Chapter 38-43 Weeks 4 & 5
After an unimmunized individual is exposed to hepatitis B through a needle-stick injury, which actions will the nurse plan to take (select all that apply)? a. Administer hepatitis B vaccine. b. Test for antibodies to hepatitis B. c. Teach about a-interferon therapy. d. Give hepatitis B immune globulin. e. Teach about choices for oral antiviral therapy.
A, B, D a. Administer hepatitis B vaccine. b. Test for antibodies to hepatitis B. d. Give hepatitis B immune globulin. The recommendations for hepatitis B exposure include both vaccination and immune globulin administration. In addition, baseline testing for hepatitis B antibodies will be needed. Interferon and oral antivirals are not used for hepatitis B prophylaxis.
25. A 34-year-old female patient with a new ileostomy asks how much drainage to expect. The nurse explains that after the bowel adjusts to the ileostomy, the usual drainage will be about _____ cups. a. 2 b. 3 c. 4 d. 5
A. 2 After the proximal small bowel adapts to reabsorb more fluid, the average amount of ileostomy drainage is about 500 mL daily. One cup is about 240 mL.
15. A 51-year-old male patient has a new diagnosis of Crohn's disease after having frequent diarrhea and a weight loss of 10 pounds (4.5 kg) over 2 months. The nurse will plan to teach about a. medication use. b. fluid restriction. c. enteral nutrition. d. activity restrictions.
ANS: A Medications are used to induce and maintain remission in patients with inflammatory bowel disease (IBD). Decreased activity level is indicated only if the patient has severe fatigue and weakness. Fluids are needed to prevent dehydration. There is no advantage to enteral feedings.
18. The nurse preparing for the annual physical exam of a 50-year-old man will plan to teach the patient about a. endoscopy. b. colonoscopy. c. computerized tomography screening. d. carcinoembryonic antigen (CEA) testing.
ANS: B At age 50, individuals with an average risk for colorectal cancer (CRC) should begin screening for CRC. Colonoscopy is the gold standard for CRC screening. The other diagnostic tests are not recommended as part of a routine annual physical exam at age 50.
20. A 74-year-old patient preparing to undergo a colon resection for cancer of the colon asks about the elevated carcinoembryonic antigen (CEA) test result. The nurse explains that the test is used to a. identify any metastasis of the cancer. b. monitor the tumor status after surgery. c. confirm the diagnosis of a specific type of cancer. d. determine the need for postoperative chemotherapy.
ANS: B CEA is used to monitor for cancer recurrence after surgery. CEA levels do not help to determine whether there is metastasis of the cancer. Confirmation of the diagnosis is made on the basis of biopsy. Chemotherapy use is based on factors other than CEA.
16. A 24-year-old woman with Crohn's disease develops a fever and symptoms of a urinary tract infection (UTI) with tan, fecal-smelling urine. What information will the nurse add to a general teaching plan about UTIs in order to individualize the teaching for this patient? a. Bacteria in the perianal area can enter the urethra. b. Fistulas can form between the bowel and bladder. c. Drink adequate fluids to maintain normal hydration. d. Empty the bladder before and after sexual intercourse.
ANS: B Fistulas between the bowel and bladder occur in Crohn's disease and can lead to UTI. Teaching for UTI prevention in general includes good hygiene, adequate fluid intake, and voiding before and after intercourse.
19. The nurse is providing preoperative teaching for a 61-year-old man scheduled for an abdominal-perineal resection. Which information will the nurse include? a. Another surgery in 8 to 12 weeks will be used to create an ileal-anal reservoir. b. The patient will begin sitting in a chair at the bedside on the first postoperative day. c. The patient will drink polyethylene glycol lavage solution (GoLYTELY) preoperatively. d. IV antibiotics will be started at least 24 hours before surgery to reduce the bowel bacteria.
ANS: C A bowel-cleansing agent is used to empty the bowel before surgery to reduce the risk for infection. A permanent colostomy is created with this surgery. Sitting is contraindicated after an abdominal-perineal resection. Oral antibiotics (rather than IV antibiotics) are given to reduce colonic and rectal bacteria.
21. A 71-year-old patient had an abdominal-perineal resection for colon cancer. Which nursing action is most important to include in the plan of care for the day after surgery? a. Teach about a low-residue diet. b. Monitor output from the stoma. c. Assess the perineal drainage and incision. d. Encourage acceptance of the colostomy stoma.
ANS: C Because the perineal wound is at high risk for infection, the initial care is focused on assessment and care of this wound. Teaching about diet is best done closer to discharge from the hospital. There will be very little drainage into the colostomy until peristalsis returns. The patient will be encouraged to assist with the colostomy, but this is not the highest priority in the immediate postoperative period.
17. A 73-year-old patient with diverticulosis has a large bowel obstruction. The nurse will monitor for a. referred back pain. b. metabolic alkalosis. c. projectile vomiting. d. abdominal distention.
ANS: D Abdominal distention is seen in lower intestinal obstruction. Referred back pain is not a common clinical manifestation of intestinal obstruction. Metabolic alkalosis is common in high intestinal obstruction because of the loss of HCl acid from vomiting. Projectile vomiting is associated with higher intestinal obstruction.
22. A 47-year-old female patient is transferred from the recovery room to a surgical unit after a transverse colostomy. The nurse observes the stoma to be deep pink with edema and a small amount of sanguineous drainage. The nurse should a. place ice packs around the stoma. b. notify the surgeon about the stoma. c. monitor the stoma every 30 minutes. d. document stoma assessment findings.
ANS: D The stoma appearance indicates good circulation to the stoma. There is no indication that surgical intervention is needed or that frequent stoma monitoring is required. Swelling of the stoma is normal for 2 to 3 weeks after surgery, and an ice pack is not needed.
The nurse is planning care for a patient with acute severe pancreatitis. The highest priority patient outcome is a. maintaining normal respiratory function. b. expressing satisfaction with pain control. c. developing no ongoing pancreatic disease. d. having adequate fluid and electrolyte balance.
a. maintaining normal respiratory function. Respiratory failure can occur as a complication of acute pancreatitis and maintenance of adequate respiratory function is the priority goal. The other outcomes would also be appropriate for the patient.
5. A patient complains of gas pains and abdominal distention two days after a small bowel resection. Which nursing action is best to take? a. Encourage the patient to ambulate. b. Instill a mineral oil retention enema. c. Administer the ordered IV morphine sulfate. d. Offer the ordered promethazine (Phenergan) suppository.
a. Encourage the patient to ambulate Ambulation will improve peristalsis and help the patient eliminate flatus and reduce gas pain. A mineral oil retention enema is helpful for constipation with hard stool. A return-flow enema might be used to relieve persistent gas pains. Morphine will further reduce peristalsis. Promethazine (Phenergan) is used as an antiemetic rather than to decrease gas pains or distention.
8. Which nursing action will be included in the plan of care for a 27-year-old male patient with bowel irregularity and a new diagnosis of irritable bowel syndrome (IBS)? a. Encourage the patient to express concerns and ask questions about IBS. b. Suggest that the patient increase the intake of milk and other dairy products. c. Educate the patient about the use of alosetron (Lotronex) to reduce symptoms. d. Teach the patient to avoid using nonsteroidal antiinflammatory drugs (NSAIDs).
a. Encourage the patient to express concerns and ask questions about IBS. Because psychologic and emotional factors can affect the symptoms for IBS, encouraging the patient to discuss emotions and ask questions is an important intervention. Alosetron has serious side effects, and is used only for female patients who have not responded to other therapies. Although yogurt may be beneficial, milk is avoided because lactose intolerance can contribute to symptoms in some patients. NSAIDs can be used by patients with IBS.
