Practice Questions
A nurse is completing nutrition teaching for a client who has pancreatitis. Which of the following statements by the client indicates an understanding of the teaching (select all that apply.)? A. "I plan to eat small, frequent meals." B. "I will eat easy-to-digest foods with limited spice." C. "I will use skim milk when cooking." D. "I plan to drink regular cola." E. "I will limit alcohol intake to two drinks per day."
A. "I plan to eat small, frequent meals." B. "I will eat easy-to-digest foods with limited spice." C. "I will use skim milk when cooking." Small, frequent meals are recommended for the client who has pancreatitis. Bland, easy-to-digest foods are recommended for the client who has pancreatitis. Low-fat foods are recommended for the client who has pancreatitis. Caffeine-free beverages are recommended for the client who has pancreatitis. The client who has pancreatitis should avoid any alcohol intake.
When teaching a patient infected with HIV regarding transmission of the virus to others, which statement made by the patient would indicate a need for further teaching? A. "I will need to isolate any tissues I use so as not to infect my family." B. "I will notify all of my sexual partners so they can get tested for HIV." C. "Unprotected sexual contact is the most common mode of transmission." D. "I do not need to worry about spreading this virus to others by sweating at the gym."
A. "I will need to isolate any tissues I use so as not to infect my family." HIV is not spread casually. The virus cannot be transmitted through hugging, dry kissing, shaking hands, sharing eating utensils, using toilet seats, or attending school with an HIV-infected person. It is not transmitted through tears, saliva, urine, emesis, sputum, feces, or sweat.
The patient with cirrhosis is being taught self-care. Which statement indicates the patient needs more teaching? A. "If I notice a fast heart rate or irregular beats, this is normal for cirrhosis." B. "I need to take good care of my belly and ankle skin where it is swollen." C. "A scrotal support may be more comfortable when I have scrotal edema." D. "I can use pillows to support my head to help me breathe when I am in bed."
A. "If I notice a fast heart rate or irregular beats, this is normal for cirrhosis." If the patient with cirrhosis experiences 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 is caring for a woman recently diagnosed with viral hepatitis A. Which individual should the nurse refer for an immunoglobulin (IG) injection? A. A caregiver who lives in the same household with the patient B. A friend who delivers meals to the patient and family each week C. A relative with a history of hepatitis A who visits the patient daily D. A child living in the home who received the hepatitis A vaccine 3 months ago
A. A caregiver who lives in the same household with the patient IG is recommended for persons who do not have anti-HAV antibodies and are exposed as a result 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.
The nurse teaches the staff ensuring that standard precautions should be used when providing care for which type of patient? A. All patients regardless of diagnosis B. Pediatric and gerontologic patients C. Patients who are immunocompromised D. Patients with a history of infectious diseases
A. All patients regardless of diagnosis Standard precautions are designed for all care of all patients in hospitals and health care facilities.
A patient who is infected with human immunodeficiency virus (HIV) is being taught by the nurse about health promotion activities such as good nutrition; avoiding alcohol, tobacco, drug use, and exposure to infectious agents; keeping up to date with vaccines; getting adequate rest; and stress management. What is the rationale behind these interventions that the nurse knows? A. Delaying disease progression B. Preventing disease transmission C. Helping to cure the HIV infection D. Enabling an increase in self-care activities
A. Delaying disease progression These health promotion activities along with mental health counseling, support groups, and a therapeutic relationship with health care providers will promote a healthy immune system, which may delay disease progression. These measures will not cure HIV infection, prevent disease transmission, or increase self-care activities.
A nurse is caring for a client who has cirrhosis. Which of the following medications can the nurse expect to administer to this client (select all that apply.)? A. Diuretic B. Beta-blocking agent C. Opioid analgesic D. Lactulose E. Sedative
A. Diuretic B. Beta-blocking agent D. Lactulose Diuretics facilitate excretion of excess fluid from the body in a client who has cirrhosis. Beta-blocking agents are prescribed for a client who has cirrhosis to prevent bleeding from varices. Lactulose is prescribed for a client who has cirrhosis to aid in the elimination of ammonia in the stool. Opioid analgesics are metabolized in the liver. They should not be administered to a client who has cirrhosis. Sedatives are metabolized by the liver. They should not be administered to a client who has cirrhosis.
A nurse is teaching a client who has hepatitis B about home care. Which of the following instructions should the nurse include in the teaching (select all that apply.)? A. Limit physical activity B. Avoid alcohol C. Take acetaminophen for comfort D. Wear a mask when in public places E. Eat small frequent meals
A. Limit physical activity B. Avoid alcohol E. Eat small frequent meals Limiting physical activity and taking frequent rest breaks conserves energy and assists in the recovery process for a client who has hepatitis B. Alcohol is metabolized in the liver and should be avoided by the client who has hepatitis B. A client who has hepatitis B should eat small, frequent meals to promote improved nutrition due to the presence of anorexia. Acetaminophen is metabolized in the liver and should be avoided by the client who has hepatitis B. Hepatitis B is a blood-borne disease. Wearing a mask is not necessary to prevent transmission to others.
