MCA 2 - Med-surg - Review Exam 1

The family of a patient newly diagnosed with hepatitis A asks the nurse what they can do to prevent becoming ill. Which response by the nurse is most appropriate? "You will need to be tested first; then treatment can be determined." "The hepatitis vaccine will provide immunity from this and future exposures." "There is nothing you can do since the patient was infectious before admission." "An immunoglobulin injection will be given to prevent infection or limit symptoms."

"An immunoglobulin injection will be given to prevent infection or limit symptoms." Rationale: Immunoglobulin provides temporary (1 to 2 months) passive immunity and is effective for preventing hepatitis A if given within 2 weeks after exposure. It may not prevent infection in all persons, but it will at least modify the illness to a subclinical infection. The hepatitis vaccine is only used for preexposure prophylaxis.

The nurse provides discharge instructions for a patient with ascites and peripheral edema related to cirrhosis. Which patient statement indicates teaching was effective? "Lactulose should be taken every day to prevent constipation." "It is safe to take acetaminophen up to four times a day for pain." "Herbs and other spices should be used to season my foods instead of salt." "I will eat foods high in potassium while taking spironolactone (Aldactone)."

"Herbs and other spices should be used to season my foods instead of salt." Rationale: A low-sodium diet is indicated for patients with ascites and edema related to cirrhosis. Table salt is a well-known source of sodium and should be avoided. Alternatives to salt to season foods include the use of seasonings such as garlic, parsley, onion, lemon juice, and spices. Pain medications such as acetaminophen, aspirin, and ibuprofen should be avoided because these medications may be toxic to the liver. The patient should avoid potentially hepatotoxic over-the-counter drugs (e.g., acetaminophen) because the diseased liver is unable to metabolize these drugs. Spironolactone is a potassium-sparing diuretic. Lactulose results in the acidification of feces in bowel and trapping of ammonia, causing its elimination in feces.

When teaching the patient with acute hepatitis C (HCV), which statement demonstrates understanding of the disease process? "I will use care when kissing my wife to prevent giving it to her." "I will need to take adefovir (Hepsera) to prevent chronic HCV." "Now that I have had HCV, I will have immunity and not get it again." "I will need to be monitored for chronic HCV and other liver problems."

"I will need to be monitored for chronic HCV and other liver problems." Rationale: Many patients who acquire HCV develop chronic infection, which may lead to cirrhosis or liver cancer. HCV is not transmitted via saliva but by blood exposures such as sharing needles and high-risk sexual activity. The treatment for acute viral hepatitis focuses on resting the body and adequate nutrition for liver regeneration. Adefovir (Hepsera) is taken for severe hepatitis B (HBV) with liver failure. HCV is treated with oral direct-acting antivirals (DAAs). Immunity with HCV does not occur as it does with HAV and HBV, so the patient may be reinfected with another type of HCV.

The patient with cirrhosis is being taught self-care. Which statement indicates the patient needs further teaching? "A scrotal support may be more comfortable when I have scrotal edema." "I need to take good care of my belly and ankle skin where it is swollen." "I can use pillows to support my head to help me breathe when I am in bed." "If I notice a fast heart rate or irregular beats, this is normal for cirrhosis."

"If I notice a fast heart rate or irregular beats, this is normal for cirrhosis." Rationale: If the patient with cirrhosis develops a fast or irregular heart rate, it may be indicative of hypokalemia and should be reported to the health care provider because this is not normal for cirrhosis. Edematous tissue is subject to breakdown and needs meticulous skin care. Pillows and a semi-Fowler's or Fowler's position increase respiratory efficiency. A scrotal support may improve comfort if there is scrotal edema.

The nurse teaches a patient about cholestyramine to reduce pruritus caused by gallbladder disease. Which statement indicates understanding of the instructions? "This medication will help me digest fats and fat-soluble vitamins." "I will apply the medicated lotion sparingly to the areas where I itch." "The medication is a powder and needs to be mixed with milk or juice." "I should take this medication on an empty stomach at the same time each day."

"The medication is a powder and needs to be mixed with milk or juice." Rationale: For treatment of pruritus, cholestyramine may provide relief. This is a resin that binds bile salts in the intestine, increasing their excretion in the feces. Cholestyramine is in powder form and should be mixed with milk or juice before oral administration.

