NCLEX® - RN & PN TEST PREP COURSE...2 NCLEX-RN & PN TEST PREP COURSE Conducted by: George Mata Montaus RN, MSN/Ed and Walter Urdas Donato BSN, RN Visit us @ Telephone # 714-679-9320

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NCLEX® - RN & PN TEST PREP COURSE Conductedby:

GeorgeMataMontausRN,MSN/EdandWalterUrdasDonatoBSN,RN [email protected]#714-679-9320Fax#909-247-2721

NCLEX-RN & PN TEST PREP COURSE

Conductedby:GeorgeMataMontausRN,MSN/EdandWalterUrdasDonatoBSN,RN

[email protected]#714-679-9320Fax#909-247-2721

Functions of the Liver

1.  Metabolism of Carbohydrates, fats, proteins 2.  Production of bile salts 3.  Detoxification of substances 4.  Storage of vitamins and minerals----------

ADEK , B12, Iron 5.  Blood reservoir 6.  Filtering out old rbc or phagocytocis

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HEPATO-BILIARYandPANCREATICSYSTEM




LABORATORY AND DIAGNOSTIC TESTS FOR LIVER FUNCTION

Fat Metabolism Serum Total Cholesterol and Cholesterol Esters Serum Phospholipids Immunoglobulins

ü  ↑ IgA, IgG - ↑ in liver cirrhosis ü  ↑ IgG – chronic active hepatitis biliary cirrhosis ü  ↑ IgM – hepatitis A

BUN Pro Time ; PTT, APTT Blood ammonia levels

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Serum Enzymes : ↑ hepatocellular damage

v  AST / SGOT v  ALT / SGPT

ü  most specific indicator of liver function

v LDH v  GGT

ü  ↑ : liver cirrhosis is alcohol – induced




Ultrasound of the Liver

v Preparation ü  NPO 8 – 12 hrs. ü  Laxative the night before the procedure ü  Adequate hydration

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Biopsy Of The Liver v  Preparation

ü  secure written consent ü  NPO 2 – 4 hours ü  Vitamin K injection ü  monitor Pro Time ; initial VS ü  instruct to exhale deeply; hold breath for 5 – 10 seconds,

during needle insertion

v  Care After Liver Biopsy ü  Right side ü  Bed rest for 24 hrs. ü  Monitor VS ▪  every 30 minutes – every hour for the first 24 hours




Paracentesis (Peritoneal tap)

v Preparation ü  secure written consent ü  check initial VS ü  ask to empty bladder ü  check s. protein studies ü  place in sitting / upright position

v Care After Paracentesis

ü  Assess: ▪ VS ▪ Urine output ▪ Rigidity of abdomen (S & Sx of bleeding, peritonitis)

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PARACENTESIS




Liver Cirrhosis v  Causes

ü  Alcohol Abuse ü  Malnutrition ü  Infection ü  Drugs ü  Biliary Obstruction ü  RSCHF ↓ Destruction of HEPATOCYTES

↓ FIBROSIS / SCARRING

↓ A.   Obstruction of blood flow

B.   ↑ pressure in the venous and sinusoidal channels

C.   Fatty infiltration ↓

PORTAL HYPERTENSION

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Portal Hypertension

v hepatomegaly v splenomegaly v caput medusae v spider angioma v palmar erythema v ascites v esophageal varices v internal hemorrhoids v leg varicosities v dependent edema




q Small, nodular liverq Males

(↑ estrogen) v gynecomastia v  ↓ libido v impotence

v fall of body hair v atrophy of testicles

q Females (↑ androgen)

v hirsutism v acne

v deepening of voice v ↑ virilism

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q Asterixis q Hepatic encephalopathy

v confusion / disorientation

v delirium / hallucination

v fetor hepaticus v coma




DISEASE MANAGEMENT

•  Rest •  Diet •  Skin care •  Avoid trauma / injury •  Avoid infection •  Ascites •  Esophageal varices •  ↓Ammonia formation •  Avoid sedatives , acetaminophen •  Avoid ASA •  Eliminate Alcohol

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Hepatitis • Hepatitis A (HAV) • Hepatitis B (HBV)

• Hepatitis C Post- transfusion Hepatitis

• Hepatitis D Co- infection of hepatitis B

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Gallbladder q Ultrasound of the Gallbladder q Cholecystography

v Radiographic examination of the gallbladder after the administration of contrast medium.

v Two types of cholecystography: ü Oral cholecystography (Gall bladder Series) ü Intravenous Cholecystography




CHOLELITHIASIS WITH CHOLECYSTITIS •  Cause: •  Predisposing Factors: •  Theories

Gallstone ↓

Pressure / Obstruction ↓

BILE STASIS

v  ↓ fat emulsification ü  Fat intolerance ü Anorexia ü  n/v ü Weight loss ü Gasseous eructation ü  Flatulence ü  Steatorrhea

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q Inflammation v Pain (RUQ) v Fever

v Leukocytosis

q  ↓ bile flow into the colon v  acholic stool v  ↓ Vit. K absorption

q ↑ S. bilirubin v  Jaundice v Pruritus

v Tea – colored urine

q  Infection v Cholecystitis

v Pancreatitis




DISEASE MANAGEMENT q Relief of pain q Diet q Bile salts

q Surgery v  Preop

ü  Deep Breathing Coughing Turning exercises

ü  Vitamin K injection

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CHOLECYSTECTOMY- RIGHT SUBCOSTAL INCISION




DISEASE MANAGEMENT q Surgery v  Postop

ü  Position ü  NGT ü  DBCT exercises ü Incentive spirometer

ü  Diet ü  Ambulation

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T-TUBE




PANCREATITIS q Acute q Chronic

q Causes:

v  Alcohol Abuse

v  Drugs v  Biliary Obstruction

v Autoimmune

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ASSESSMENT ¡ Pain (LUQ) ¡ Anorexia ¡ Fever ¡ Nausea and Vomiting ¡ Severe Dehydration ¡ Weight Loss ¡ Steatorrhea ¡ ↑ s. amylase ¡ ↑ s. lipase