A patient with type 2 diabetes and cirrhosis 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? A. Milk thistle may affect liver enzymes and thus alter drug metabolism. B. Milk thistle is generally safe in recommended doses for up to 10 years. C. There is unclear scientific evidence for the use of milk thistle in treating cirrhosis. D. Milk thistle may elevate the serum glucose levels and is thus contraindicated in diabetes.
A. Milk thistle may affect liver enzymes and thus alter drug metabolism. Scientific evidence indicates there is no real benefit from milk thistle to protect liver cells from toxic damage in the treatment of cirrhosis. Milk thistle does affect liver enzymes and thus could alter drug metabolism. Therefore, patients will need to be monitored for drug interactions. It is noted to be safe for up to 6 years, not 10 years, and it may lower, not elevate, blood glucose levels.
A nurse is reviewing risk factors with a client who has cholecystitis. The nurse should identify that which of the following as a risk factor for cholecystitis? A. Obesity B. Rapid weight gain C. Decreased blood triglyceride level D. Male sex
A. Obesity Obesity is considered a risk factor for the development of cholecystitis. Rapid weight loss is a risk factor for the development of cholecystitis. Increased blood cholesterol levels are a risk factor for developing cholecystitis. Female sex is a risk factor for the development of cholecystitis.
A nurse in an outpatient clinic is assessing a client who reports night sweats and fatigue. The client reports having a cough along with nausea and vomiting. Their temperature is 38.1°C (100.6°F) orally. The client is concerned about the possibility of having HIV. Which of the following actions should the nurse take (select all that apply.)? A. Perform a physical assessment B. Determine when manifestations began C. Teach the client about HIV transmission D. Draw blood for HIV testing E. Obtain a sexual history
A. Perform a physical assessment B. Determine when manifestations began E. Obtain a sexual history Perform a physical assessment to gather data about the client's condition. Gather more data to determine whether the manifestations are acute or chronic. Obtain a sexual history to determine how the virus was transmitted. Teaching the client about HIV transmission is not an appropriate action at this time. Drawing blood for HIV testing is not an appropriate action at this time
A nurse is assessing a client for HIV. The nurse should identify which of the following are risk factors associated with this virus (select all that apply.)? A. Perinatal exposure B. Pregnancy C. Monogamous sex partner D. Older adult women E. Occupational exposure
A. Perinatal exposure D. Older adult women E. Occupational exposure Perinatal exposure is a risk factor associated with HIV. Women who are pregnant should take precautionary measure to prevent HIV exposure. Being an older adults woman is a risk factor associated with the HIV virus due to vaginal dryness and the thinning of the vaginal wall. Occupational exposure, such as being a healthcare worker, is a risk factor associated with the HIV virus. Women who are pregnant should be tested for HIV, but pregnancy is not a risk factor associated with this virus. Having a monogamous sex partner is not a risk factor associated with the HIV virus.
A patient has acquired immunodeficiency syndrome (AIDS) and the viral load is reported as undetectable. What patient teaching should be provided by the nurse related to this laboratory study result? A. The patient has the virus present and can transmit the infection to others. B. The patient is not able to transmit the virus to others through sexual contact. C. The patient will be prescribed lower doses of antiretroviral medications for 2 months. D. The syndrome has been cured, and the patient will be able to discontinue all medications.
A. The patient has the virus present and can transmit the infection to others. In human immunodeficiency virus (HIV) infections, viral loads are reported as real numbers of copies/µL or as undetectable. "Undetectable" indicates that the viral load is lower than the test is able to report. "Undetectable" does not mean that the virus has been eliminated from the body or that the individual can no longer transmit HIV to others.
An older adult patient is brought to the primary health care provider by an adult child reporting confusion. What testing should the nurse anticipate obtaining from this patient? A. Urinalysis B. Sputum culture C. Red blood cell count D. White blood cell count
A. Urinalysis The developments of urinary tract infections commonly contribute to atypical manifestations such as cognitive and behavior changes in older adults. Sputum culture, red blood cell count, and white blood cell count may be done, but the first step would be to assess for a possible urinary tract infection.
A patient has been diagnosed with human immunodeficiency virus (HIV) infection. What rationale for taking more than one antiretroviral medication should the nurse give to the patient to improve compliance? A. Viral replication will be inhibited B. They will decrease CD4+ T cell counts. C. It will prevent interaction with other drugs. D. More than one drug has a better chance of curing HIV.
A. Viral replication will be inhibited The major advantage of using several classes of antiretroviral drugs is that viral replication can be inhibited in several ways, making it more difficult for the virus to recover and decreasing the likelihood of drug resistance that is a major problem with monotherapy. Combination therapy also delays disease progression and decreases HIV symptoms and opportunistic diseases. HIV cannot be cured. CD4+ T-cell counts increase with therapy. There are dangerous interactions with many antiretroviral drugs and other commonly used drugs.
