Exam #4 Adult Health 2 (chapters 49, 50, 53, 54 and 55)

The nurse is teaching assistive personnel (AP) about care of a client who has advanced cirrhosis. Which statements would the nurse include in the staff teaching? (Select all that apply.) "Apply lotion to the client's dry skin areas." "Use a basin with warm water to bathe the patient." "For the patient's oral care, use a soft toothbrush." "Provide clippers so the patient can trim the fingernails." "Bathe with antibacterial and water-based soaps."

Ans: "Apply lotion to the client's dry skin areas." "For the patient's oral care, use a soft toothbrush." "Provide clippers so the patient can trim the fingernails." Rationale: Clients with advanced cirrhosis often have pruritus. Lotion will help decrease itchiness from dry skin. A soft toothbrush would be used to prevent gum bleeding, and the client's nails would need to be trimmed short to prevent the patient from scratching himself or herself. These clients should use cool, not warm, water on their skin, and should not use excessive amounts of soap.

The nurse is teaching a client diagnosed with gastroesophageal reflux disease (GERD) who is planning to have an endoscopic radiofrequency (Stretta) procedure. What pre-procedure health teaching would the nurse include? (Select all that apply.) "You will need to be on a liquid diet for the first week after the procedure." "Avoid taking any NSAIDs like ibuprofen for 10 days before the procedure." "Contact the primary health care provider after the procedure if you have increased pain." "You will need a nasogastric tube for a few days after the procedure." "You will have a small incision in your stomach area that will have a wound closure.

Ans: "Avoid taking any NSAIDs like ibuprofen for 10 days before the procedure." "Contact the primary health care provider after the procedure if you have increased pain." Rationale: The client having this procedure does not have an incision and will not require a nasogastric tube (NGT). The client should avoid an NGT placement for at least a month after the procedure. A liquid diet is required for only 24 hours after the procedure and then the client should progress to include soft floods like custard and applesauce.

The nurse is teaching a client about the use of viscous lidocaine for oral pain. What health teaching would the nurse include? "Use the drug before every meal to prevent aspiration." "Increase your intake of citrus foods to help with healing." "Use the drug only at bedtime because you won't be eating." "Be sure to check food temperatures before eating."

Ans: "Be sure to check food temperatures before eating." Rationale: Viscous lidocaine has an anesthetic effect in the oral cavity. Therefore, to promote client safety, the nurse would want to teach the client to check food temperature before eating.

The nurse is caring for a client who is prescribed lactulose. The client states, "I do not want to take this medication because it causes diarrhea." How would the nurse respond? "Diarrhea is expected; that's how your body gets rid of ammonia." "You may take antidiarrheal medication to prevent loose stools." "Do not take any more of the medication until your stools firm up." "We will need to send a stool specimen to the laboratory as soon as possible."

Ans: "Diarrhea is expected; that's how your body gets rid of ammonia." Rationale: The purpose of administering lactulose to this patient is to help ammonia leave the circulatory system through the colon. Lactulose draws water into the bowel with its high osmotic gradient, thereby producing a laxative effect and subsequently evacuating ammonia from the bowel. The patient must understand that this is an expected and therapeutic effect for him or her to remain compliant. The nurse would not suggest administering anything that would decrease the excretion of ammonia or holding the medication. There is no need to send a stool specimen to the laboratory because diarrhea is the therapeutic response to this medication.

The nurse is assessing a client with hepatitis C. The client asks the nurse how it was possible to have this disease. What questions might the nurse ask to help the client determine how the disease was contracted? (Select all that apply.) "How old are you?" "Do you work in health care? "Are you receiving hemodialysis?" "Do you use IV drugs?" "Did you receive blood before 1992?" "Have you even been in prison or jail?"

Ans: "How old are you?" "Do you work in health care? "Are you receiving hemodialysis?" "Do you use IV drugs?" "Did you receive blood before 1992?" "Have you even been in prison or jail?" Rationale: The nurse would ask all of these questions because "baby boomers," people who use illicit drugs, people on hemodialysis, health workers, and prisoners are at a very high risk for hepatitis C. Additionally, individuals who received blood, blood products, or an organ transplant prior to 1992 before bloodborne disease screening of these products was mandated are at risk for hepatitis C.

The nurse is teaching a client who has been treated for acute gastritis. What statement by the client indicates a need for further teaching? "I need to cut down on drinking martinis every might." "I should decrease my intake of caffeinated drinks, especially coffee." "I will only take ibuprofen once in a while when I really need it." "I can continue smoking cigarettes which is better than chewing tobacco."

Ans: "I can continue smoking cigarettes which is better than chewing tobacco." Rationale: To prevent another episode of acute gastritis, alcohol, caffeinated drinks, and NSAIDs should be avoided or kept at a minimum. Smoking and all forms of tobacco should also be avoided.

A nurse cares for a client with end-stage pancreatic cancer. The client asks, "Why is this happening to me?" How would the nurse respond? "I don't know. I wish I had an answer for you, but I don't." "It's important to keep a positive attitude for your family right now." "Scientists have not determined why cancer develops in certain people." "I think that this is a trial so you can become a better person because of it."