45. A 51-year-old woman with Crohn's disease who is taking infliximab (Remicade) calls the nurse in the outpatient clinic about new symptoms. Which symptom is most important to communicate to the health care provider? a. Fever b. Nausea c. Joint pain d. Headache
a. Fever Since infliximab suppresses the immune response, rapid treatment of infection is essential. The other patient complaints are common side effects of the medication, but they do not indicate any potentially life-threatening complications.
51. Which menu choice by the patient with diverticulosis is best for preventing diverticulitis? a. Navy bean soup and vegetable salad b. Whole grain pasta with tomato sauce c. Baked potato with low-fat sour cream d. Roast beef sandwich on whole wheat bread
a. Navy bean soup and vegetable salad A diet high in fiber and low in fats and red meat is recommended to prevent diverticulitis. Although all of the choices have some fiber, the bean soup and salad will be the highest in fiber and the lowest in fat.
48. A female patient is awaiting surgery for acute peritonitis. Which action will the nurse include in the plan of care? a. Position patient with the knees flexed. b. Avoid use of opioids or sedative drugs. c. Offer frequent small sips of clear liquids. d. Assist patient to breathe deeply and cough.
a. Position patient with the knees flexed. There is less peritoneal irritation with the knees flexed, which will help decrease pain. Opioids and sedatives are typically given to control pain and anxiety. Preoperative patients with peritonitis are given IV fluids for hydration. Deep breathing and coughing will increase the patient's discomfort.
26. The nurse admitting a patient with acute diverticulitis explains that the initial plan of care is to a. administer IV fluids. b. give stool softeners and enemas. c. order a diet high in fiber and fluids. d. prepare the patient for colonoscopy.
a. administer IV fluids A patient with acute diverticulitis will be NPO and given parenteral fluids. A diet high in fiber and fluids will be implemented before discharge. Bulk-forming laxatives, rather than stool softeners, are usually given, and these will be implemented later in the hospitalization. The patient with acute diverticulitis will not have enemas or a colonoscopy because of the risk for perforation and peritonitis.
30. A 50-year-old female patient calls the clinic to report a new onset of severe diarrhea. The nurse anticipates that the patient will need to a. collect a stool specimen. b. prepare for colonoscopy. c. schedule a barium enema. d. have blood cultures drawn.
a. collect a stool specimen. Acute diarrhea is usually caused by an infectious process, and stool specimens are obtained for culture and examined for parasites or white blood cells. There is no indication that the patient needs a colonoscopy, blood cultures, or a barium enema.
A patient has been admitted with acute liver failure. Which assessment data are most important for the nurse to communicate to the health care provider? a. Asterixis and lethargy b. Jaundiced sclera and skin c. Elevated total bilirubin level d. Liver 3 cm below costal margin
a. Asterixis and lethargy The patient's findings of asterixis and lethargy are consistent with grade 2 hepatic encephalopathy. Patients with acute liver failure can deteriorate rapidly from grade 1 or 2 to grade 3 or 4 hepatic encephalopathy and need early transfer to a transplant center. The other findings are typical of patients with hepatic failure and would be reported but would not indicate a need for an immediate change in the therapeutic plan.
A patient in the outpatient clinic is diagnosed with acute hepatitis C (HCV) infection. Which action by the nurse is appropriate? a. Schedule the patient for HCV genotype testing. b. Administer the HCV vaccine and immune globulin. c. Teach the patient about ribavirin (Rebetol) treatment. d. Explain that the infection will resolve over a few months.
a. Schedule the patient for HCV genotype testing. Genotyping of HCV has an important role in managing treatment and is done before drug therapy is initiated. Because most patients with acute HCV infection convert to the chronic state, the nurse should not teach the patient that the HCV will resolve in a few months. Immune globulin or vaccine is not available for HCV. Ribavirin is used for chronic HCV infection.
Which finding indicates to the nurse that lactulose is effective for an older adult who has advanced cirrhosis? a. The patient is alert and oriented. b. The patient denies nausea or anorexia. c. The patient's bilirubin level decreases. d. The patient has at least one stool daily.
a. The patient is alert and oriented. The purpose of lactulose in the patient with cirrhosis is to lower ammonia levels and prevent encephalopathy. Although lactulose may be used to treat constipation, that is not the purpose for this patient. Lactulose will not decrease nausea and vomiting or lower bilirubin levels.
The nurse administering a-interferon and ribavirin (Rebetol) to a patient with chronic hepatitis C will plan to monitor for a. leukopenia. b. hypokalemia. c. polycythemia. d. hypoglycemia.
a. leukopenia. Therapy with ribavirin and a-interferon may cause leukopenia. The other problems are not associated with this drug therapy.
53. The nurse is admitting a 67-year-old patient with new-onset steatorrhea. Which question is most important for the nurse to ask? a. "How much milk do you usually drink?" b. "Have you noticed a recent weight loss?" c. "What time of day do your bowels move?" d. "Do you eat meat or other animal products?"
b. "Have you noticed a recent weight loss?" Although all of the questions provide useful information, it is most important to determine if the patient has an imbalance in nutrition because of the steatorrhea.
11. Which patient statement indicates that the nurse's teaching about sulfasalazine (Azulfidine) for ulcerative colitis has been effective? a. "The medication will be tapered if I need surgery." b. "I will need to use a sunscreen when I am outdoors." c. "I will need to avoid contact with people who are sick." d. "The medication will prevent infections that cause the diarrhea."
b. "I will need to use a sunscreen when I am outdoors." Sulfasalazine may cause photosensitivity in some patients. It is not used to treat infections. Sulfasalazine does not reduce immune function. Unlike corticosteroids, tapering of sulfasalazine is not needed.
52. After change-of-shift report, which patient should the nurse assess first? a. 40-year-old male with celiac disease who has frequent frothy diarrhea b. 30-year-old female with a femoral hernia who has abdominal pain and vomiting c. 30-year-old male with ulcerative colitis who has severe perianal skin breakdown d. 40-year-old female with a colostomy bag that is pulling away from the adhesive wafer
b. 30-year-old female with a femoral hernia who has abdominal pain and vomiting Pain and vomiting with a femoral hernia suggest possible strangulation, which will necessitate emergency surgery. The other patients have less urgent problems.
14. After a total proctocolectomy and permanent ileostomy, the patient tells the nurse, "I cannot manage all these changes. I don't want to look at the stoma." What is the best action by the nurse? a. Reassure the patient that ileostomy care will become easier. b. Ask the patient about the concerns with stoma management. c. Develop a detailed written list of ostomy care tasks for the patient. d. Postpone any teaching until the patient adjusts to the ileostomy.
b. Ask the patient about the concerns with stoma management. Encouraging the patient to share concerns assists in helping the patient adjust to the body changes. Acknowledgment of the patient's feelings and concerns is important rather than offering false reassurance. Because the patient indicates that the feelings about the ostomy are the reason for the difficulty with the many changes, development of a detailed ostomy care plan will not improve the patient's ability to manage the ostomy. Although detailed ostomy teaching may be postponed, the nurse should offer teaching about some aspects of living with an ostomy.
