acetaminophen (found in many over-the-counter
medications used to treat fever and pain) has been identified as the
leading cause of acute liver failure. Finishing prescribed antibiotics
and avoiding expired medications are unrelated to this disease. Drug
interactions are rarely the cause of drug-induced hepatitis.
12. Diagnostic testing has revealed that a patient’s hepatocellular
carcinoma (HCC) is limited to one lobe. The nurse should anticipate
that this patient’s plan of care will focus on what
D) Laser hyperthermia
Surgical resection is the treatment of
choice when HCC is confined to one lobe of the liver and the function
of the remaining liver is considered adequate for postoperative
recovery. Removal of a lobe of the liver (lobectomy) is the most
common surgical procedure for excising a liver tumor. While
cryosurgery and liver transplantation are other surgical options for
management of liver cancer, these procedures are not performed at the
same frequency as a lobectomy. Laser hyperthermia is a nonsurgical
treatment for liver cancer.
13. A patient has been diagnosed with advanced stage breast cancer
and will soon begin aggressive treatment. What assessment findings
would most strongly suggest that the patient may have developed liver
A) Persistent fever and cognitive changes
Abdominal pain and hepatomegaly
C) Peripheral edema unresponsive
D) Spontaneous bleeding and jaundice
The early manifestations of malignancy
of the liver include pain—a continuous dull ache in the right upper
quadrant, epigastrium, or back. Weight loss, loss of strength,
anorexia, and anemia may also occur. The liver may be enlarged and
irregular on palpation. Jaundice is present only if the larger bile
ducts are occluded by the pressure of malignant nodules in the hilum
of the liver. Fever, cognitive changes, peripheral edema, and bleeding
are atypical signs.
14. A patient is being discharged after a liver transplant and the
nurse is performing discharge education. When planning this patient’s
continuing care, the nurse should prioritize which of the following
A) Risk for Infection Related to
B) Risk for Injury Related to Decreased
C) Risk for Unstable Blood Glucose Related to Impaired
D) Risk for Contamination Related to Accumulation
Infection is the leading cause of death
after liver transplantation. Pulmonary and fungal infections are
common; susceptibility to infection is increased by the
immunosuppressive therapy that is needed to prevent rejection. This
risk exceeds the threats of injury and unstable blood glucose. The
diagnosis of Risk for Contamination relates to environmental toxin exposure.
15. A patient with a liver mass is undergoing a percutaneous liver
biopsy. What action should the nurse perform when assisting with this
A) Position the patient on the right side with a
pillow under the costal margin after the procedure.
1 unit of albumin 90 minutes before the procedure as ordered.
Administer at least 1 unit of packed red blood cells as ordered the
day before the scheduled procedure.
D) Confirm that the patient’s
electrolyte levels have been assessed prior to the procedure.
Immediately after a percutaneous liver
biopsy, assist the patient to turn onto the right side and place a
pillow under the costal margin. Prior administration of albumin or
PRBCs is unnecessary. Coagulation tests should be performed, but
electrolyte analysis is not necessary.
16. A nurse is caring for a patient with hepatic encephalopathy. The
nurse’s assessment reveals that the patient exhibits episodes of
confusion, is difficult to arouse from sleep and has rigid
extremities. Based on these clinical findings, the nurse should
document what stage of hepatic encephalopathy?
A) Stage 1
C) Stage 3
D) Stage 4
Patients in the third stage of hepatic
encephalopathy exhibit the following symptoms: stuporous, difficult to
arouse, sleeps most of the time, exhibits marked confusion, incoherent
in speech, asterixis, increased deep tendon reflexes, rigidity of
extremities, marked EEG abnormalities. Patients in stages 1 and 2
exhibit clinical symptoms that are not as advanced as found in stage
3, and patients in stage 4 are comatose. In stage 4, there is an
absence of asterixis, absence of deep tendon reflexes, flaccidity of
extremities, and EEG abnormalities.
17. A patient has developed hepatic encephalopathy secondary to
cirrhosis and is receiving care on the medical unit. The patient’s
current medication regimen includes lactulose (Cephulac) four times
daily. What desired outcome should the nurse relate to this
A) Two to 3 soft bowel movements
B) Significant increase in appetite and food intake
Absence of nausea and vomiting
D) Absence of blood or mucus in stool
Lactulose (Cephulac) is administered to
reduce serum ammonia levels. Two or three soft stools per day are
desirable; this indicates that lactulose is performing as intended.
Lactulose does not address the patient’s appetite, symptoms of nausea
and vomiting, or the development of blood and mucus in the stool.