The nurse is teaching a patient with acromegaly from an unresectable benign pituitary tumor about octreotide therapy. The nurse should provide further teaching if the patient makes which statement? "The provider will infuse this medication through an IV." "I will inject the medication in the subcutaneous layer of the skin." "The medication should decrease the growth hormone production to normal." "I will have my growth hormone level measured every 2 weeks for several weeks."

"The provider will infuse this medication through an IV." Rationale: Drug therapy is an option for patients whose tumors are not surgically resectable. The primary drug used is octreotide, a somatostatin analog. It reduces growth hormone (GH) levels to normal in many patients. Octreotide is given by subcutaneous injection three times a week. GH levels are measured every 2 weeks to K guide drug dosing, and then every 6 months until the desired response is obtained.

A patient with cholelithiasis is being prepared for surgery. Which patient assessment represents a contraindication for a cholecystectomy? Low-grade fever of 100° F and dehydration Abscess in the right upper quadrant of the abdomen Multiple obstructions in the cystic and common bile duct Activated partial thromboplastin time (aPTT) of 54 secondsCorrect Answer

Activated partial thromboplastin time (aPTT) of 54 seconds Rationale: An aPTT of 54 seconds is above normal and indicates insufficient clotting ability. If the patient had surgery, significant bleeding complications postoperatively are very likely. Fluids can be given to eliminate the dehydration. The abscess can be assessed during surgery, and the obstructions in the cystic and common bile duct would be relieved with the cholecystectomy.

A patient with a severe pounding headache has been diagnosed with hypertension. However, the hypertension is not responding to traditional treatment. What should the nurse expect as the next step in determining a diagnosis for this patient? Administration of β-blocker medications Abdominal palpation to search for a tumor Administration of potassium-sparing diuretics A 24-hour urine collection for fractionated metanephrines

A 24-hour urine collection for fractionated metanephrines Rationale: Pheochromocytoma should be suspected when hypertension does not respond to traditional treatment. The 24-hour urine collection for fractionated metanephrines is simple and reliable with elevated values in 95% of people with pheochromocytoma. In a patient with pheochromocytoma, an α-adrenergic receptor blocker is used preoperatively to reduce blood pressure. Abdominal palpation is avoided to avoid a sudden release of catecholamines and severe hypertension. Potassium-sparing diuretics are not needed. Most likely they would be used for hyperaldosteronism, which is another cause of hypertension.

The nurse is caring for a group of patients. Which patient has the highest risk for developing pancreatic cancer? A 72-yr-old black man who has smoked cigarettes for 50 yearsCorrect Answer A 19-yr-old patient who has a 5-year history of uncontrolled type 1 diabetes A 38-yr-old Hispanic woman who is obese and has hyperinsulinemia A 23-yr-old man who has cystic fibrosis-related pancreatic enzyme insufficiency

A 72-yr-old black man who has smoked cigarettes for 50 years Rationale: Risk factors for pancreatic cancer include chronic pancreatitis, diabetes, age, cigarette smoking, family history of pancreatic cancer, high-fat diet, and exposure to chemicals such as benzidine. Blacks have a higher incidence of pancreatic cancer than whites. The most firmly established environmental risk factor is cigarette smoking. Smokers are 2 to 3 times more likely to develop pancreatic cancer compared with nonsmokers. The risk is related to duration and number of cigarettes smoked.

The nurse is caring for a woman recently diagnosed with viral hepatitis A. Which person should the nurse refer for an immunoglobulin (IG) injection? A friend who delivers meals to the patient and family each week. A relative with a history of hepatitis A who visits the patient daily. A child living in the home who received the hepatitis A vaccine 3 months ago. A caregiver with no history of hepatitis A antibodies who lives in the same household with the patient.

A caregiver with no history of hepatitis A antibodies who lives in the same household with the patient. Rationale: IG is recommended for persons who do not have anti-HAV antibodies and are exposed because of close contact with persons who have HAV or foodborne exposure. Persons who have received a dose of HAV vaccine more than 1 month previously or who have a history of HAV infection do not require IG.

When providing discharge teaching for a patient after a laparoscopic cholecystectomy, what information should the nurse include? Do not return to work or normal activities for 3 weeks. A low-fat diet may be better tolerated for several weeks. Bile-colored drainage will probably drain from the incision. Keep the bandages on and the puncture site dry until it heals.