36. A 25-year-old male patient calls the clinic complaining of diarrhea for 24 hours. Which action should the nurse take first? a. Inform the patient that laboratory testing of blood and stools will be necessary. b. Ask the patient to describe the character of the stools and any associated symptoms. c. Suggest that the patient drink clear liquid fluids with electrolytes, such as Gatorade or Pedialyte. d. Advise the patient to use over-the-counter loperamide (Imodium) to slow gastrointestinal (GI) motility.
b. Ask the patient to describe the character of the stools and any associated symptoms. The initial response by the nurse should be further assessment of the patient. The other responses may be appropriate, depending on what is learned in the assessment.
2. A 71-year-old male patient tells the nurse that growing old causes constipation so he has been using a suppository for constipation every morning. Which action should the nurse take first? a. Encourage the patient to increase oral fluid intake. b. Assess the patient about risk factors for constipation. c. Suggest that the patient increase intake of high-fiber foods. d. Teach the patient that a daily bowel movement is unnecessary.
b. Assess the patient about risk factors for constipation. The nurse's initial action should be further assessment of the patient for risk factors for constipation and for his usual bowel pattern. The other actions may be appropriate but will be based on the assessment.
35. A patient in the emergency department has just been diagnosed with peritonitis caused by a ruptured diverticulum. Which prescribed intervention will the nurse implement first? a. Insert a urinary catheter to drainage. b. Infuse metronidazole (Flagyl) 500 mg IV. c. Send the patient for a computerized tomography scan. d. Place a nasogastric (NG) tube to intermittent low suction.
b. Infuse metronidazole (Flagyl) 500 mg IV. Because peritonitis can be fatal if treatment is delayed, the initial action should be to start antibiotic therapy (after any ordered cultures are obtained). The other actions can be done after antibiotic therapy is initiated.
54. Which information will the nurse teach a 23-year-old patient with lactose intolerance? a. Ice cream is relatively low in lactose. b. Live-culture yogurt is usually tolerated. c. Heating milk will break down the lactose. d. Nonfat milk is a better choice than whole milk.
b. Live-culture yogurt is usually tolerated. Lactose-intolerant individuals can usually eat yogurt without experiencing discomfort. Ice cream, nonfat milk, and milk that has been heated are all high in lactose.
10. Which nursing action will the nurse include in the plan of care for a 35-year-old male patient admitted with an exacerbation of inflammatory bowel disease (IBD)? a. Restrict oral fluid intake. b. Monitor stools for blood. c. Ambulate four times daily. d. Increase dietary fiber intake.
b. Monitor stools for blood. Because anemia or hemorrhage may occur with IBD, stools should be assessed for the presence of blood. The other actions would not be appropriate for the patient with IBD. Because dietary fiber may increase gastrointestinal (GI) motility and exacerbate the diarrhea, severe fatigue is common with IBD exacerbations, and dehydration may occur.
6. A 58-year-old man with blunt abdominal trauma from a motor vehicle crash undergoes peritoneal lavage. If the lavage returns brown fecal drainage, which action will the nurse plan to take next? a. Auscultate the bowel sounds. b. Prepare the patient for surgery. c. Check the patient's oral temperature. d. Obtain information about the accident.
b. Prepare the patient for surgery Return of brown drainage and fecal material suggests perforation of the bowel and the need for immediate surgery. Auscultation of bowel sounds, checking the temperature, and obtaining information about the accident are appropriate actions, but the priority is to prepare to send the patient for emergency surgery.
32. The nurse is assessing a 31-year-old female patient with abdominal pain. Th nurse,who notes that there is ecchymosis around the area of umbilicus, will document this finding as a. Cullen sign. b. Rovsing sign. c. McBurney sign. d. Grey-Turner's signt.
b. Rovsing sign. Cullen sign is ecchymosis around the umbilicus. Rovsing sign occurs when palpation of the left lower quadrant causes pain in the right lower quadrant. Deep tenderness at McBurney's point (halfway between the umbilicus and the right iliac crest), known as McBurney's sign, is a sign of acute appendicitis.
50. A new 19-year-old male patient has familial adenomatous polyposis (FAP). Which action will the nurse in the gastrointestinal clinic include in the plan of care? a. Obtain blood samples for DNA analysis. b. Schedule the patient for yearly colonoscopy. c. Provide preoperative teaching about total colectomy. d. Discuss lifestyle modifications to decrease cancer risk.
b. Schedule the patient for yearly colonoscopy. Patients with FAP should have annual colonoscopy starting at age 16 and usually have total colectomy by age 25 to avoid developing colorectal cancer. DNA analysis is used to make the diagnosis, but is not needed now for this patient. Lifestyle modifications will not decrease cancer risk for this patient.
41. Which information obtained by the nurse interviewing a 30-year-old male patient is most important to communicate to the health care provider? a. The patient has a history of constipation. b. The patient has noticed blood in the stools. c. The patient had an appendectomy at age 27. d. The patient smokes a pack/day of cigarettes.
b. The patient has noticed blood in the stools. Blood in the stools is a possible clinical manifestation of colorectal cancer and requires further assessment by the health care provider. The other patient information will also be communicated to the health care provider, but does not indicate an urgent need for further testing or intervention.
46. A 33-year-old male patient with a gunshot wound to the abdomen undergoes surgery, and a colostomy is formed as shown in the accompanying figure. Which information will be included in patient teaching? a. Stool will be expelled from both stomas. b. This type of colostomy is usually temporary. c. Soft, formed stool can be expected as drainage. d. Irrigations can regulate drainage from the stomas.
b. This type of colostomy is usually temporary. A loop, or double-barrel stoma, is usually temporary. Stool will be expelled from the proximal stoma only. The stool from the transverse colon will be liquid and regulation through irrigations will not be possible.
33. A 54-year-old critically ill patient with sepsis is frequently incontinent of watery stools. What action by the nurse will prevent complications associated with ongoing incontinence? a. Apply incontinence briefs. b. Use a fecal management system c. Insert a rectal tube with a drainage bag. d. Assist the patient to a commode frequently.
b. Use a fecal management system Fecal management systems are designed to contain loose stools and can be in place for as long as 4 weeks without causing damage to the rectum or anal sphincters. Although incontinence briefs may be helpful, unless they are changed frequently, they are likely to increase the risk for skin breakdown. Rectal tubes are avoided because of possible damage to the anal sphincter and ulceration of the rectal mucosa. A critically ill patient will not be able to tolerate getting up frequently to use the commode or bathroom.
23. Which information will the nurse include in teaching a patient who had a proctocolectomy and ileostomy for ulcerative colitis? a. Restrict fluid intake to prevent constant liquid drainage from the stoma. b. Use care when eating high-fiber foods to avoid obstruction of the ileum. c. Irrigate the ileostomy daily to avoid having to wear a drainage appliance. d. Change the pouch every day to prevent leakage of contents onto the skin.
b. Use care when eating high-fiber foods to avoid obstruction of the ileum. High-fiber foods are introduced gradually and should be well chewed to avoid obstruction of the ileostomy. Patients with ileostomies lose the absorption of water in the colon and need to take in increased amounts of fluid. The pouch should be drained frequently but is changed every 5 to 7 days. The drainage from an ileostomy is liquid and continuous, so control by irrigation is not possible.