When caring for a patient with a biliary obstruction, the nurse will anticipate administering which vitamin supplements (select all that apply.)? A. Vitamin A B. Vitamin D C. Vitamin E D. Vitamin K E. Vitamin B
A. Vitamin A B. Vitamin D C. Vitamin E D. Vitamin K 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.
What should the nurse teach the patients in the assisted living facility to decrease their risk for antibiotic-resistant infection (select all that apply.)? A. Wash hands frequently. B. Take antibiotics as prescribed. C. Take the antibiotic until it is gone. D. Take antibiotics to prevent illnesses like colds. E. Save leftover antibiotics to take if needed later.
A. Wash hands frequently. B. Take antibiotics as prescribed. C. Take the antibiotic until it is gone. To decrease the risk for antibiotic-resistant infections, people should wash their hands frequently, follow the directions when taking the antibiotics, finish the antibiotic, do not request antibiotics for colds or flu, do not save leftover antibiotics, or take antibiotics to prevent an illness without them being prescribed by a health care provider.
A nurse is caring for a client who is suspected of having HIV. The nurse should identify that which of the following diagnostic tests and laboratory value are used to confirm HIV infection (select all that apply.)? A. Western blot B. Indirect immunofluorescence assay C. CD4+ T-lymphocyte count D. HIV RNA quantification test E. Cerebrospinal fluid (CSF) analysis
A. Western blot B. Indirect immunofluorescence assay Positive results of a Western blot test confirm the presence of HIV infection. Positive results of an indirect immunofluorescence assay confirm the presence of HIV infection. CD4+ T-lymphocyte count assists with classifying the stage of HIV infection. HIV RNA quantification tests are used to determine viral level and to monitor treatment. CSF analysis can be used to confirm meningitis.
A nurse is completing preoperative teaching for a client who is scheduled for a laparoscopic cholecystectomy. Which of the following should be included in the teaching? A. "The scope will be passed through your rectum." B. "You might have should pain after surgery." C. "You will have a Jackson-Pratt drain in place after surgery." D. "You should limit how often you walk for 1 to 2 weeks."
B. "You might have should pain after surgery." Shoulder pain is expected postoperatively due to free air that is introduced into the abdomen during laparoscopic surgery. Surgery is possibly performed through the rectum during the natural orifice transluminal endoscopic surgery (NOTES) approach. A Jackson-Pratt can be placed during the open surgery approach. The client is instructed to ambulate frequently following a laparoscopic surgical approach to minimize the free air that has been introduced.
The nurse is caring for a group of patients. Which patient has the highest risk for developing pancreatic cancer? A. A 38-yr-old Hispanic woman who is obese and has hyperinsulinemia B. A 72-yr-old African American man who has smoked cigarettes for 50 years C. A 23-yr-old man who has cystic fibrosis-related pancreatic enzyme insufficiency D. A 19-yr-old patient who has a 5-year history of uncontrolled type 1 diabetes mellitus
B. A 72-yr-old African American man who has smoked cigarettes for 50 years Risk factors for pancreatic cancer include chronic pancreatitis, diabetes mellitus, age, cigarette smoking, family history of pancreatic cancer, high-fat diet, and exposure to chemicals such as benzidine. African Americans have a higher incidence of pancreatic cancer than whites. The most firmly established environmental risk factor is cigarette smoking. Smokers are two or three times more likely to develop pancreatic cancer compared with nonsmokers. The risk is related to duration and number of cigarettes smoked.
When providing discharge teaching for a patient after a laparoscopic cholecystectomy, what information should the nurse include? A. Do not return to work or normal activities for 3 weeks. B. A lower-fat diet may be better tolerated for several weeks. C. Bile-colored drainage will probably drain from the incision. D. Keep the bandages on and the puncture site dry until it heals.
B. A lower-fat diet may be better tolerated for several weeks. 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.
A patient is admitted to the emergency department (ED) with fever, swollen lymph glands, sore throat, headache, malaise, joint pain, and diarrhea. What nursing actions will help identify the need for further assessment of the cause of this patient's manifestations (select all that apply.)? A. Assessment of lung sounds B. Assessment of sexual behavior C. Assessment of living conditions D. Assessment of drug and syringe use E. Assessment of exposure to an ill person
B. Assessment of sexual behavior D. Assessment of drug and syringe use With these symptoms, assessing this patient's sexual behavior and possible exposure to shared drug equipment will identify if further assessment for the HIV virus should be made or the manifestations are from some other illness (e.g., lung sounds and living conditions may indicate further testing for TB).
The nurse is caring for a patient newly diagnosed with Acquired Immunodeficiency Syndrome (AIDS). What does the nurse explain to the patient the criteria for diagnosis is based on? A. Presence of HIV antibodies B. CD4+ T cell count below 200/μL C. Presence of oral hairy leukoplakia D. White blood cell count below 5000/μL
B. CD4+ T cell count below 200/μL Diagnostic criteria for AIDS include a CD4+T-cell count below 200/μL or the development of specified opportunistic infections, cancers, wasting syndrome, or dementia. The other options may be found in patients with HIV disease but do not define the advancement of HIV infection to AIDS.