A low-fat diet may be better tolerated for several weeks. Rationale: Although the usual diet can be resumed, a low-fat diet is usually better tolerated for several weeks after surgery. Normal activities can be gradually resumed as the patient tolerates. Bile-colored drainage or pus, redness, swelling, severe pain, and fever may all indicate infection. The bandage may be removed the day after surgery, and the patient can shower.

The nurse is caring for a patient receiving high-dose oral corticosteroid therapy after a kidney transplant. Which side effect would the nurse monitor for as it presents the greatest risk? Infection Low blood pressure Increased urine output Decreased blood glucose

Infection Rationale: Side effects of corticosteroid therapy include increased susceptibility to infection, edema related to sodium and water retention (decreasing urine output), hypertension, and hyperglycemia.

The patient with suspected pancreatic cancer is having many diagnostic studies done. Which test can be used to establish the diagnosis of pancreatic cancer and for monitoring the response to treatment? Spiral CT scan A PET/CT scan Abdominal ultrasound Cancer-associated antigen 19-9

Cancer-associated antigen 19-9 Rationale: The cancer-associated antigen 19-9 (CA 19-9) is the tumor marker used for the diagnosis of pancreatic cancer and monitoring the response to treatment. Although a spiral CT scan may be the initial study done and provides information on metastasis and vascular involvement, this test and the positron emission tomography (PET)/CT scan or abdominal ultrasonography does not provide additional information.

Which assessment finding would the nurse expect in a patient who has been taking oral prednisone several weeks and is experiencing sudden withdrawal? (Select all that apply.) BP 80/50 Heart rate 54 Glucose 63 mg/dL Sodium 148 mEq/L Potassium 6.3 mEq/L Temperature 101.1° F

BP 80/50 Glucose 63 mg/dL Potassium 6.3 mEq/L Temperature 101.1° F Rationale: Sudden cessation of corticosteroid therapy can precipitate life-threatening adrenal insufficiency. During acute adrenal insufficiency, the patient exhibits severe manifestations of glucocorticoid and mineralocorticoid deficiencies, including hypotension, tachycardia, dehydration, hyponatremia, hyperkalemia, hypoglycemia, fever, weakness, and confusion.

The nurse is caring for a patient recently started on levothyroxine for hypothyroidism. What information reported by the patient requires immediate action? Weight gain or weight loss Chest pain and palpitations Muscle weakness and fatigue Decreased appetite and constipation

Chest pain and palpitations Rationale: Levothyroxine is used to treat hypothyroidism. With replacement, the patient can be overmedicated, causing hyperthyroidism. Any chest pain, heart palpitations, or heart rate greater than 100 beats/min experienced by a patient starting thyroid replacement should be reported immediately, and electrocardiography and serum cardiac enzyme tests should be performed.

A patient with a history of lung cancer and hepatitis C has developed liver failure and is considering liver transplantation. After a comprehensive evaluation, which finding may be a contraindication for liver transplantation? History of hypothyroidism Stopped smoking cigarettes Well-controlled type 1 diabetes Chest x-ray shows a new lung cancer lesion

Chest x-ray shows a new lung cancer lesion Rationale: Contraindications for liver transplant include severe extrahepatic disease, advanced hepatocellular carcinoma or other cancer, ongoing drug or alcohol use, and the inability to comprehend or comply with the rigorous posttransplant course.

The patient with right upper quadrant abdominal pain has an abdominal ultrasound that reveals cholelithiasis. What is the nurse's priority? Prevent all oral intake. Control abdominal pain.Correct Answer Provide enteral feedings. Avoid dietary cholesterol.

Control abdominal pain. Rationale: Patients with cholelithiasis can have severe pain, so controlling pain is important until the problem can be treated. NPO status may be needed if the patient will have surgery but will not be used for all patients with cholelithiasis. Patients with pancreatitis may be NPO. Enteral feedings should not be needed, and avoiding dietary cholesterol is not used to treat cholelithiasis.