¡ HypoCa ¡ Hyperglycemia ¡ Jaundice ¡ Post – hemorrhagic

necrosis § Purplish

discoloration Cullen’s sign

Grey – Turner’s sign




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DISEASE MANAGEMENTq Relieve pain q Diet q TPN q  IVF Therapy q NGT q Digestive Enzymes q Antimicrobials q Ca supp. q Vit. D q  Insulin q X Alcohol

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CRITICAL THINKING EXERCISES 1.   If a gallstone becomes lodged in the common bile

duct, the nurse should anticipate that the client’s stools would most likely become what color?

1. Green. 2. Gray. 3. Black. 4. brown.




2.   When the client’s common bile duct is obstructed,

the nurse should evaluate the client for signs of which of the following complications?

1.  Respiratory distress. 2.  Circulatory overload.

3.  Urinary tract infection. 4.  Prolonged bleeding time.

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3.   A client undergoes a traditional cholecystectomy and choledochotomy and returns from surgery with a T-tube. To evaluate the effectiveness of the T-tube, the nurse should understand that the primary reason for the T-tube is to accomplish which of the following goals?

1.  Promote wound drainage.

2.  Provide a way to irrigate the tract. 3.  Minimize the passage of bile into the duodenum. 4.  Prevent the bile into the duodenum.




4.   After a cholecystectomy it is recommended that the client follow a low-fat diet at home. Which of the following foods would be most appropriate to include in a low-fat diet?

1.   Cheese omelet. 2.   Peanut butter. 3.   Ham salad sandwich. 4.   Roasted beef.

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5.   A client undergoes a laparoscopic cholecystectomy. Which of the following dietary instructions would the nurse give the client immediately after surgery?

1.   “You cannot eat or drink anything for 24 hours.” 2.   “You may resume your normal diet the day after

surgery.”

3.   “Drink liquid today and eat lightly for a few days”. 4.   “You can progress from a liquid to a bland diet as

tolerated.”




6.   When providing care for a client with acute pancreatitis, the nurse would anticipate which of the following orders?

1.   Increase oral intake 3000 mls every 24hours . 2.   Insert a nasogastric tube and connect it to low

suction. 3.   Place the client in the reverse Trendelenburg

position. 4.   Place the client on precautions.

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7.   The nurse notes that a client with acute pancreatitis occasionally experiences muscle twitching and jerking. How should the nurse interpret the significance of these symptoms?

1.   The client may be developing hypocalcemia.

2.   The client is experiencing a reaction to meperidine (demerol).

3.   The client has a nutritional imbalance.

4.   The client needs a muscle relaxant to help him rest.




8.   Pancreatic enzyme replacements are ordered for the client with chronic pancreatitis. When should the nurse instruct the client to take them to obtain the most therapeutic effect?

1.   Three times daily between meals. 2.   With each meal and snack. 3.   In the morning and at bedtime. 4.   Every 4 hours, at specified times.

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9.   The nurse should teach the client with chronic pancreatitis to monitor the effectiveness of pancreatic enzyme replacement therapy by doing which of the following?

1.   Monitoring fluid intake.

2.   Performing regular glucose fingerstick tests.

3.   Observing stools for steatorrhea.

4.   Testing urine for ketones.




10.  The nurse is assessing a client who is in the early stage of cirrhosis of the liver. Which of the following signs would the nurse anticipate finding?

1.   Peripheral edema.

2.   Ascites.

3.   Anorexia.

4.   Jaundice.

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11.  Which diet should be implemented to a client who is in the early stages of cirrhosis?

1.   High calorie, high carbohydrates 2.   High protein, low fat. 3.   Low fat, low protein. 4.   High carbohydrates, low sodium.




12. A client with cirrhosis vomits bright red blood and the physician decides to insert a

Sengstaken-Blakemore tube. The nurse should explain to the client that the tube acts by

1.   Providing a large diameter for effective gastric lavage.

2.   Applying direct pressure to gastric bleeding sites.

3.   Blocking blood flow to gastric bleeding sites.

4.   Apply direct pressure to the esophagus

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14.   The physician orders oral neomycin as well as neomycin enema for the client with cirrhosis. The nurse understands that the purpose of this therapy is to

1.   reduce abdominal pressure. 2.   prevent straining during defecation. 3.   block ammonia formation 4.   reduce bleeding within the intestine.




15.   A client’s serum ammonia level is

elevated, and the physician orders 30 ml of lactulose (Cephulac). Which of the following side effects of this drug would the nurse expect to see?

1.   Increased urine output. 2.   Improved level of consciousness. 3.   Increased bowel movements 4.   Nausea vomiting.

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16.  The nurse is providing discharge instructions for the client with cirrhosis. Which of the following statements best indicates that the client has understood the teaching?

1.  “I should eat a high-protein, high-carbohydrate

diet to provide energy.” 2.  “It is safer for me to take acetaminophen (tylenol)

for pain instead of aspirin.” 3.  “I should avoid constipation to decrease chances of

bleeding” 4.  “If I get enough rest and follow my diet it is

possible for my cirrhosis to be cured.”




NCLEX® - RN & PN TEST PREP COURSE...2 NCLEX-RN & PN TEST PREP COURSE Conducted by: George Mata Montaus RN, MSN/Ed and Walter Urdas Donato BSN, RN Visit us @ Telephone # 714-679-9320

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