A nurse is assessing a client who has advanced cirrhosis. The nurse should identify which of the following findings as indicators of hepatic encephalopathy (select all that apply.)? A. Anorexia B. Change in orientation C. Asterixis D. Ascites E. Fetor hepaticus
B. Change in orientation C. Asterixis E. Fetor hepaticus A change in orientation indicates hepatic encephalopathy in a client who has advanced cirrhosis. Asterixis, a coarse tremor of the wrist and fingers, is observed as a late complication in a client who has cirrhosis and hepatic encephalopathy. Fector hepaticus (a fruity, musty breath odor) is a finding of hepatic encephalopathy in the client who has advanced cirrhosis. Anorexia is present in a client who has liver dysfunction, but it is not an indication of hepatic encephalopathy. Ascites can be present in a client who has liver dysfunction, but it is not an indication of hepatic encephalopathy.
A nurse was accidently stuck with a needle used on a patient who is infected with human immunodeficiency virus (HIV). After reporting the incident, what care should this nurse first receive? A. Personal protective equipment B. Combination antiretroviral therapy C. Counseling to report blood exposures D. A negative evaluation by the manager
B. Combination antiretroviral therapy Postexposure prophylaxis with combination antiretroviral therapy can significantly decrease the risk of infection. Personal protective equipment should be available, although it may not have stopped this needle stick. The needle stick has been reported. The negative evaluation may or may not be needed but would not occur first.
The patient is diagnosed with vancomycin-resistant enterococci (VRE) infection in a surgical wound. What infection precautions should the nurse use to best prevent transmission of the infection to others? A. Droplet precautions B. Contact precautions C. Airborne precautions D. Standard precautions
B. Contact precautions Contact precautions are used to minimize the spread of pathogens that are acquired from direct or indirect contact. Droplet precautions are used with pathogens that are spread through the air at close contact and that affect the respiratory system or mucous membranes (e.g., influenza, pertussis). Airborne precautions are used if the organism can cause infection over long distances when suspended in the air (e.g., tuberculosis, rubeola). Standard precautions are used with all patients and included in the transmission-based precautions above.
The patient with right upper quadrant abdominal pain has an abdominal ultrasound that reveals cholelithiasis. What is the nurse's priority? A. Prevent all oral intake B. Control abdominal pain C. Provide enteral feedings D. Avoid dietary cholesterol
B. Control abdominal pain 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 nurse has experienced a recent increase in the incidence of hospital care-associated infections (HAIs) on the unit. Which nursing action should be prioritized in the response to this trend? A. Use gloves during patient contact B. Frequent and thorough hand washing C. Prophylactic, broad-spectrum antibiotics D. Fitting and appropriate use of N95 masks
B. Frequent and thorough hand washing Hand washing remains the mainstay of the prevention of HAIs. Gloves, masks, and antibiotics may be appropriate in specific circumstances, but none of these replaces the central role of vigilant, thorough hand washing between patients and when moving from one task to another, even with the same patient.
The nurse is teaching a group of young adults who live in a dormitory about the prevention of antibiotic-resistant infections. What should be included in the teaching plan? A. Save leftover antibiotics for future uses. B. Hand washing can prevent many infections. C. Antibiotics are indicated for preventing most colds. D. Stop taking prescribed antibiotics when symptoms improve.
B. Hand washing can prevent many infections. Hand washing is the single most important action to prevent infections. Antibiotics are used to treat bacterial infections, not colds and flu caused by viruses. Patients should complete the entire prescription of antibiotics to prevent the development of resistant bacteria. Antibiotics should not be taken to prevent infections unless they are given prophylactically before undergoing certain surgeries and dental work.
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? A. Immediately start enteral feeding to prevent malnutrition. B. Insert an NG and maintain NPO status to allow pancreas to rest. C. Initiate early prophylactic antibiotic therapy to prevent infection. D. Administer acetaminophen (Tylenol) every 4 hours for pain relief.
B. Insert an NG and maintain NPO status to allow pancreas to rest. 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 nurse is caring for a 55-yr-old man patient with acute pancreatitis resulting from gallstones. Which clinical manifestation would the nurse expect? A. Hematochezia B. Left upper abdominal pain C. Ascites and peripheral edema D. Temperature over 102°F
B. Left upper abdominal pain Abdominal pain (usually in the left upper quadrant) is the predominant manifestation of acute pancreatitis. Other manifestations of acute pancreatitis 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).
A nurse is preparing to administer pancrelipase to a client who has pancreatitis. Which of the following actions should the nurse take? A. Instruct the client to chew the medication before swallowing B. Offer a glass of water following medication administration C. Administer the medication 30 min before meals D. Sprinkle the contents on peanut butter
B. Offer a glass of water following medication administration Drink a full glass of water following administration of pancrelipase. Pancrelipase should be swallowed without chewing to reduce irritation and slow the release of the medication. Pancrelipase should be administered with every meal and snack. The contents of the pancrelipase capsule can be sprinkled on nonprotein foods, and peanut butter is a protein food.