Ans: "I don't know. I wish I had an answer for you, but I don't." Rationale: The client is not asking the nurse to actually explain why the cancer has occurred. The client may be expressing his or her feelings of confusion, frustration, distress, and grief related to this diagnosis. Reminding the client to keep a positive attitude for his or her family does not address the client's emotions or current concerns. The nurse would validate that there is no easy or straightforward answer as to why the client has cancer. Telling a client that cancer is a trial is untrue and may negatively impact the client-nurse relationship.

After teaching a client who has been diagnosed with hepatitis A, the nurse assesses the client's understanding. Which statement by the client indicates correct understanding of the teaching? "Some medications have been known to cause hepatitis A." "I may have been exposed when we ate shrimp last weekend." "I was infected with hepatitis A through a recent blood transfusion." "My infection with Epstein-Barr virus can co-infect me with hepatitis A."

Ans: "I may have been exposed when we ate shrimp last weekend." Rationale: The route of transmission for hepatitis A infection is through close personal contact or ingestion of contaminated water or shellfish. Hepatitis A is not transmitted through medications, blood transfusions, or Epstein-Barr virus. Toxic and drug-induced hepatitis is caused from exposure to hepatotoxins, but this is not a form of hepatitis A. Hepatitis B can be spread through blood transfusions. Epstein-Barr virus causes a secondary infection that is not associated with hepatitis A.

After teaching a client who has alcohol-induced cirrhosis, a nurse assesses the client's understanding. Which statement made by the client indicates a need for further teaching? "I cannot drink any alcohol at all anymore." "I should not take over-the-counter medications." "I need to avoid protein in my diet." "I should eat small, frequent, balanced meals."

Ans: "I need to avoid protein in my diet." Rationale: Based on the degree of liver involvement and decreased function, protein intake may have to be decreased. However, some protein is necessary for the synthesis of albumin and normal healing. The other statements indicate accurate understanding of self-care measures for this client.

The nurse is caring for a client who has cirrhosis from substance abuse. The client states, "All of my family hates me." How would the nurse respond? "You should make peace with your family." "This is not unusual. My family hates me too." "I will help you identify a support system." "You must attend Alcoholics Anonymous."

Ans: "I will help you identify a support system." Rationale: Clients who have cirrhosis due to addiction may have alienated relatives over the years because of substance abuse. The nurse would assist the client to identify a friend, neighbor, clergy/spiritual leader, or group for support. The nurse would not minimize the patient's concerns. Attending AA may be appropriate, but this response doesn't address the client's concern. "Making peace" with the client's family may not be possible. This statement is not client-centered.

After teaching a client who has chronic pancreatitis and will be discharged with enzyme replacement therapy, a nurse assesses the client's understanding. Which statement by the client indicates a need for further teaching? (Select all that apply.) "I will take the enzymes between meals." "The enteric-coated preparations cannot be crushed." "Swallowing the tables without chewing is best." "I will wipe my lips after taking the enzymes." "Enzymes should be taken with high-protein foods."

Ans: "I will take the enzymes between meals." "Enzymes should be taken with high-protein foods." Rationale: Client teaching related to self-management of enzyme replacement therapy would include taking the enzymes with meals and snacks but not mixing enzyme preparations with protein-containing foods. Clients would not crush enteric-coated preparations and should swallow tablets without chewing to minimize oral irritation and allow the drug to be released slowly. Wiping lips after taking enzymes also minimizes skin irritation.

The nurse is teaching a client diagnosed with stomatitis about special mouth care. Which statement by the client indicates a need for further teaching? "I need to take out my dentures until my mouth heals." "I'll try to eat soft foods that aren't spicy and acidic." "I will use a more firm toothbrush to keep my mouth clean." "I'll be sure to rinse my mouth often with warm salt water."

Ans: "I will use a more firm toothbrush to keep my mouth clean." Rationale: The client who has stomatitis has oral inflammation, which causes discomfort. Therefore, all of these actions help to avoid irritation except for needing to use a soft toothbrush or gauze rather than a firm one.

A client has a recurrence of gastric cancer and is crying. What response by the nurse is most appropriate? "Do you have family or friends for support?" "Would you tell me what you are feeling now?" "Well, we knew this would probably happen." "Would you like me to refer you to hospice?"

Ans: "Would you tell me what you are feeling now?" Rationale: The nurse assesses the client's emotional state with open-ended questions and statements and shows a willingness to listen to the client's concerns. Asking about support people is very limited in nature, and "yes-or-no" questions are not therapeutic. Stating that this was expected dismisses the client's concerns. The client may or may not be ready to hear about hospice, and this is another limited, yes-or-no question.

Which of the following is (are) (a) risk factor(s) for gastric cancer? (Select all that apply.) Achlorhydria Chronic atrophic gastritis H. pylori infection Iron deficiency anemia Pernicious anemia

Ans: Achlorhydria Chronic atrophic gastritis H. pylori infection Pernicious anemia Rationale: Achlorhydria, chronic atrophic gastritis, H. pylori infection, and pernicious anemia are all risk factors for developing gastric cancer. Iron deficiency anemia is not a risk factor.