18. A nurse is performing an admission assessment for an 81-year-old
patient who generally enjoys good health. When considering normal,
age-related changes to hepatic function, the nurse should anticipate
A) Similar liver size and texture as in younger
B) A nonpalpable liver
C) A slightly enlarged liver
with palpably hard edges
D) A slightly decreased size of the liver
The most common age-related change in
the liver is a decrease in size and weight. The liver is usually still
palpable, however, and is not expected to have hardened edges.
19. A nurse is caring for a patient with a blocked bile duct from a
tumor. What manifestation of obstructive jaundice should the nurse
A) Watery, blood-streaked diarrhea
B) Orange and
C) Increased abdominal girth
D) Decreased cognition
If the bile duct is obstructed, the bile
will be reabsorbed into the blood and carried throughout the entire
body. It is excreted in the urine, which becomes deep orange and
foamy. Bloody diarrhea, ascites, and cognitive changes are not
associated with obstructive jaundice.
20. During a health education session, a participant has asked about
the hepatitis E virus. What prevention measure should the nurse
recommend for preventing infection with this virus?
proper hand-washing techniques
B) Avoiding chemicals that are
toxic to the liver
C) Wearing a condom during sexual
D) Limiting alcohol intake
Avoiding contact with the hepatitis E
virus through good hygiene, including hand-washing, is the major
method of prevention. Hepatitis E is transmitted by the fecal–oral
route, principally through contaminated water in areas with poor
sanitation. Consequently, none of the other listed preventative
measures is indicated.
21. A patient’s physician has ordered a “liver panel” in response to
the patient’s development of jaundice. When reviewing the results of
this laboratory testing, the nurse should expect to review what blood
tests? Select all that apply.
A) Alanine aminotransferase
B) C-reactive protein (CRP)
D) Aspartate aminotransferase (AST)
B-type natriuretic peptide (BNP)
Ans: A, C, D
Liver function testing includes
GGT, ALT, and AST. CRP addresses the presence of generalized
inflammation and BNP is relevant to heart failure; neither is included
in a liver panel.
22. A patient with liver disease has developed jaundice; the nurse is
collaborating with the patient to develop a nutritional plan. The
nurse should prioritize which of the following in the patient’s
A) Increased potassium intake
B) Fluid restriction to
2 L per day
C) Reduction in sodium intake
Patients with ascites require a sharp
reduction in sodium intake. Potassium intake should not be
correspondingly increased. There is no need for fluid restriction or
increased protein intake.
23. A nurse is amending a patient’s plan of care in light of the fact
that the patient has recently developed ascites. What should the nurse
include in this patient’s care plan?
A) Mobilization with
assistance at least 4 times daily
B) Administration of
beta-adrenergic blockers as ordered
C) Vitamin B12 injections as
D) Administration of diuretics as ordered
Use of diuretics along with sodium
restriction is successful in 90% of patients with ascites.
Beta-blockers are not used to treat ascites and bed rest is often more
beneficial than increased mobility. Vitamin B12 injections are not necessary.
24. A nurse is caring for a patient who has been admitted for the
treatment of advanced cirrhosis. What assessment should the nurse
prioritize in this patient’s plan of care?
A) Measurement of
abdominal girth and body weight
B) Assessment for variceal
C) Assessment for signs and symptoms of jaundice
Monitoring of results of liver function testing
Esophageal varices are a major cause of
mortality in patients with uncompensated cirrhosis. Consequently, this
should be a focus of the nurse’s assessments and should be prioritized
over the other listed assessments, even though each should be performed.
25. A patient with a diagnosis of cirrhosis has developed variceal
bleeding and will imminently undergo variceal banding. What
psychosocial nursing diagnosis should the nurse most likely prioritize
during this phase of the patient’s treatment?
B) Deficient Knowledge
C) Death Anxiety
Disturbed Thought Processes
The sudden hemorrhage that accompanies
variceal bleeding is intensely anxiety-provoking. The nurse must
address the patient’s likely fear of death, which is a realistic
possibility. For most patients, anxiety is likely to be a more acute
concern than lack of knowledge or decisional conflict. The patient may
or may not experience disturbances in thought processes.
26. A patient with a diagnosis of esophageal varices has undergone
endoscopy to gauge the progression of this complication of liver
disease. Following the completion of this diagnostic test, what
nursing intervention should the nurse perform?
A) Keep patient
NPO until the results of test are known.
B) Keep patient NPO
until the patient’s gag reflex returns.
C) Administer analgesia
until post-procedure tenderness is relieved.
D) Give the patient
a cold beverage to promote swallowing ability.