A patient with cirrhosis has increased abdominal girth from ascites. Which items identify the pathophysiology related to ascites (select all that apply.)? A. Hepatocytes are unable to convert ammonia to urea. B. Osmoreceptors in the hypothalamus stimulate thirst. C. An enlarged spleen removes blood cells from the circulation. D. Portal hypertension causes leaking of protein and water into the peritoneal cavity. E. Aldosterone is released to stabilize intravascular volume by saving salt and water. F. Inability of the liver to synthesize albumin reducing intravascular oncotic pressure.
B. Osmoreceptors in the hypothalamus stimulate thirst. D. Portal hypertension causes leaking of protein and water into the peritoneal cavity. E. Aldosterone is released to stabilize intravascular volume by saving salt and water. F. Inability of the liver to synthesize albumin reducing intravascular oncotic pressure. 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.
A 54-yr-old patient admitted with diabetes mellitus, malnutrition, osteomyelitis, and alcohol abuse has a serum amylase level of 280 U/L and a serum lipase level of 310 U/L. Which diagnosis does the nurse expect? A. Starvation B. Pancreatitis C. Systemic sepsis D. Diabetic ketoacidosis
B. Pancreatitis The patient with alcohol abuse could develop pancreatitis as a complication, which would increase the serum amylase (normal, 30-122 U/L) and serum lipase (normal, 31-186 U/L) levels as shown.
A nurse is caring for a client who has a new diagnosis of hepatitis C. Which of the following laboratory findings should the nurse expect? A. Presence of immunoglobulin G antibodies (IgG) B. Positive EIA test C. Aspartate aminotransferase (AST) 35 units/L D. Alanine aminotransferase (ALT) 15 IU/L
B. Positive EIA test A positive EIA test is an expected laboratory finding in a client who has a new diagnosis of hepatitis C. The presence of IgG is an expected laboratory finding in a client who has hepatitis A infection. AST is elevated in clients who have hepatitis C infection; 35 units/L is within the expected reference range. ALT is elevated in clients who have hepatitis C infection; 15 units/L is within the expected reference range.
A nurse is providing discharge teaching to a client who is postoperative following laparoscopic cholecystectomy. Which of the following instructions should the nurse include in the teaching (select all that apply.)? A. Take baths rather than showers B. Resume a diet of choice C. Cleanse the puncture site using mild soap and water D. Remove adhesive strips from the puncture site in 24 hr E. Report nausea and vomiting to the surgeon
B. Resume a diet of choice C. Cleanse the puncture site using mild soap and water E. Report nausea and vomiting to the surgeon The client is able to resume a regular diet of choice upon discharge. The client should cleanse the puncture site with mild soap and water to decrease the risk fo infection. The client should report nausea, vomiting, or abdominal pain to the surgeon. The client can take a bath or shower within 1 to 2 days following surgery. The adhesive strips covering the puncture site should remain in place until they fall off naturally.
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.)? A. Provide a high-protein, low-carbohydrate diet. B. Teach the patient to use soft-bristle toothbrush and electric razor. C. Teach the patient to avoid vigorous blowing of nose and coughing. D. Apply gentle pressure for the shortest possible time after venipuncture. E. Use the smallest gauge needle possible when giving injections or drawing blood. F. Instruct the patient to avoid aspirin and nonsteroidal antiinflammatory (NSAIDs).
B. Teach the patient to use soft-bristle toothbrush and electric razor. C. Teach the patient to avoid vigorous blowing of nose and coughing. E. Use the smallest gauge needle possible when giving injections or drawing blood. F. Instruct the patient to avoid aspirin and nonsteroidal antiinflammatory (NSAIDs). 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.
A parent does not want their child to have any extra immunizations for diseases that no longer occur. What teaching about immunization should the nurse provide this mother? A. There is currently no need for those older vaccines. B. There is a reemergence of some of the infections, such as pertussis. C. There is no longer an immunization available for some of those diseases. D. The only way to protect your child is to have the federally required vaccines.
B. There is a reemergence of some of the infections, such as pertussis. Teaching the parent that some of the diseases are reemerging and the damage they can do to her child gives the mother the information to make an informed decision. The immunizations still exist and do protect individuals.
The nurse provides discharge instructions for a 64-yr-old woman with ascites and peripheral edema related to cirrhosis. Which patient statement indicates teaching was effective? A. "Lactulose should be taken every day to prevent constipation." B. "It is safe to take acetaminophen up to four times a day for pain." C. "Herbs and other spices should be used to season my foods instead of salt." D. "I will eat foods high in potassium while taking spironolactone (Aldactone)."
C. "Herbs and other spices should be used to season my foods instead of salt." 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.