9. A patient being admitted with an acute exacerbation of ulcerative colitis reports crampy abdominal pain and passing 15 or more bloody stools a day. The nurse will plan to a. administer IV metoclopramide (Reglan). b. discontinue the patient's oral food intake. c. administer cobalamin (vitamin B12) injections. d. teach the patient about total colectomy surgery.
b. discontinue the patient's oral food intake. An initial therapy for an acute exacerbation of inflammatory bowel disease (IBD) is to rest the bowel by making the patient NPO. Metoclopramide increases peristalsis and will worsen symptoms. Cobalamin (vitamin B12) is absorbed in the ileum, which is not affected by ulcerative colitis. Although total colectomy is needed for some patients, there is no indication that this patient is a candidate.
24. The nurse will determine that teaching a 67-year-old man to irrigate his new colostomy has been effective if the patient a. inserts the irrigation tubing 4 to 6 inches into the stoma. b. hangs the irrigating container 18 inches above the stoma. c. stops the irrigation and removes the irrigating cone if cramping occurs. d. fills the irrigating container with 1000 to 2000 mL of lukewarm tap water.
b. hangs the irrigating container 18 inches above the stoma. The irrigating container should be hung 18 to 24 inches above the stoma. If cramping occurs, the irrigation should be temporarily stopped and the cone left in place. Five hundred to 1000 mL of water should be used for irrigation. An irrigation cone, rather than tubing, should be inserted into the stoma; 4 to 6 inches would be too far for safe insertion.
A patient admitted with an abrupt onset of jaundice and nausea has abnormal liver function studies but serologic testing is negative for viral causes of hepatitis. Which question by the nurse is appropriate? a. "Do you have a history of IV drug use?" b. "Do you use any over-the-counter drugs?" c. "Have you used corticosteroids for any reason?" d. "Have you recently traveled to a foreign country?"
b. "Do you use any over-the-counter drugs?" The patient's symptoms, lack of antibodies for hepatitis, and the abrupt onset of symptoms suggest toxic hepatitis, which can be caused by commonly used over-the-counter drugs such as acetaminophen (Tylenol). Travel to a foreign country and a history of IV drug use are risk factors for viral hepatitis. Corticosteroid use does not cause the symptoms listed.
The nurse recognizes that teaching a patient following a laparoscopic cholecystectomy has been effective when the patient makes which statement? a. "I can expect yellow-green drainage from the incision for a few days." b. "I can remove the bandages on my incisions tomorrow and take a shower." c. "I should plan to limit my activities and not return to work for 4 to 6 weeks." d. "I will need to maintain a low-fat diet for life because I no longer have a gallbladder."
b. "I can remove the bandages on my incisions tomorrow and take a shower." After a laparoscopic cholecystectomy, the patient will have Band-Aids in place over the incisions. Patients are discharged the same (or next) day and have few restrictions on activities of daily living. Drainage from the incisions would be abnormal, and the patient should be instructed to call the health care provider if this occurs. A low-fat diet may be recommended for a few weeks after surgery but will not be a lifelong requirement.
Which action should the nurse take to evaluate treatment effectiveness for a patient who has hepatic encephalopathy? a. Request that the patient stand on one foot. b. Ask the patient to extend both arms forward. c. Request that the patient walk with eyes closed. d. Ask the patient to perform the Valsalva maneuver.
b. Ask the patient to extend both arms forward. Extending the arms allows the nurse to check for asterixis, a classic sign of hepatic encephalopathy. The other tests might also be done as part of the neurologic assessment but would not be diagnostic for hepatic encephalopathy.
Which goal has the highest priority in the plan of care for a 26-yr-old patient who is homeless who was admitted with viral hepatitis who has severe anorexia and fatigue? a. Increase activity level. b. Maintain adequate nutrition. c. Establish a stable environment. d. Identify source of hepatitis exposure.
b. Maintain adequate nutrition. The highest priority outcome is to maintain nutrition because adequate nutrition is needed for hepatocyte regeneration. Finding a home for the patient and identifying the source of the infection would be appropriate activities, but they do not have as high a priority as ensuring adequate nutrition. Although the patient's activity level will be gradually increased, rest is indicated during the acute phase of hepatitis.
A patient is being treated for bleeding esophageal varices with balloon tamponade. Which nursing action will be included in the plan of care? a. Instruct the patient to cough every hour. b. Monitor the patient for shortness of breath. c. Verify the position of the balloon every 4 hours. d. Deflate the gastric balloon if the patient reports nausea.
b. Monitor the patient for shortness of breath. The most common complication of balloon tamponade is aspiration pneumonia. In addition, if the gastric balloon ruptures, the esophageal balloon may slip upward and occlude the airway. Coughing increases the pressure on the varices and increases the risk for bleeding. Balloon position is verified after insertion and does not require further verification. Balloons may be deflated briefly every 8 to 12 hours to avoid tissue necrosis, but if only the gastric balloon is deflated, the esophageal balloon may occlude the airway. Balloons are not deflated for nausea.
A 36-yr-old female patient is receiving treatment for chronic hepatitis C with pegylated interferon (PEG-Intron, Pegasys), ribavirin (Rebetol), and telaprevir (Incivek). Which finding is important to communicate to the health care provider to suggest a change in therapy? a. Weight loss of 2 lb (1 kg) b. Positive urine pregnancy test c. Hemoglobin level of 10.4 g/dL d. Complaints of nausea and anorexia
b. Positive urine pregnancy test Because ribavirin is teratogenic, the medication will need to be discontinued immediately. Anemia, weight loss, and nausea are common adverse effects of the prescribed regimen and may require actions such as patient teaching, but they would not require immediate cessation of the therapy.
For a patient with cirrhosis, which nursing action can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP)? a. Assessing the patient for jaundice b. Providing oral hygiene after a meal c. Palpating the abdomen for distention d. Teaching the patient the prescribed diet
b. Providing oral hygiene after a meal Providing oral hygiene is within the scope of UAP. Assessments and assisting patients to choose therapeutic diets are nursing actions that require higher level nursing education and scope of practice and would be delegated to licensed practical/vocational nurses (LPNs/LVNs) or RNs.
Which action will the nurse include in the plan of care for a patient who has been diagnosed with chronic hepatitis B? a. Advise limiting alcohol intake to 1 drink daily. b. Schedule for liver cancer screening every 6 months. c. Initiate administration of the hepatitis C vaccine series. d. Monitor anti-hepatitis B surface antigen (anti-HBs) levels.
b. Schedule for liver cancer screening every 6 months. Patients with chronic hepatitis are at higher risk for development of liver cancer and should be screened for liver cancer every 6 to 12 months. Patients with chronic hepatitis are advised to completely avoid alcohol. There is no hepatitis C vaccine. Because anti-HBs is present whenever there has been a past hepatitis B infection or vaccination, there is no need to regularly monitor for this antibody.
Which information given by a 70-yr-old patient during a health history indicates to the nurse that the patient should be screened for hepatitis C? a. The patient had a blood transfusion in 2005. b. The patient used IV drugs about 20 years ago. c. The patient frequently eats in fast-food restaurants. d. The patient traveled to a country with poor sanitation.
b. The patient used IV drugs about 20 years ago. Any patient with a history of IV drug use should be tested for hepatitis C. Blood transfusions given after 1992 (when an antibody test for hepatitis C became available) do not pose a risk for hepatitis C. Hepatitis C is not spread by the oral-fecal route and therefore is not caused by contaminated food or by traveling in underdeveloped countries.