After the examination, fluids are not
given until the patient’s gag reflex returns. Lozenges and gargles may
be used to relieve throat discomfort if the patient’s physical
condition and mental status permit. The result of the test is known
immediately. Food and fluids are contraindicated until the gag reflex returns.
27. A patient with esophageal varices is being cared for in the ICU.
The varices have begun to bleed and the patient is at risk for
hypovolemia. The patient has Ringer’s lactate at 150 cc/hr infusing.
What else might the nurse expect to have ordered to maintain volume
for this patient?
A) Arterial line
D) Volume expanders
Because patients with bleeding
esophageal varices have intravascular volume depletion and are subject
to electrolyte imbalance, IV fluids with electrolytes and volume
expanders are provided to restore fluid volume and replace
electrolytes. Diuretics would reduce vascular volume. An arterial line
and Foley catheter are likely to be ordered, but neither actively
maintains the patient’s volume.
28. A patient with a history of injection drug use has been diagnosed
with hepatitis C. When collaborating with the care team to plan this
patient’s treatment, the nurse should anticipate what
A) Administration of immune globulins
regimen of antiviral medications
C) Rest and watchful
D) Administration of fresh-frozen plasma (FFP)
There is no benefit from rest, diet, or
vitamin supplements in HCV treatment. Studies have demonstrated that a
combination of two antiviral agents, Peg-interferon and ribavirin
(Rebetol), is effective in producing improvement in patients with
hepatitis C and in treating relapses. Immune globulins and FFP are not indicated.
29. A group of nurses have attended an inservice on the prevention of
occupationally acquired diseases that affect healthcare providers.
What action has the greatest potential to reduce a nurse’s risk of
acquiring hepatitis C in the workplace?
A) Disposing of sharps
appropriately and not recapping needles
B) Performing meticulous
hand hygiene at the appropriate moments in care
C) Adhering to
the recommended schedule of immunizations
D) Wearing an N95 mask
when providing care for patients on airborne precautions
HCV is bloodborne. Consequently,
prevention of needlestick injuries is paramount. Hand hygiene,
immunizations and appropriate use of masks are important aspects of
overall infection control, but these actions do not directly mitigate
the risk of HCV.
30. A patient has been admitted to the critical care unit with a
diagnosis of toxic hepatitis. When planning the patient’s care, the
nurse should be aware of what potential clinical course of this health
problem? Place the following events in the correct sequence.
Fever rises. 2. Hematemesis. 3. Clotting abnormalities. 4. Vascular
collapse. 5. Coma.
A) 1, 2, 5, 4, 3
B) 1, 2, 3, 4, 5
2, 3, 1, 4, 5
D) 3, 1, 2, 5, 4
Recovery from acute toxic hepatitis is
rapid if the hepatotoxin is identified early and removed or if
exposure to the agent has been limited. Recovery is unlikely if there
is a prolonged period between exposure and onset of symptoms. There
are no effective antidotes. The fever rises; the patient becomes toxic
and prostrated. Vomiting may be persistent, with the emesis containing
blood. Clotting abnormalities may be severe, and hemorrhages may
appear under the skin. The severe GI symptoms may lead to vascular
collapse. Delirium, coma, and seizures develop, and within a few days
the patient may die of fulminant hepatic failure unless he or she
receives a liver transplant.
31. A previously healthy adult’s sudden and precipitous decline in
health has been attributed to fulminant hepatic failure, and the
patient has been admitted to the intensive care unit. The nurse should
be aware that the treatment of choice for this patient is
A) IV administration of immune globulins
Transfusion of packed red blood cells and fresh-frozen plasma
C) Liver transplantation
Liver transplantation carries the
highest potential for the resolution of fulminant hepatic failure.
This is preferred over other interventions, such as pharmacologic
treatments, transfusions, and surgery.
32. A nurse is caring for a patient with cirrhosis secondary to heavy
alcohol use. The nurse’s most recent assessment reveals subtle changes
in the patient’s cognition and behavior. What is the nurse’s most
A) Ensure that the patient’s sodium intake
does not exceed recommended levels.
B) Report this finding to the
primary care provider due to the possibility of hepatic
C) Inform the primary care provider that the
patient should be assessed for alcoholic hepatitis.
interventions aimed at ensuring a calm and therapeutic care environment.
Monitoring is an essential nursing
function to identify early deterioration in mental status. The nurse
monitors the patient’s mental status closely and reports changes so
that treatment of encephalopathy can be initiated promptly. This
change in status is likely unrelated to sodium intake and would not
signal the onset of hepatitis. A supportive care environment is
beneficial, but does not address the patient’s physiologic deterioration.