The provider was unable to spare a patient's parathyroid gland during a thyroidectomy. Which assessments should the nurse prioritize when providing postoperative care for this patient? White blood cell levels and signs of infection Serum calcium levels and signs of hypocalcemia Hemoglobin, hematocrit, and red blood cell levels Level of consciousness and signs of acute delirium

Serum calcium levels and signs of hypocalcemia Rationale: Loss of the parathyroid gland is associated with hypocalcemia. Whereas infection and anemia are not associated with loss of the parathyroid gland, cognitive changes are less pronounced than the signs and symptoms of hypocalcemia.

What should be included in the interprofessional plan of care for a patient with Cushing disease? Lab monitoring for hyperkalemia Vital sign monitoring for hypotension Counseling related to body image changes Diet consultation to determine low protein choices

Counseling related to body image changes Rationale: Elevated corticosteroid levels can cause body changes, including truncal obesity, moon face, and hirsutism in women and gynecomastia in men. Counseling and support should be offered because of the changes in body image. Hypokalemia and hypertension are consistent with Cushing disease. Sodium restriction and potassium supplementation are indicated. High-protein choices are necessary to counteract catabolic processes and assist with wound healing.

The health care provider orders lactulose for a patient with hepatic encephalopathy. Which finding indicates the medication has been effective? Relief of constipation Relief of abdominal pain Decreased liver enzymes Decreased ammonia levels

Decreased ammonia levels. Rationale: Hepatic encephalopathy is a complication of liver disease and is associated with elevated serum ammonia levels. Lactulose traps ammonia in the intestinal tract. Its laxative effect then expels the ammonia from the colon, resulting in decreased serum ammonia levels and correction of hepatic encephalopathy. An additional finding may be an improvement in level of consciousness.

The nurse is providing discharge instructions to a patient with diabetes insipidus. Which instruction about desmopressin acetate would be most appropriate? Expect to have some nasal irritation while using this drug. Monitor for symptoms of hypernatremia as a drug side effect. Report any decrease in urinary output to the health care provider. Drink at least 3000 mL of water per day while taking this medication.

Expect to have some nasal irritation while using this drug. Rationale: Desmopressin acetate is used to treat diabetes insipidus by replacing the antidiuretic hormone that the patient is lacking. Diuresis will be decreased and is expected. Inhaled desmopressin can cause nasal irritation, headache, nausea, and other signs of hyponatremia, not hypernatremia. Drinking too much water or other fluids increases the risk of hyponatremia. The patient should follow the provider's directions for limiting fluids and be taught to seek medical attention if they have severe nausea; vomiting; severe headache; muscle weakness, spasms, or cramps; sudden weight gain; unusual tiredness; mental/mood changes; seizures; and slow or shallow breathing.

The nurse is providing discharge instructions to a patient with diabetes insipidus. Which instruction about desmopressin acetate would be most appropriate? Expect to have some nasal irritation while using this drug. Monitor for symptoms of hypernatremia as a drug side effect. Report any decrease in urinary output to the health care provider. Drink at least 3000 mL of water per day while taking this medication.

Expect to have some nasal irritation while using this drug. Rationale: Desmopressin acetate is used to treat diabetes insipidus by replacing the antidiuretic hormone that the patient is lacking. Diuresis will be decreased and is expected. Inhaled desmopressin can cause nasal irritation, headache, nausea, and other signs of hyponatremia, not hypernatremia. Drinking too much water or other fluids increases the risk of hyponatremia. The patient should follow the provider's directions for limiting fluids and be taught to seek medical attention if they have severe nausea; vomiting; severe headache; muscle weakness, spasms, or cramps; sudden weight gain; unusual tiredness; mental/mood changes; seizures; and slow or shallow breathing.

The nurse is caring for a patient after a parathyroidectomy. The nurse would prepare to administer IV calcium gluconate if the patient has which manifestations? Facial muscle spasms and laryngospasms Tingling in the hands and around the mouth Decreased muscle tone and muscle weakness Shortened QT interval on the electrocardiogram

Facial muscle spasms and laryngospasms. Rationale: Nursing care for a patient after a parathyroidectomy includes monitoring for a sudden decrease in serum calcium levels causing tetany, a condition of neuromuscular hyperexcitability. If tetany is severe (e.g., muscular spasms or laryngospasms develop), IV calcium gluconate should be administered. Mild tetany, characterized by unpleasant tingling of the hands and around the mouth, may be present but should decrease over time without treatment. Decreased muscle tone, muscle weakness, and shortened QT interval are manifestations of hyperparathyroidism.