The nurse is caring for a patient who has cirrhosis. Which data obtained by the nurse during the assessment will be of most concern? a. The patient complains of right upper-quadrant pain with palpation. b. The patient's hands flap back and forth when the arms are extended. c. The patient has ascites and a 2-kg weight gain from the previous day. d. The patient's abdominal skin has multiple spider-shaped blood vessels.
b. The patient's hands flap back and forth when the arms are extended. Asterixis indicates that the patient has hepatic encephalopathy, and hepatic coma may occur. The spider angiomas and right upper quadrant abdominal pain are not unusual for the patient with cirrhosis and do not require a change in treatment. The ascites and weight gain indicate the need for treatment but not as urgently as the changes in neurologic status.
Which assessment information will be most important for the nurse to report to the health care provider about a patient with acute cholecystitis? a. The patient's urine is bright yellow. b. The patient's stools are tan colored. c. The patient has increased pain after eating. d. The patient complains of chronic heartburn.
b. The patient's stools are tan colored. Tan or gray stools indicate biliary obstruction, which requires rapid intervention to resolve. The other data are not unusual for a patient with this diagnosis, although the nurse would also report the other assessment information to the health care provider.
To detect possible complications in a patient with severe cirrhosis who has bleeding esophageal varices, it is most important for the nurse to monitor a. bilirubin levels. b. ammonia levels. c. potassium levels. d. prothrombin time.
b. ammonia levels. The protein in the blood in the gastrointestinal tract will be absorbed and may result in an increase in the ammonia level because the liver cannot metabolize protein very well. The prothrombin time, bilirubin, and potassium levels should also be monitored, but they will not be affected by the bleeding episode.
The nurse evaluates that administration of hepatitis B vaccine to a healthy patient has been effective when the patient's blood specimen reveals a. HBsAg. b. anti-HBs. c. anti-HBc IgG. d. anti-HBc IgM.
b. anti-HBs. The presence of surface antibody to HBV (anti-HBs) is a marker of a positive response to the vaccine. The other laboratory values indicate current infection with HBV.
The nurse will teach a patient with chronic pancreatitis to take the prescribed pancrelipase (Viokase) a. at bedtime. b. with meals. c. in the morning. d. for abdominal pain.
b. with meals. Pancreatic enzymes are used to help with digestion of nutrients and should be taken with every meal.
4. A 26-year-old woman is being evaluated for vomiting and abdominal pain. Which question from the nurse will be most useful in determining the cause of the patient's symptoms? a. "What type of foods do you eat?" b. "Is it possible that you are pregnant?" c. "Can you tell me more about the pain?" d. "What is your usual elimination pattern?"
c. "Can you tell me more about the pain?" A complete description of the pain provides clues about the cause of the problem. Although the nurse should ask whether the patient is pregnant to determine whether the patient might have an ectopic pregnancy and before any radiology studies are done, this information is not the most useful in determining the cause of the pain. The usual diet and elimination patterns are less helpful in determining the reason for the patient's symptoms.
42. Which care activity for a patient with a paralytic ileus is appropriate for the registered nurse (RN) to delegate to unlicensed assistive personnel (UAP)? a. Auscultation for bowel sounds b. Nasogastric (NG) tube irrigation c. Applying petroleum jelly to the lips d. Assessment of the nares for irritation
c. Applying petroleum jelly to the lips UAP education and scope of practice include patient hygiene such as oral care. The other actions require education and scope of practice appropriate to the RN.
49. A 72-year-old male patient with dehydration caused by an exacerbation of ulcerative colitis is receiving 5% dextrose in normal saline at 125 mL/hour. Which assessment finding by the nurse is most important to report to the health care provider? a. Patient has not voided for the last 4 hours. b. Skin is dry with poor turgor on all extremities. c. Crackles are heard halfway up the posterior chest. d. Patient has had 5 loose stools over the last 6 hours.
c. Crackles are heard halfway up the posterior chest. The presence of crackles in an older patient receiving IV fluids at a high rate suggests volume overload and a need to reduce the rate of the IV infusion. The other data will also be reported, but are consistent with the patient's age and diagnosis and do not require a change in the prescribed treatment.
40. Which activity in the care of a 48-year-old female patient with a new colostomy could the nurse delegate to unlicensed assistive personnel (UAP)? a. Document the appearance of the stoma. b. Place a pouching system over the ostomy. c. Drain and measure the output from the ostomy. d. Check the skin around the stoma for breakdown.
c. Drain and measure the output from the ostomy. Draining and measuring the output from the ostomy is included in UAP education and scope of practice. The other actions should be implemented by LPNs or RNs.
47. A 76-year-old patient with obstipation has a fecal impaction and is incontinent of liquid stool. Which action should the nurse take first? a. Administer bulk-forming laxatives. b. Assist the patient to sit on the toilet. c. Manually remove the impacted stool. d. Increase the patient's oral fluid intake.
c. Manually remove the impacted stool. The initial action with a fecal impaction is manual disimpaction. The other actions will be used to prevent future constipation and impactions.
13. Which diet choice by the patient with an acute exacerbation of inflammatory bowel disease (IBD) indicates a need for more teaching? a. Scrambled eggs b. White toast and jam c. Oatmeal with cream d. Pancakes with syrup
c. Oatmeal with cream During acute exacerbations of IBD, the patient should avoid high-fiber foods such as whole grains. High-fat foods also may cause diarrhea in some patients. The other choices are low residue and would be appropriate for this patient.
29. A 62-year-old patient has had a hemorrhoidectomy at an outpatient surgical center. Which instructions will the nurse include in discharge teaching? a. Maintain a low-residue diet until the surgical area is healed. b. Use ice packs on the perianal area to relieve pain and swelling. c. Take prescribed pain medications before a bowel movement is expected. d. Delay having a bowel movement for several days until healing has occurred.
c. Take prescribed pain medications before a bowel movement is expected. Bowel movements may be very painful, and patients may avoid defecation unless pain medication is taken before the bowel movement. A high-residue diet will increase stool bulk and prevent constipation. Delay of bowel movements is likely to lead to constipation. Warm sitz baths rather than ice packs are used to relieve pain and keep the surgical area clean.
12. A 22-year-old female patient with an exacerbation of ulcerative colitis is having 15 to 20 stools daily and has excoriated perianal skin. Which patient behavior indicates that teaching regarding maintenance of skin integrity has been effective? a. The patient uses incontinence briefs to contain loose stools. b. The patient asks for antidiarrheal medication after each stool. c. The patient uses witch hazel compresses to decrease irritation. d. The patient cleans the perianal area with soap after each stool.
c. The patient uses witch hazel compresses to decrease irritation. Witch hazel compresses are suggested to reduce anal irritation and discomfort. Incontinence briefs may trap diarrhea and increase the incidence of skin breakdown. Antidiarrheal medications are not given 15 to 20 times a day. The perianal area should be washed with plain water after each stool.
39. A 19-year-old female is brought to the emergency department with a knife handle protruding from the abdomen. During the initial assessment of the patient, the nurse should a. remove the knife and assess the wound. b. determine the presence of Rovsing sign. c. check for circulation and tissue perfusion. d. insert a urinary catheter and assess for hematuria.
c. check for circulation and tissue perfusion. The initial assessment is focused on determining whether the patient has hypovolemic shock. The knife should not be removed until the patient is in surgery, where bleeding can be controlled. Rovsing sign is assessed in the patient with suspected appendicitis. A patient with a knife in place will be taken to surgery and assessed for bladder trauma there.