33. A patient with end-stage liver disease has developed
hypervolemia. What nursing interventions would be most appropriate
when addressing the patient’s fluid volume excess? Select all that
A) Administering diuretics
B) Administering calcium
C) Implementing fluid restrictions
Implementing a 1500 kcal/day restriction
E) Enhancing patient positioning
Ans: A, C, E
implementing fluid restrictions, and enhancing patient positioning can
optimize the management of fluid volume excess. Calcium channel
blockers and calorie restriction do not address this problem.
34. A patient with liver cancer is being discharged home with a
biliary drainage system in place. The nurse should teach the patient’s
family how to safely perform which of the following actions?
Aspirating bile from the catheter using a syringe
B) Removing the
catheter when output is £ 15 mL in 24 hours
antibiotics into the catheter
D) Assessing the patency of the
Families should be taught to provide
basic catheter care, including assessment of patency. Antibiotics are
not instilled into the catheter and aspiration using a syringe is
contraindicated. The family would not independently remove the
catheter; this would be done by a member of the care team when deemed necessary.
35. A patient with cirrhosis has experienced a progressive decline in
his health; and liver transplantation is being considered by the
interdisciplinary team. How will the patient’s prioritization for
receiving a donor liver be determined?
A) By considering the
patient’s age and prognosis
B) By objectively determining the
patient’s medical need
C) By objectively assessing the patient’s
willingness to adhere to post-transplantation care
systematically ruling out alternative treatment options
The patient would undergo a
classification of the degree of medical need through an objective
determination known as the Model of End-Stage Liver Disease (MELD)
classification, which stratifies the level of illness of those
awaiting a liver transplant. This algorithm considers multiple
variables, not solely age, prognosis, potential for adherence, and the
rejection of alternative options.
36. A nurse has entered the room of a patient with cirrhosis and
found the patient on the floor. The patient states that she fell when
transferring to the commode. The patient’s vital signs are within
reference ranges and the nurse observes no apparent injuries. What is
the nurse’s most appropriate action?
A) Remove the patient’s
commode and supply a bedpan.
B) Complete an incident report and
submit it to the unit supervisor.
C) Have the patient assessed by
the physician due to the risk of internal bleeding.
D) Perform a
focused abdominal assessment in order to rule out injury.
A fall would necessitate thorough
medical assessment due to the patient’s risk of bleeding. The nurse’s
abdominal assessment is an appropriate action, but is not wholly
sufficient to rule out internal injury. Medical assessment is a
priority over removing the commode or filling out an incident report,
even though these actions are appropriate.
37. A patient with liver cancer is being discharged home with a
hepatic artery catheter in place. The nurse should be aware that this
catheter will facilitate which of the following?
monitoring for portal hypertension
B) Administration of
immunosuppressive drugs during the first weeks after
C) Real-time monitoring of vascular changes in
the hepatic system
D) Delivery of a continuous chemotherapeutic dose
In most cases, the hepatic artery
catheter has been inserted surgically and has a prefilled infusion
pump that delivers a continuous chemotherapeutic dose until completed.
The hepatic artery catheter does not monitor portal hypertension,
deliver immunosuppressive drugs, or monitor vascular changes in the
38. A nurse on a solid organ transplant unit is planning the care of
a patient who will soon be admitted upon immediate recovery following
liver transplantation. What aspect of nursing care is the nurse’s
A) Implementation of infection-control measures
Close monitoring of skin integrity and color
assessment of the patient’s psychosocial status
of antiretroviral medications
Infection control is paramount following
liver transplantation. This is a priority over skin integrity and
psychosocial status, even though these are valid areas of assessment
and intervention. Antiretrovirals are not indicated.
39. A 55-year-old female patient with hepatocellular carcinoma (HCC)
is undergoing radiofrequency ablation. The nurse should recognize what
goal of this treatment?
A) Destruction of the patient’s liver
B) Restoration of portal vein patency
of a liver abscess
D) Reversal of metastasis
Using radiofrequency ablation, a tumor
up to 5 cm in size can be destroyed in one treatment session. This
technique does not address circulatory function or abscess formation.
It does not allow for the reversal of metastasis.
40. A nurse is caring for a patient with severe hemolytic jaundice.
Laboratory tests show free bilirubin to be 24 mg/dL. For what
complication is this patient at risk?
A) Chronic jaundice
Pigment stones in portal circulation
C) Central nervous system
Prolonged jaundice, even if mild,
predisposes to the formation of pigment stones in the gallbladder, and
extremely severe jaundice (levels of free bilirubin exceeding 20 to 25
mg/dL) poses a risk for CNS damage. There are not specific risks of
hepatomegaly or chronic jaundice resulting from high bilirubin.