The patient in the emergency department after a car accident is wearing medical identification listing Addison's disease. What should the nurse expect to be included in the care of this patient?Low-sodium diet Increased glucocorticoid replacement Limiting IV fluid replacement therapy Withholding mineralocorticoid replacement

Increased glucocorticoid replacement. Rationale: The patient with Addison's disease needs lifelong glucocorticoid and mineralocorticoid replacement and has an increased need with illness, injury, or stress, as this patient is experiencing. The patient with Addison's may need large volumes of IV fluid replacement and a high-sodium diet. Withholding mineralocorticoid replacement cannot be done for patients with Addison's disease.

A patient with chronic hepatitis B is being discharged with pain medication after knee surgery. Which medication order should the nurse question? Tramadol Hydromorphone (Dilaudid) Hydrocodone with acetaminophenCorrect Answer Oxycodone with aspirin (Percodan

Hydrocodone with acetaminophen Rationale: The analgesic with acetaminophen should be questioned because this patient has chronic hepatitis B and is likely to have impaired liver function. Acetaminophen is not suitable for this patient because it is converted to a toxic metabolite in the liver after absorption, increasing the risk of hepatocellular damage.

When planning care for a patient with cirrhosis, the nurse will give highest priority to which nursing diagnosis? Fluid imbalance Impaired tissue integrity Impaired nutritional status Ineffective breathing pattern

Ineffective breathing pattern Rationale: Although all these nursing diagnoses are appropriate and important in the care of a patient with cirrhosis, airway and breathing are always the highest priorities.

A patient with sudden pain in the left upper quadrant radiating to the back and vomiting was diagnosed with acute pancreatitis. Which intervention should the nurse include in the patient's plan of care? Immediately start enteral feeding to prevent malnutrition. Insert an NG and maintain NPO status to allow pancreas to rest. Initiate early prophylactic antibiotic therapy to prevent infection. Administer acetaminophen (Tylenol) every 4 hours for pain relief.

Insert an NG and maintain NPO status to allow pancreas to rest. Rationale: Initial treatment with acute pancreatitis will include an NG tube if there is vomiting and being NPO to decrease pancreatic enzyme stimulation and allow the pancreas to rest and heal. Fluid will be administered to treat or prevent shock. The pain will be treated with IV morphine because of the NPO status. Enteral feedings will only be used for the patient with severe acute pancreatitis in whom oral intake is not resumed. Antibiotic therapy is only needed with acute necrotizing pancreatitis and signs of infection.

The condition of a patient who has cirrhosis of the liver has deteriorated. Which diagnostic study would best help determine if the patient has developed liver cancer? MRI scanningCorrect Answer Serum α-fetoprotein level Ventilation/perfusion scan Abdominal girth measurement

MRI scanning Rationale: Hepatic ultrasonography, CT scan, and MRI scanning are used to screen for and diagnose liver cancer. Serum α-fetoprotein level may be elevated with liver cancer or other liver problems. Ventilation/perfusion scans are used to diagnose pulmonary emboli. Abdominal girth measurement would not differentiate between cirrhosis and liver cancer.

A patient with type 2 diabetes and chronic hepatitis C asks the nurse if it would be acceptable to take silymarin (milk thistle) to help minimize liver damage. The nurse responds based on what knowledge? Milk thistle may affect liver enzymes and thus alter drug metabolism. Milk thistle is generally safe in recommended doses for up to 10 years. There is unclear scientific evidence for the use of milk thistle in treating cirrhosis. Milk thistle may increase serum glucose levels and is thus contraindicated in diabetes.

Milk thistle may affect liver enzymes and thus alter drug metabolism. Rationale: Scientific evidence indicates there is no real benefit from milk thistle to protect liver cells from toxic damage in the treatment of chronic hepatitis C. Milk thistle does affect liver enzymes and thus could alter drug metabolism. Therefore, patients will need to be monitored for drug interactions. It is generally well tolerated. It may lower, not elevate, blood glucose levels.