38. Four hours after a bowel resection, a 74-year-old male patient with a nasogastric tube to suction complains of nausea and abdominal distention. The first action by the nurse should be to a. auscultate for hypotonic bowel sounds. b. notify the patient's health care provider. c. reposition the tube and check for placement. d. remove the tube and replace it with a new one.
c. reposition the tube and check for placement. Repositioning the tube will frequently facilitate drainage. Because this is a common occurrence, it is not appropriate to notify the health care provider unless other interventions do not resolve the problem. Information about the presence or absence of bowel sounds will not be helpful in improving drainage. Removing the tube and replacing it are unnecessarily traumatic to the patient, so that would only be done if the tube was completely occluded.
In reviewing the medical record shown in the accompanying figure for a patient admitted with acute pancreatitis, the nurse sees that the patient has a positive Cullen's sign. Indicate the area where the nurse will assess for this change. a. 1 b. 2 c. 3 d. 4
c. 3 The area around the umbilicus should be indicated. Cullen's sign consists of ecchymosis around the umbilicus. Cullen's sign occurs because of seepage of bloody exudates from the inflamed pancreas and indicates severe acute pancreatitis.
During change-of-shift report, the nurse learns about the following four patients. Which patient requires assessment first? a. A 40-yr-old patient with chronic pancreatitis who has gnawing abdominal pain b. A 58-yr-old patient who has compensated cirrhosis and is complaining of anorexia c. A 55-yr-old patient with cirrhosis and ascites who has an oral temperature of 102° F (38.8° C) d. A 36-yr-old patient recovering from a laparoscopic cholecystectomy who has severe shoulder pain
c. A 55-yr-old patient with cirrhosis and ascites who has an oral temperature of 102° F (38.8° C) This patient's history and fever suggest possible spontaneous bacterial peritonitis, which would require rapid assessment and interventions such as antibiotic therapy. The clinical manifestations for the other patients are consistent with their diagnoses and do not indicate complications are occurring.
The nurse is caring for a patient with pancreatic cancer. Which nursing action is the highest priority? a. Offer psychologic support for depression. b. Offer high-calorie, high-protein dietary choices. c. Administer prescribed opioids to relieve pain as needed. d. Teach about the need to avoid scratching any pruritic areas.
c. Administer prescribed opioids to relieve pain as needed. Effective pain management will be necessary in order for the patient to improve nutrition, be receptive to teaching, or manage anxiety or depression.
Which laboratory test result will the nurse monitor when evaluating the effects of therapy for a patient who has acute pancreatitis? a. Calcium b. Bilirubin c. Amylase d. Potassium
c. Amylase Amylase is elevated in acute pancreatitis. Although changes in the other values may occur, they would not be useful in evaluating whether the prescribed therapies have been effective.
A patient born in 1955 had hepatitis A infection 1 year ago. According to Centers for Disease Control and Prevention (CDC) guidelines, which action should the nurse include in care when the patient is seen for a routine annual physical examination? a. Start the hepatitis B immunization series. b. Teach the patient about hepatitis A immune globulin. c. Ask whether the patient has been screened for hepatitis C. d. Test for anti-hepatitis-A virus immune globulin M (anti-HAV-IgM).
c. Ask whether the patient has been screened for hepatitis C. Current CDC guidelines indicate that all patients who were born between 1945 and 1965 should be screened for hepatitis C because many individuals who are positive have not been diagnosed. Although routine hepatitis B immunization is recommended for infants, children, and adolescents, vaccination for hepatitis B is recommended only for adults at risk for blood-borne infections. Because the patient has already had hepatitis A, immunization and anti-HAV IgM levels will not be needed.
Which topic is most important to include in patient teaching for a 41-yr-old patient diagnosed with early alcoholic cirrhosis? a. Taking lactulose b. Maintaining good nutrition c. Avoiding alcohol ingestion d. Using vitamin B supplements
c. Avoiding alcohol ingestion The disease progression can be stopped or reversed by alcohol abstinence. The other interventions may be used when cirrhosis becomes more severe to decrease symptoms or complications, but the priority for this patient is to stop the progression of the disease.
Which action should the nurse in the emergency department take first for a new patient who is vomiting blood? a. Insert a large-gauge IV catheter. b. Draw blood for coagulation studies. c. Check blood pressure and heart rate. d. Place the patient in the supine position.
c. Check blood pressure and heart rate. The nurse's first action should be to determine the patient's hemodynamic status by assessing vital signs. Drawing blood for coagulation studies and inserting an IV catheter are also appropriate. However, the vital signs may indicate the need for more urgent actions. Because aspiration is a concern for this patient, the nurse will need to assess the patient's vital signs and neurologic status before placing the patient in a supine position.
When taking the blood pressure (BP) on the right arm of a patient with severe acute pancreatitis, the nurse notices carpal spasms of the patient's right hand. Which action should the nurse take next? a. Ask the patient about any arm pain. b. Retake the patient's blood pressure. c. Check the calcium level in the chart. d. Notify the health care provider immediately.
c. Check the calcium level in the chart. The patient with acute pancreatitis is at risk for hypocalcemia, and the assessment data indicate a positive Trousseau's sign. The health care provider should be notified after the nurse checks the patient's calcium level. There is no indication that the patient needs to have the BP rechecked or that there is any arm pain.
Which assessment finding would the nurse need to report most quickly to the health care provider regarding a patient with acute pancreatitis? a. Nausea and vomiting b. Hypotonic bowel sounds c. Muscle twitching and finger numbness d. Upper abdominal tenderness and guarding
c. Muscle twitching and finger numbness Muscle twitching and finger numbness indicate hypocalcemia, which may lead to tetany unless calcium gluconate is administered. Although the other findings should also be reported to the health care provider, they do not indicate complications that require rapid action.
A patient with chronic hepatitis C infection has several medications prescribed. Which medication requires further discussion with the health care provider before administration? a. Ribavirin (Rebetol, Copegus) 600 mg PO bid b. Diphenhydramine 25 mg PO every 4 hours PRN itching c. Pegylated a-interferon (PEG-Intron, Pegasys) 1.5 mcg/kg PO daily d. Dimenhydrinate (Dramamine) 50 mg PO every 6 hours PRN nausea
c. Pegylated a-interferon (PEG-Intron, Pegasys) 1.5 mcg/kg PO daily Pegylated a-interferon is administered subcutaneously, not orally. The medications are all appropriate for a patient with chronic hepatitis C infection.
1. Which action will the nurse include in the plan of care for a 42-year-old patient who is being admitted with Clostridium difficile? a. Educate the patient about proper food storage. b. Order a diet with no dairy products for the patient. c. Place the patient in a private room on contact isolation. d. Teach the patient about why antibiotics will not be used.
c. Place the patient in a private room on contact isolation. Because C. difficile is highly contagious, the patient should be placed in a private room and contact precautions should be used. There is no need to restrict dairy products for this type of diarrhea. Metronidazole (Flagyl) is frequently used to treat C. difficile. Improper food handling and storage do not cause C. difficile.