The nurse instructs a 50-yr-old woman about cholestyramine to reduce pruritus caused by gallbladder disease. Which patient statement indicates understanding of the instructions? A. "This medication will help me digest fats and fat-soluble vitamins." B. "I will apply the medicated lotion sparingly to the areas where I itch." C. "The medication is a powder and needs to be mixed with milk or juice." D. "I should take this medication on an empty stomach at the same time each day."
C. "The medication is a powder and needs to be mixed with milk or juice." 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.
A pregnant woman who was tested and diagnosed with human immunodeficiency virus (HIV) infection is very upset. What should the nurse teach this patient about her baby's risk of being born with HIV infection? A. "The baby will probably be infected with HIV." B. "Only an abortion will keep your baby from having HIV." C. "Treatment with antiretroviral therapy will decrease the baby's chance of HIV infection." D. "The duration and frequency of contact with the organism will determine if the baby gets HIV infection."
C. "Treatment with antiretroviral therapy will decrease the baby's chance of HIV infection." On average, 25% of infants born to women with untreated HIV will be born with HIV. The risk of transmission is reduced to less than 2% if the infected pregnant woman is treated with antiretroviral therapy. Duration and frequency of contact with the HIV organism is one variable that influences whether transmission of HIV occurs. Volume, virulence, and concentration of the organism as well as host immune status are variables related to transmission via blood, semen, vaginal secretions, or breast milk.
The nurse is providing care for a patient who has been living with human immunodeficiency virus (HIV) for several years. Which assessment finding most clearly indicates an acute exacerbation of the disease? A. A new onset of polycythemia B. Presence of mononucleosis-like symptoms C. A sharp decrease in the patient's CD4+ count D. A sudden increase in the patient's WBC count
C. A sharp decrease in the patient's CD4+ count A decrease in CD4+ count signals an exacerbation of the severity of HIV. Polycythemia is not characteristic of the course of HIV. A patient's WBC count is very unlikely to suddenly increase, with decreases being typical. Mononucleosis-like symptoms such as malaise, headache, and fatigue are typical of early HIV infection and seroconversion.
A nurse in a clinic is reviewing the laboratory reports of a client who has suspected cholelithiasis. Which of the following is an expected finding? A. Blood amylase 80 units/L B. WBC 9,000/mm3 C. Direct bilirubin 2.1 mg/dL D. Alkaline phosphatase 25 units/L
C. Direct bilirubin 2.1 mg/dL Expect the client who has cholelithiasis to have an elevated direct bilirubin level if the bile duct is obstructed. A direct bilirubin level of 2.1 mg/dL is above the expected reference range. Expect the client who has cholelithiasis to have an elevated blood amylase level if pancreatic involvement is present. A blood amylase of 80 units/L is within the expected reference range. Expect the client who has cholelithiasis to have an elevated WBC level due to inflammation. A WBC of 9,000/mm3 is within the expected reference range. Expect the client who has cholelithiasis to have an elevated alkaline phosphatase (ALP) level if the common bile duct is obstructed. An ALP of 25 units/L is less than the expected reference range.
A nurse is assessing a client who has pancreatitis. Which of the following findings should the nurse identify as a manifestation of pancreatitis? A. Generalized cyanosis B. Hyperactive bowel sounds C. Gray-blue discoloration of the skin around the umbilicus D. Wheezing in the lower lung fields
C. Gray-blue discoloration of the skin around the umbilicus A gray-blue discoloration in the periumbilical area is a manifestation of pancreatitis. Expect to find generalized jaundice, not generalized cyanosis. Expect to find absent or decreased bowel sounds. Expect to find diminished breath sounds as well as dyspnea or orthopnea.
The condition of a patient who has cirrhosis of the liver has deteriorated. Which diagnostic study would help determine if the patient has developed liver cancer? A. Serum α-fetoprotein level B. Ventilation/perfusion scan C. Hepatic structure ultrasound D. Abdominal girth measurement
C. Hepatic structure ultrasound Hepatic structure ultrasonography, CT scan, and MRI 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.
The nurse is monitoring the effectiveness of antiretroviral therapy (ART) for a patient with acquired immunodeficiency syndrome (AIDS). What laboratory study result indicates the medications are effective? A. Increased viral load B. Decreased neutrophil count C. Increased CD4+ T cell count D. Decreased white blood cell count
C. Increased CD4+ T cell count Antiretroviral therapy is effective if there are decreased viral loads and increased CD4+ T cell counts.
A heterosexual patient is concerned that they may contract human immunodeficiency virus (HIV) from a bisexual partner. What should the nurse include when teaching about preexposure prophylaxis (select all that apply.)? A. Take fluconazole (Diflucan) B. Take amphotericin B (Fungizone) C. Use condoms for risk-reducing sexual relations. D. Take emtricitabine and tenofovir (Truvada) regularly. E. Have regular HIV testing for herself and her husband.
