Biliary Tract Problems – Clinical Situations

Biliary Tract Problems – Clinical Situations

Read the following case studies. Circle the correct answer.

CASE STUDY: Liver Biopsy

Veronica is scheduled for a liver biopsy. The staff nurse assigned to care for Veronica is to accompany her to the treatment room.

1. Before a liver biopsy, the nurse should check to see that:

a. A compatible donor blood is available.

b. Coagulation studies have been completed.

c. Vital signs have been assessed.

d. All of the above have been done. (Blood must be compatible with the patient’s to prevent a transfusion reaction. Due to bleeding risks, coagulation studies should have been completed before liver biopsy. Standard percutaneous liver biopsy observations include monitoring the patient’s vital signs every 15 minutes for the first two hours, then every 30 minutes for two hours and then hourly for the rest of the remaining period. This protocol is reasonable when one considers that 61% of complications occur within the first two hours.)

1. The nurse begins preparing Veronica for the biopsy by assisting her to the correct position, which is:

a. Jackknife, with her entire back exposed.

b. Recumbent, with her right upper abdomen exposed. (Percutaneous Liver biopsy procedure uses needle inserted between 6th and 7th or 8th and 9th intercostal spaces on the right side to obtain specimen of hepatic tissue.)

c. Lying on her right side, with the left upper thoracic area exposed.

d. Supine, with the left lateral chest wall exposed.

1. The nurse knows that the biopsy needle will be inserted into the liver between the:

a. Third and fourth ribs.

b. Fourth and fifth ribs.

c. Sixth and seventh ribs.

d. Eight and ninth ribs.

1. Immediately before needle insertion, Veronica needs to be instructed to:

a. Breathe slowly and deeply so that rib cage expansion will be minimized during needle insertion.

b. Inhale and exhale deeply several times then exhale and hold her breath at the end of expiration until the needle is inserted.

c. Pant deeply and continue panting during needle insertion so pain perception will be minimized.

d. Take a deep inspiration and not breathe for 30 to 40 seconds so that the area for needle insertion can be determined; she should then resume normal breathing for the remainder of the procedure.

1. After the biopsy, the nurse assists Veronica to:

a. High-Fowler’s position, in which she can effectively take deep breaths and cough.

b. Ambulate while splinting her incision

c. Assume the Trendelenburg position to prevent post biopsy shock.

d. The right side-lying position with a pillow placed under the right costal margin. (Keep patient lying on right side to splint puncture site.)

CASE STUDY: Paracentesis

Wendy is scheduled for a paracentesis because of ascites formation subsequent to cirrhosis of the liver.

1. Before the procedure, the nurse obtains several drainage bottles. She knows that the maximum amount of fluid to be aspirate at one time is:

a. 1L

b. 2L

c. 3L

d. 4L (Therapeutic paracentesis refers to the removal of maximum amount of fluid of 4L to reduce intra-abdominal pressure and relieve the associated dyspnea, abdominal pain, and early satiety.)

1. The nurse helps Wendy to assume the proper position for a paracentesis, which is:

a. Recumbent so that the fluid will pool to the lower abdomen.

b. Laying on her left side so that fluid will not exert pressure on the liver.

c. Semi-Fowler’s to avoid shock and provide the most comfort.

d. Upright with her feet resting on a support so that the puncture site will be readily visible. (Clients who have ascites are typically more comfortable sitting up.)

1. After the paracentesis, Wendy should be observed for signs of vascular collapse, which include all of the following except:

a. Bradycardia (Fluid volume deficit can occur due to increased fluid excretion by the kidneys or excessive diaphoresis which leads to tachycardia, not bradycardia.)

b. Hypotension

c. Oliguria

d. Pallor

CASE STUDY: Cholecystectomy

Brenda, a 33-year-old obese mother of four, is diagnosed as having acute gallbladder inflammation. She is 5 feet tall and weighs 190 lb. The physician decides to delay surgical intervention until Brenda’s acute symptoms subside.

1. Brenda’s initial course of treatment would probably consist of:

a. Analgesics and antibiotics

b. Intravenous fluids

c. Nasogastric suctioning

d. All of the above (Pain management using analgesics is critical during an acute episode of cholecystitis. Morphine may be initially given for pain management. Vomiting associated with cholecystitis may lead to metabolic alkalosis and chloride shift. Administering NaCl will help compensate the shift in chloride levels. Inserting NG Tube experiencing severe vomiting will help decompress the stomach and minimize gallbladder stimulation.)

1. After her acute attack, Brenda was limited to low-fat liquids. As foods are added to her diet, she needs to know that she should avoid:

a. Cooked fruit

b. Eggs and cheese

c. Lean meats

d. Rice and tapioca

1. Brenda is being medicated with chenodeoxycholic acid. The nurse needs to tell Brenda that the drug may not be effective if it is taken in conjunction with:

a. Dietary cholesterol

b. Estrogens

c. Oral contraceptives

d. Any of the above

Because Brenda’s symptoms continue to recur, she is scheduled for gallbladder surgery.

1. Brenda has signed a consent form for removal of her gallbladder and ligation of the cystic duct and artery. She is scheduled for to undergo a:

a. Cholecystectomy

b. Cholecystostomy

c. Choledochotomy

d. Choledocholithotomy

1. Postoperative nursing observation includes assessing for:

a. Indicators of infection

b. Leakage of bile into the peritoneal cavity

c. Obstruction of bile drainage

d. All of the above

1. Brenda needs to know that fat restriction is usually lifted after the biliary ducts dilate to accommodate bile once held by the gallbladder. This takes about:

a. 1 week

b. 2 to 3 weeks

c. 4 to 6 weeks

d. 2 months.

CASE STUDY: Alcoholic or Nutritional Cirrhosis

Nathan, a 50-year-old physically disabled veteran, has lived alone for 30 years. He has maintained his independence despite chronic back pain resulting from a war injury. He has a long history of depression and limited food intake. He drinks 6 to 10 bottles of beer daily. He was recently admitted to a veteran’s hospital with a diagnosis of alcoholic or nutritional cirrhosis. He was asymptomatic for ascites.

1. On assessment, the nurse notes early clinical manifestations of alcoholic or nutritional cirrhosis, which include all of the following except:

a. Pain caused by liver enlargement

b. A sharp edge to the periphery of the liver

c. A liver decreased in size and nodular

d. A firm liver

1. An abnormal laboratory finding for Nathan is a:

a. Blood ammonia level of 35 mg/dL

b. Serum albumin concentration of 4.0 g/dL

c. Total serum bilirubin level of 0.9mg/Dl

d. Total serum protein level of 5.5 g/Dl

1. Nathan is 5 feet 8 inches tall and weighs 154 lb. The physician recommends 50 cal/kg for weight gain. Nathan’s daily caloric intake would be approximately:

a. 2,200 calories

b. 2,800 calories

c. 3,500 calories

d. 3,800 calories

1. A recommended daily protein intake for Nathan to gain weight is:

a. 31 to 44 g

b. 41 to 54 g

c. 51 to 64 g

d. 61 to 74 g

1. The physician recommends a sodium-restricted diet. The nurse expects the suggested sodium intake to be approximately:

a. 250 to 500 mg/24 h

b. 500 to 1,000 mg/24 h

c. 2,000 to 2,500 mg/24 h

d. 3,000 to 3,500 mg/24 h