A patient with cirrhosis and esophageal varices has a new prescription for propranolol (Inderal). Which finding is the best indicator to the nurse that the medication has been effective? a. The patient reports no chest pain. b. Blood pressure is 140/90 mm Hg. c. Stools test negative for occult blood. d. The apical pulse rate is 68 beats/minute.
c. Stools test negative for occult blood. Because the purpose of b-blocker therapy for patients with esophageal varices is to decrease the risk for bleeding from esophageal varices, the best indicator of the effectiveness for propranolol is the lack of blood in the stools. Although propranolol is used to treat hypertension, angina, and tachycardia, the purpose for use in this patient is to decrease the risk for bleeding from esophageal varices.
Which finding is most important for the nurse to communicate to the health care provider about a patient who received a liver transplant 1 week ago? a. Dry palpebral and oral mucosa b. Crackles at bilateral lung bases c. Temperature 100.8° F (38.2° C) d. No bowel movement for 4 days
c. Temperature 100.8° F (38.2° C) The risk of infection is high in the first few months after liver transplant and fever is frequently the only sign of infection. The other patient data indicate the need for further assessment or nursing actions and might be communicated to the health care provider, but they do not indicate a need for urgent action.
Which response by the nurse best explains the purpose of ranitidine (Zantac) for a patient admitted with bleeding esophageal varices? a. The medication will reduce the risk for aspiration. b. The medication will inhibit development of gastric ulcers. c. The medication will prevent irritation of the enlarged veins. d. The medication will decrease nausea and improve the appetite.
c. The medication will prevent irritation of the enlarged veins. Esophageal varices are dilated submucosal veins. The therapeutic action of H2-receptor blockers in patients with esophageal varices is to prevent irritation and bleeding from the varices caused by reflux of acid gastric contents. Although ranitidine does decrease the risk for peptic ulcers, reduce nausea, and help prevent aspiration pneumonia, these are not the primary purposes for H2-receptor blockade in this patient.
To prepare a patient with ascites for paracentesis, the nurse a. places the patient on NPO status. b. assists the patient to lie flat in bed. c. asks the patient to empty the bladder. d. positions the patient on the right side.
c. asks the patient to empty the bladder. The patient should empty the bladder to decrease the risk of bladder perforation during the procedure. The patient would be positioned in Fowler's position and would not be able to lie flat without compromising breathing. Because no sedation is required for paracentesis, the patient does not need to be NPO.
The nurse will plan to teach the patient diagnosed with acute hepatitis B about a. administering a-interferon b. side effects of nucleotide analogs. c. measures for improving the appetite. d. ways to increase activity and exercise.
c. measures for improving the appetite. Maintaining adequate nutritional intake is important for regeneration of hepatocytes. Interferon and antivirals may be used for chronic hepatitis B, but they are not prescribed for acute hepatitis B infection. Rest is recommended.
A patient had an incisional cholecystectomy 6 hours ago. The nurse will place the highest priority on assisting the patient to a. perform leg exercises hourly while awake. b. ambulate the evening of the operative day. c. turn, cough, and deep breathe every 2 hours. d. choose preferred low-fat foods from the menu.
c. turn, cough, and deep breathe every 2 hours. Postoperative nursing care after a cholecystectomy focuses on prevention of respiratory complications because the surgical incision is high in the abdomen and impairs coughing and deep breathing. The other nursing actions are also important to implement but are not as high a priority as ensuring adequate ventilation.
34. Which question from the nurse would help determine if a patient's abdominal pain might indicate irritable bowel syndrome? a. "Have you been passing a lot of gas?" b. "What foods affect your bowel patterns?" c. "Do you have any abdominal distention?" d. "How long have you had abdominal pain?"
d. "How long have you had abdominal pain?" One criterion for the diagnosis of irritable bowel syndrome (IBS) is the presence of abdominal discomfort or pain for at least 3 months. Abdominal distention, flatulence, and food intolerance are also associated with IBS, but are not diagnostic criteria.
44. Which patient should the nurse assess first after receiving change-of-shift report? a. 60-year-old patient whose new ileostomy has drained 800 mL over the previous 8 hours b. 50-year-old patient with familial adenomatous polyposis who has occult blood in the stool c. 40-year-old patient with ulcerative colitis who has had six liquid stools in the previous 4 hours d. 30-year-old patient who has abdominal distention and an apical heart rate of 136 beats/minute
d. 30-year-old patient who has abdominal distention and an apical heart rate of 136 beats/minute The patient's abdominal distention and tachycardia suggest hypovolemic shock caused by problems such as peritonitis or intestinal obstruction, which will require rapid intervention. The other patients should also be assessed as quickly as possible, but the data do not indicate any life-threatening complications associated with their diagnoses.
27. A 42-year-old male patient has had a herniorrhaphy to repair an incarcerated inguinal hernia. Which patient teaching will the nurse provide before discharge? a. Soak in sitz baths several times each day. b. Cough 5 times each hour for the next 48 hours. c. Avoid use of acetaminophen (Tylenol) for pain. d. Apply a scrotal support and ice to reduce swelling.
d. Apply a scrotal support and ice to reduce swelling. A scrotal support and ice are used to reduce edema and pain. Coughing will increase pressure on the incision. Sitz baths will not relieve pain and would not be of use after this surgery. Acetaminophen can be used for postoperative pain.
7. A 27-year-old female patient is admitted to the hospital for evaluation of right lower quadrant abdominal pain with nausea and vomiting. Which action should the nurse take? a. Encourage the patient to sip clear liquids. b. Assess the abdomen for rebound tenderness. c. Assist the patient to cough and deep breathe. d. Apply an ice pack to the right lower quadrant.
d. Apply an ice pack to the right lower quadrant. The patient's clinical manifestations are consistent with appendicitis, and application of an ice pack will decrease inflammation at the area. Checking for rebound tenderness frequently is unnecessary and uncomfortable for the patient. The patient should be NPO in case immediate surgery is needed. The patient will need to know how to cough and deep breathe postoperatively, but coughing will increase pain at this time.
28. Which breakfast choice indicates a patient's good understanding of information about a diet for celiac disease? a. Oatmeal with nonfat milk b. Whole wheat toast with butter c. Bagel with low-fat cream cheese d. Corn tortilla with scrambled eggs
d. Corn tortilla with scrambled eggs Avoidance of gluten-containing foods is the only treatment for celiac disease. Corn does not contain gluten, while oatmeal and wheat do.
37. A 45-year-old patient is admitted to the emergency department with severe abdominal pain and rebound tenderness. Vital signs include temperature 102° F (38.3° C), pulse 120, respirations 32, and blood pressure (BP) 82/54. Which prescribed intervention should the nurse implement first? a. Administer IV ketorolac (Toradol) 15 mg. b. Draw blood for a complete blood count (CBC). c. Obtain a computed tomography (CT) scan of the abdomen. d. Infuse 1 liter of lactated Ringer's solution over 30 minutes.
d. Infuse 1 liter of lactated Ringer's solution over 30 minutes. The priority for this patient is to treat the patient's hypovolemic shock with fluid infusion. The other actions should be implemented after starting the fluid infusion.