The nurse is caring for a patient with acute pancreatitis resulting from gallstones. Which clinical manifestation would the nurse expect? (Select all that apply.) Hematochezia Nausea and vomiting Hyperactive bowel sounds Left upper abdominal pain Ascites and peripheral edema Temperature 99.3° F (37.4° C)

Nausea and vomiting Left upper abdominal pain Temperature 99.3° F (37.4° C) Rationale: Abdominal pain (usually in the left upper quadrant) is the predominant manifestation of acute pancreatitis. Other manifestations include nausea and vomiting, low-grade fever, leukocytosis, hypotension, tachycardia, and jaundice. Abdominal tenderness with muscle guarding is common. Bowel sounds may be decreased or absent. Ileus may occur and causes marked abdominal distention. Areas of cyanosis or greenish to yellow-brown discoloration of the abdominal wall may occur. Other areas of ecchymoses are the flanks (Grey Turner's spots or sign, a bluish flank discoloration) and the periumbilical area (Cullen's sign, a bluish periumbilical discoloration).

The nurse is caring for a patient admitted with suspected hyperparathyroidism. Which manifestations would represent the expected electrolyte imbalance? (Select all that apply.) Nausea and vomiting Neurologic irritability Lethargy and weakness Increasing urine output Hyperactive bowel sounds

Nausea and vomiting Lethargy and weakness Increasing urine output Rationale: Hyperparathyroidism can cause hypercalcemia. Signs of hypercalcemia include muscle weakness, polyuria, constipation, nausea and vomiting, lethargy, and memory impairment. Neurologic irritability and hyperactive bowel sounds do not occur with hypercalcemia.

The patient with systemic lupus erythematosus is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). What interventions should be included in the plan of care? (Select all that apply.) Obtain daily weights. Limit fluids to 1000 mL/day. Administer diuretics as ordered. Monitor for signs of hypernatremia. Minimize turning and range of motion. Elevate the head of the bed at 10 degrees or less.

Obtain daily weights. Limit fluids to 1000 mL/day. Administer diuretics as ordered. Elevate the head of the bed at 10 degrees or less. Rationale: The care for the patient with SIADH will include limiting fluids to 1000 mL/day or less to decrease weight, increase osmolality, and improve symptoms and keeping the head of the bed elevated at 10 degrees or less to enhance venous return to the heart and increase left atrial filling pressure, thereby reducing the release of ADH. Measure weights daily and maintain accurate intake and output. Monitor for signs of hyponatremia. Frequent turning, positioning, and range-of-motion exercises are important to maintain skin integrity and joint mobility.

A patient admitted with diabetes, malnutrition, osteomyelitis, and chronic alcohol use has a serum amylase level of 480 U/L and a serum lipase level of 610 U/L. Which diagnosis does the nurse expect? Starvation PancreatitisCorrect Answer Systemic sepsis Diabetic ketoacidosis

Pancreatitis Rationale: The patient with chronic alcohol use could develop pancreatitis as a complication, which would increase the serum amylase (normal, 30 to 122 U/L) and serum lipase (normal, 31 to 186 U/L) levels as shown.

What is a nursing priority when caring for a patient with hypothyroidism? Patient teaching related to levothyroxine Providing a dark, low-stimulation environment Closely monitoring the patient's intake and output Initiating precautions related to radioactive iodine therapy

Patient teaching related to levothyroxine. Rationale: A euthyroid state is most often achieved in patients with hypothyroidism by the administration of levothyroxine. It is not necessary to closely monitor intake and output. Low stimulation and radioactive iodine therapy are used to treat hyperthyroidism.

A patient with cirrhosis has increased abdominal girth from ascites. Which statements describe the pathophysiology of ascites? (Select all that apply.) Hepatocytes are unable to convert ammonia to urea. Osmoreceptors in the hypothalamus stimulate thirst. An enlarged spleen removes blood cells from the circulation. Portal hypertension causes leaking of protein and water into the peritoneal cavity. Aldosterone is released to stabilize intravascular volume by saving salt and water. Inability of the liver to synthesize albumin reducing intravascular oncotic pressure.

Portal hypertension causes leaking of protein and water into the peritoneal cavity. Aldosterone is released to stabilize intravascular volume by saving salt and water. Inability of the liver to synthesize albumin reducing intravascular oncotic pressure. Rationale: Ascites related to cirrhosis is caused by decreased colloid oncotic pressure. The liver does not produce albumin that holds fluid in the vascular space, so fluid shifts into interstitial and third spaces. Portal hypertension causes back pressure in the vessels, shifting protein and fluids into the peritoneal cavity. Decreased intravascular volume stimulates the release of aldosterone, which increases sodium and fluid retention. Oral intake of fluids and removal of blood cells by the spleen do not directly contribute to ascites.