C. Use condoms for risk-reducing sexual relations. D. Take emtricitabine and tenofovir (Truvada) regularly. E. Have regular HIV testing for herself and her husband. Using male or female condoms, having monthly HIV testing for the patient and partner, and taking emtricitabine and tenofovir regularly have shown to decrease the infection of heterosexual women having sex with a partner who participates in high-risk behavior. Fluconazole and amphotericin B are taken for Candida albicans, Coccidioides immitis, and Cryptococcus neoformans, which are all opportunistic diseases associate with HIV infection.
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? A. "You will need to be tested first; then treatment can be determined." B. "The hepatitis vaccine will provide immunity from this and future exposures." C. "There is nothing you can do since the patient was infectious before admission." D. "An immunoglobulin injection will be given to prevent infection or limit symptoms."
D. "An immunoglobulin injection will be given to prevent infection or limit symptoms." Immunoglobulin provides temporary (1-2 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.
A nurse is providing teaching for a client who has stage 2 HIV disease and is having difficulty maintaining a normal weight. Which of the following statements by the client should indicate to the nurse an understanding of the teaching? A. "I will choose a diet high in fat to help gain weight." B. "I will be sure to eat three large meals daily." C. "I will drink up to 1 liter of liquid each day." D. "I will add high-protein foods to my diet."
D. "I will add high-protein foods to my diet." The client should be taught to add high-protein, high-calorie foods to the diet daily as the best way to gain weight and maintain health. The client should be taught to avoid high-fat foods to gain weight because fat intolerance-causing flatus, bloating, and diarrhea- is common in clients who have HIV/AIDS. The client should be taught that small frequent meals (such as six meals daily) are better tolerated than three large meals. The client should be taught to drink 2 to 3 L of liquids daily to maintain nutrition status.
A nurse is providing teaching for a client who has stage 3 HIV disease. Which of the following statements by the client should indicate to the nurse an understanding of the teaching? A. "I will wear gloves while changing the pet litter box." B. "I will rinse raw fruits with water before eating them." C. "I will wear a mask when around family members who are ill." D. "I will cook vegetables before eating them."
D. "I will cook vegetables before eating them." A client who has AIDS should cook vegetables before eating to kill bacteria that cause opportunistic infections. A client who has AIDS should avoid changing the litter box to prevent acquiring toxoplasmosis. A client who has AIDS should avoid consuming raw fruits due to the presence of bacteria that can cause opportunistic infections. Due to compromised immune response, a client who has AIDS should avoid all contact with family members who are ill.
When teaching the patient with acute hepatitis C (HCV), which statement demonstrates understanding of the disease process? A. "I will use care when kissing my wife to prevent giving it to her." B. "I will need to take adefovir (Hepsera) to prevent chronic HCV." C. "Now that I have had HCV, I will have immunity and not get it again." D. "I will need to be monitored for chronic HCV and other liver problems."
D. "I will need to be monitored for chronic HCV and other liver problems." The majority of patients who acquire HCV usually 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. Chronic HCV is treated with pegylated interferon with ribavirin. Immunity with HCV does not occur as it does with HAV and HBV, so the patient may be reinfected with another type of HCV.
A patient with cholelithiasis is being prepared for surgery. Which patient assessment represents a contraindication for a cholecystectomy? A. Low-grade fever of 100°F and dehydration B. Abscess in the right upper quadrant of the abdomen C. Multiple obstructions in the cystic and common bile duct D. Activated partial thromboplastin time (aPTT) of 54 seconds
D. Activated partial thromboplastin time (aPTT) of 54 seconds 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.
The patient with suspected pancreatic cancer is having many diagnostic studies done. Which one can be used to establish the diagnosis of pancreatic adenocarcinoma and for monitoring the response to treatment? A. Spiral CT scan B. A PET/CT scan C. Abdominal ultrasound D. Cancer-associated antigen 19-9
D. Cancer-associated antigen 19-9 The cancer-associated antigen 19-9 (CA 19-9) is the tumor marker used for the diagnosis of pancreatic adenocarcinoma 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.
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? A. History of hypothyroidism B. Stopped smoking cigarettes C. Well-controlled type 1 diabetes mellitus D. Chest x-ray showed another lung cancer lesion
D. Chest x-ray showed another lung cancer lesion Contraindications for liver transplant include severe extrahepatic disease, advanced hepatocellular carcinoma or other cancer, ongoing drug or alcohol abuse, and the inability to comprehend or comply with the rigorous posttransplant course.
The health care provider orders lactulose for a patient with hepatic encephalopathy. Which finding indicates the medication has been effective? A. Relief of constipation B. Relief of abdominal pain C. Decreased liver enzymes D. Decreased ammonia levels
D. Decreased ammonia levels 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.
A nurse is completing an admission assessment of a client who has pancreatitis. Which of the following findings should the nurse expect? A. Pain in right upper quadrant radiating to right shoulder B. Report of pain being worse when sitting up C. Pain relieved with defecation D. Epigastric pain radiating to the left shoulder
D. Epigastric pain radiating to the left shoulder A client who has pancreatitis will report severe, boring epigastric pain that radiates to the back, left flank, or left shoulder. A client who has cholecystitis will report pain in the right upper quadrant radiating to the right shoulder. A client who has pancreatitis will report pain being worse when lying down. A client who has pancreatitis will report that pain is relieved by assuming the fetal position.