3. A 64-year-old woman who has chronic constipation asks the nurse about the use of psyllium (Metamucil). Which information will the nurse include in the response? a. Absorption of fat-soluble vitamins may be reduced by fiber-containing laxatives. b. Dietary sources of fiber should be eliminated to prevent excessive gas formation. c. Use of this type of laxative to prevent constipation does not cause adverse effects. d. Large amounts of fluid should be taken to prevent impaction or bowel obstruction.
d. Large amounts of fluid should be taken to prevent impaction or bowel obstruction. A high fluid intake is needed when patients are using bulk-forming laxatives to avoid worsening constipation. Although bulk-forming laxatives are generally safe, the nurse should emphasize the possibility of constipation or obstipation if inadequate fluid intake occurs. Although increased gas formation is likely to occur with increased dietary fiber, the patient should gradually increase dietary fiber and eventually may not need the psyllium. Fat-soluble vitamin absorption is blocked by stool softeners and lubricants, not by bulk-forming laxatives.
43. After several days of antibiotic therapy, an older hospitalized patient develops watery diarrhea. Which action should the nurse take first? a. Notify the health care provider. b. Obtain a stool specimen for analysis. c. Teach the patient about handwashing. d. Place the patient on contact precautions.
d. Place the patient on contact precautions. The patient's history and new onset diarrhea suggest a C. difficile infection, which requires implementation of contact precautions to prevent spread of the infection to other patients. The other actions are also appropriate but can be accomplished after contact precautions are implemented.
31. The nurse will plan to teach a patient with Crohn's disease who has megaloblastic anemia about the need for a. oral ferrous sulfate tablets. b. regular blood transfusions. c. iron dextran (Imferon) infusions. d. cobalamin (B12) spray or injections.
d. cobalamin (B12) spray or injections. Crohn's disease frequently affects the ileum, where absorption of cobalamin occurs. Cobalamin must be administered regularly by nasal spray or IM to correct the anemia. Iron deficiency does not cause megaloblastic anemia. The patient may need occasional transfusions but not regularly scheduled transfusions.
A patient with acute pancreatitis is NPO and has a nasogastric (NG) tube to suction. Which information obtained by the nurse indicates that these therapies have been effective? a. Bowel sounds are present. b. Grey Turner sign resolves. c. Electrolyte levels are normal. d. Abdominal pain is decreased.
d. Abdominal pain is decreased. NG suction and NPO status will decrease the release of pancreatic enzymes into the pancreas and decrease pain. Although bowel sounds may be hypotonic with acute pancreatitis, the presence of bowel sounds does not indicate that treatment with NG suction and NPO status has been effective. Electrolyte levels may be abnormal with NG suction and must be replaced by appropriate IV infusion. Although Grey Turner sign will eventually resolve, it would not be appropriate to wait for this to occur to determine whether treatment was effective.
A serum potassium level of 3.2 mEq/L (3.2 mmol/L) is reported for a patient with cirrhosis who has scheduled doses of spironolactone (Aldactone) and furosemide (Lasix) due. Which action should the nurse take? a. Withhold both drugs. b. Administer both drugs c. Administer the furosemide. d. Administer the spironolactone.
d. Administer the spironolactone. Spironolactone is a potassium-sparing diuretic and will help increase the patient's potassium level. The nurse does not need to talk with the doctor before giving the spironolactone, although the health care provider should be notified about the low potassium value. The furosemide will further decrease the patient's potassium level and should be held until the nurse talks with the health care provider.
Which focused data will the nurse monitor in relation to the 4+ pitting edema assessed in a patient with cirrhosis? a. Hemoglobin b. Temperature c. Activity level d. Albumin level
d. Albumin level The low oncotic pressure caused by hypoalbuminemia is a major pathophysiologic factor in the development of edema. The other parameters are not directly associated with the patient's edema.
Which finding indicates to the nurse that a patient's transjugular intrahepatic portosystemic shunt (TIPS) placed 3 months ago has been effective? a. Increased serum albumin level b. Decreased indirect bilirubin level c. Improved alertness and orientation d. Fewer episodes of bleeding varices
d. Fewer episodes of bleeding varices TIPS is used to lower pressure in the portal venous system and decrease the risk of bleeding from esophageal varices. Indirect bilirubin level and serum albumin levels are not affected by shunting procedures. TIPS will increase the risk for hepatic encephalopathy.
Which assessment finding is of most concern for a patient with acute pancreatitis? a. Absent bowel sounds b. Abdominal tenderness c. Left upper quadrant pain d. Palpable abdominal mass
d. Palpable abdominal mass A palpable abdominal mass may indicate the presence of a pancreatic abscess, which will require rapid surgical drainage to prevent sepsis. Absent bowel sounds, abdominal tenderness, and left upper quadrant pain are common in acute pancreatitis and do not require rapid action to prevent further complications.
A nurse is considering which patient to admit to the same room as a patient who had a liver transplant 3 weeks ago and is now hospitalized with acute rejection. Which patient would be the best choice? a. Patient who is receiving chemotherapy for liver cancer b. Patient who is receiving treatment for acute hepatitis C c. Patient who has a wound infection after cholecystectomy d. Patient who requires pain management for chronic pancreatitis
d. Patient who requires pain management for chronic pancreatitis The patient with chronic pancreatitis does not present an infection risk to the immunosuppressed patient who had a liver transplant. The other patients either are at risk for infection or currently have an infection, which will place the immunosuppressed patient at risk for infection.
A patient with cirrhosis has ascites and 4+ edema of the feet and legs. Which nursing action will be included in the plan of care? a. Restrict daily dietary protein intake. b. Reposition the patient every 4 hours. c. Perform passive range of motion twice daily. d. Place the patient on a pressure-relief mattress.
d. Place the patient on a pressure-relief mattress. The pressure-relieving mattress will decrease the risk for skin breakdown for this patient. Adequate dietary protein intake is necessary in patients with ascites to improve oncotic pressure. Repositioning the patient every 4 hours will not be adequate to maintain skin integrity. Passive range of motion will not take the pressure off areas such as the sacrum that are vulnerable to breakdown.
Which action will be included in the care for a patient who has recently been diagnosed with asymptomatic nonalcoholic fatty liver disease (NAFLD)? a. Teach symptoms of variceal bleeding. b. Draw blood for hepatitis serology testing. c. Discuss the need to increase caloric intake. d. Review the patient's current medication list.
d. Review the patient's current medication list. Some medications can increase the risk for NAFLD, and they should be eliminated. NAFLD is not associated with hepatitis, weight loss is usually indicated, and variceal bleeding would not be a concern in a patient with asymptomatic NAFLD.
The nurse will ask a patient being admitted with acute pancreatitis specifically about a history of a. diabetes mellitus. b. high-protein diet. c. cigarette smoking. d. alcohol consumption.
d. alcohol consumption. Alcohol use is one of the most common risk factors for pancreatitis in the United States. Cigarette smoking, diabetes, and high-protein diets are not risk factors.
A young adult contracts hepatitis from contaminated food. During the acute (icteric) phase of the patient's illness, the nurse would expect serologic testing to reveal a. antibody to hepatitis D (anti-HDV). b. hepatitis B surface antigen (HBsAg). c. anti-hepatitis A virus immunoglobulin G (anti-HAV IgG). d. anti-hepatitis A virus immunoglobulin M (anti-HAV IgM).
d. anti-hepatitis A virus immunoglobulin M (anti-HAV IgM). Hepatitis A is transmitted through the oral-fecal route, and antibody to HAV IgM appears during the acute phase of hepatitis A. The patient would not have antigen for hepatitis B or antibody for hepatitis D. Anti-HAV IgG would indicate past infection and lifelong immunity.