The patient with an adrenal hyperplasia is returning from surgery after an adrenalectomy. The nurse should monitor the patient for what immediate postoperative complication? Vomiting Infection Thromboembolism Rapid blood pressure changes

Rapid blood pressure changes. Rationale: The risk of hemorrhage is increased with surgery on the adrenal glands as well as large amounts of hormones being released in the circulation, which may produce hypertension and cause fluid and electrolyte imbalances to occur for the first 24 to 48 hours after surgery. Vomiting, infection, and thromboembolism may occur postoperatively with any surgery.

The nurse receives a phone call from a patient taking cyclophosphamide for treatment of non-Hodgkin's lymphoma. The patient tells the nurse that she has muscle cramps, weakness, and very little urine output. Which response by the nurse is best? "Start taking supplemental potassium, calcium, and magnesium." "Stop taking the medication now and call your health care provider." "These symptoms will decrease with continued use of the medication." "Increase your fluid intake to 3000 mL for 24 hours to improve your urine output."

Stop taking the medication now and call your health care provider." Rationale: Cyclophosphamide may cause syndrome of inappropriate antidiuretic hormone (SIADH). Medications that stimulate the release of ADH should be avoided or discontinued. Treatment may include restriction of fluids to 800 to 1000 mL/day. A loop diuretic such as furosemide (Lasix) is used to promote diuresis, and supplements of potassium, calcium, and magnesium may be needed.

A patient who smokes reports having significant stress and has some eye problems. On assessment, the nurse notes exophthalmos. What additional abnormal findings should the nurse assess for? Muscle weakness and slow movements Puffy face, decreased sweating, and dry hair Systolic hypertension and increased heart rate Decreased appetite, increased thirst, and pallor

Systolic hypertension and increased heart rate Rationale: The manifestations are consistent with Graves' disease or hyperthyroidism. Systolic hypertension, increased heart rate, and increased thirst are associated with hyperthyroidism. Cigarette smoking places the patient at increased risk for Graves' disease. The inhaled cigarette toxins may absorb via the eye orbits, causing exophthalmos. A puffy face; decreased sweating; dry, coarse hair; muscle weakness and slow movements; decreased appetite; and pallor are all manifestations of hypothyroidism.

The nurse is aware of potential complications related to cirrhosis. Which interventions would be included in a safe plan of care? (Select all that apply.) Provide a high-protein, low-carbohydrate diet. Tell the patient to use soft-bristle toothbrush and electric razor. Teach the patient to avoid vigorous blowing of nose and coughing. Apply gentle pressure for the shortest possible time after venipuncture. Use the smallest gauge needle possible when giving injections or drawing blood. Teach the patient to avoid aspirin and nonsteroidal antiinflammatory (NSAIDs).

Tell the patient to use soft-bristle toothbrush and electric razor. Teach the patient to avoid vigorous blowing of nose and coughing. Use the smallest gauge needle possible when giving injections or drawing blood. Teach the patient to avoid aspirin and nonsteroidal antiinflammatory (NSAIDs). Rationale: Using the smallest gauge needle for injections, using a soft bristle toothbrush and an electric razor will minimize the risk of bleeding into the tissues. Avoiding straining, nose blowing, and coughing will reduce the risk of hemorrhage at these sites. The nurse should apply gentle but prolonged pressure to venipuncture sites to minimize the risk of bleeding. Aspirin and NSAIDs should not be used in patients with liver disease because they interfere with platelet aggregation, thus increasing the risk for bleeding. A low-salt, low-protein, high-carbohydrate diet may be recommended.

When caring for a patient with a biliary obstruction, the nurse will anticipate administering which vitamin supplements? (Select all that apply.) Vitamin A Vitamin B Vitamin D Vitamin E Vitamin K

Vitamin A Vitamin D Vitamin E Vitamin K Rationale: Biliary obstruction prevents bile from entering the small intestine and thus prevents the absorption of fat-soluble vitamins. Vitamins A, D, E, and K are all fat-soluble and thus would need to be supplemented in a patient with biliary obstruction.