A patient was exposed to human immunodeficiency virus (HIV) 2 weeks ago through sharing needles with other substance users. What symptoms will the nurse teach the patient to report that would indicate the patient has developed an acute HIV infection? A. Cough, diarrhea, headaches, blurred vision, muscle fatigue B. Night sweats, fatigue, fever, and persistent generalized lymphadenopathy C. Oropharyngeal candidiasis or thrush, vaginal candidal infection, or oral or genital herpes D. Flu-like symptoms such as fever, sore throat, swollen lymph glands, nausea, or diarrhea
D. Flu-like symptoms such as fever, sore throat, swollen lymph glands, nausea, or diarrhea Clinical manifestations of an acute infection with HIV include flu-like symptoms between 2 to 4 weeks after exposure. Early chronic HIV infection clinical manifestations are either asymptomatic or include fatigue, headache, low-grade fever, night sweats, and persistent generalized lymphadenopathy. Intermediate chronic HIV infection clinical manifestations include candidal infections, shingles, oral or genital herpes, bacterial infections, Kaposi sarcoma, or oral hairy leukoplakia. Late chronic HIV infection or acquired immunodeficiency syndrome (AIDS) includes opportunistic diseases (infections and cancer).
A patient with hepatitis B surface antigen (HBsAg) present in the serum is being discharged with pain medication after knee surgery. Which medication order should the nurse question? A. Tramadol B. Hydromorphone (Dilaudid) C. Oxycodone with aspirin (Percodan) D. Hydrocodone with acetaminophen
D. Hydrocodone with acetaminophen The analgesic with acetaminophen should be questioned because this patient is a chronic carrier of 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.
A nurse is reviewing the admission laboratory results of a client who has acute pancreatitis. Which of the following findings should the nurse expect? A. Decreased blood lipase level B. Decrease blood amylase level C. Increased blood calcium level D. Increased blood glucose level
D. Increased blood glucose level The client will experience an increased blood glucose level due to pancreatic cell injury, which results in impaired metabolism of carbohydrates due to a decrease in the release of insulin. The client will experience an elevated blood lipase level due to pancreatic cell injury. The client will experience an elevated blood amylase level due to pancreatic cell injury. The client will experience a decrease blood calcium level due to fat necrosis.
When planning care for a patient with cirrhosis, the nurse will give highest priority to which nursing diagnosis? A. Impaired skin integrity related to edema, ascites, and pruritus B. Imbalanced nutrition: less than body requirements related to anorexia C. Excess fluid volume related to portal hypertension and hyperaldosteronism D. Ineffective breathing pattern related to pressure on diaphragm and reduced lung volume
D. Ineffective breathing pattern related to pressure on diaphragm and reduced lung volume Although all of these nursing diagnoses are appropriate and important in the care of a patient with cirrhosis, airway and breathing are always the highest priorities.
A nurse on a medical-surgical unit is admitting a client who has hepatitis B with ascites. Which of the following actions should the nurse include in the plan of care? A. Initiate contact precautions B. Weigh the client weekly C. Measure abdominal girth at the base of the ribcage D. Provide a high-calorie, high-carbohydrate diet
D. Provide a high-calorie, high-carbohydrate diet The client who has hepatitis B should have a diet high in calories and carbohydrates. Hepatitis B is transmitted via blood, so standard precautions are adequate. Daily weights are obtained to monitor fluid status. The client's abdominal girth is measure over the largest part of the abdomen, which will vary by client.
The nurse is providing postoperative care for a patient with human immunodeficiency virus (HIV) infection after an appendectomy. What type of precautions should the nurse observe to prevent the transmission of this disease? A. Droplet precautions B. Contact precautions C. Airborne precautions D. Standard precautions
D. Standard precautions Standard precautions are indicated for prevention of transmission of HIV to the health care worker. HIV is not transmitted by casual contact or respiratory droplets. HIV may be transmitted through sexual intercourse with an infected partner; exposure to HIV-infected blood or blood products; and perinatal transmission during pregnancy, at delivery, or though breastfeeding.
A nurse is reviewing a new prescription for chenodiol with a client who has cholelithiasis. Which of the following should the nurse include in the teaching? A. This medication is used to decreased acute biliary pain. B. This medication requires thyroid function monitoring every 6 months. C. This medication is not recommended for clients who have diabetes mellitus. D. This medication dissolves gallstones gradually over a period of up to 2 years.
D. This medication dissolves gallstones gradually over a period of up to 2 years. Chenodiol is a bile acid that gradually dissolves cholesterol-based gallstones. This medication can be taken for up to 2 years. Opioid analgesics are preferred treatment of acute biliary pain. The client should have an ultrasound of the gallbladder every 6 months during the first year of treatment to determine effectiveness of the medication. Chenodiol is used cautiously in clients who has hepatic conditions or disorders with varices.