A nurse is preparing to administer pantoprazole intravenously to prevent stress ulcers during surgery. What action(s) by the nurse is (are) most appropriate? (Select all that apply.) Administer the drug through a separate IV line. Infuse pantoprazole using an IV pump. Keep the drug in its original brown container. Take vital signs frequently during infusion. Use an in-line IV filter when infusing.

Ans: Administer the drug through a separate IV line. Infuse pantoprazole using an IV pump. Use an in-line IV filter when infusing. Rationale: When infusing pantoprazole, use a separate IV line, a pump, and an in-line filter. A brown wrapper and frequent vital signs are not needed.

What action(s) by the nurse is (are) appropriate to promote nutrition in a client who had a partial gastrectomy? (Select all that apply.) Administer vitamin B12 injections. Ask the primary health care provider about folic acid replacement. Educate the client on enteral feedings. Obtain consent for total parenteral nutrition. Provide iron supplements for the client.

Ans: Administer vitamin B12 injections. Ask the primary health care provider about folic acid replacement. Provide iron supplements for the client. Rationale: After a partial or total gastrectomy, clients are at high risk for anemia due to vitamin B12 deficiency, folic acid deficiency, or iron deficiency. The nurse would provide supplements for all these nutrients. The client does not need enteral feeding or total parenteral nutrition.

The nurse is teaching a client about risk factors for esophageal cancer. Which risk factors would the nurse include? (Select all that apply.) Alcohol intake Obesity Smoking Lack of fresh fruits and vegetables Untreated GERD Use of NSAIDs

Ans: Alcohol intake Obesity Smoking Lack of fresh fruits and vegetables Untreated GERD Rationale: All of these factors increase the risk of esophageal cancer except for the use of NSAIDs. Untreated GERD causes damage to esophageal tissue which may develop into Barrett esophagus or precancerous cells.

When working with older adults to promote good nutrition, what action(s) by the nurse is(are) most appropriate? (Select all that apply.) Allow uninterrupted time for eating. Assess dentures (if worn) for appropriate fit. Ensure that the client has glasses on or contacts in when eating. Provide salty or highly spicy foods that the client can taste. Serve high-calorie, high-protein snacks one to two times a day.

Ans: Allow uninterrupted time for eating. Assess dentures (if worn) for appropriate fit. Ensure that the client has glasses on or contacts in when eating. Serve high-calorie, high-protein snacks one to two times a day. Rationale: Older adults need unhurried and uninterrupted time for eating. Dentures should fit appropriately and glasses or contacts, if used, should be on. High-calorie, high-protein snacks are a good choice. Salty or spicy snacks are not recommended because all adults should limit sodium in their diets and spicy foods may not be tolerated.

The nurse is assessing a client who has undernutrition. What signs and symptom(s) would the nurse expect? (Select all that apply.) Alopecia Stomatitis Muscle wasting Peripheral edema Anemia Dry, scaly skin

Ans: Alopecia Stomatitis Muscle wasting Peripheral edema Anemia Dry, scaly skin Rationale: All of these body changes occur due to nutrient deficiencies associated with low protein, zinc, Vitamin A, and complex B vitamins.

The nurse is caring for a client with sialadenitis. What comfort measures are appropriate for this client? (Select all that apply.) Applying warm compresses Applying ice to salivary glands Offering fluids every hour Providing lemon-glycerin swabs Reminding the patient to avoid speaking

Ans: Applying warm compresses Offering fluids every hour Rationale: Warm compresses and fluids can help promote comfort for this client. Application of ice or lemon-glycerin swabs would not be used. Speaking has no effect on this condition.

A client has dumping syndrome. What menu selections indicate the client understands the correct diet to manage this condition? (Select all that apply.) Apricots Coffee cake Milk shake Potato soup Steamed broccoli

Ans: Apricots Potato soup Rationale: Canned apricots and potato soup are appropriate selections as they are part of a high-protein, high-fat, and low- to moderate-carbohydrate diet. Coffee cake and other sweets must be avoided. Milk products and sweet drinks such as shakes must be avoided. Gas-forming foods such as broccoli must also be avoided.

The nurse assesses a client who has chronic pancreatitis. What assessment findings would the nurse expect for this client? (Select all that apply.) Ascites Weight gain Steatorrhea Jaundice Polydipsia Polyuria

Ans: Ascites Steatorrhea Jaundice Polydipsia Polyuria Rationale: The client who has chronic pancreatitis has all of these signs and symptoms except he or she loses weight. Ascites and jaundice result from biliary obstruction; ascites is associated with portal hypertension. Steatorrhea is fatty stool that occurs because lipase is not available in the duodenum; because it is released by the disease pancreas into the bloodstream. Polydipsia, polyuria, and polyphagia result from diabetes mellitus, a common problem seen in clients whose pancreas is unable to release adequate amounts of insulin.

The nurse is performing an initial assessment and notes that the client weighs 186.4 lb (84.7 kg). Six months ago, the client weighed 211.8 lb (96.2 kg). What action by the nurse is appropriate? Ask the client if the weight loss was intentional. Determine if there are food allergies or intolerances. Perform a comprehensive nutritional assessment. Perform a rapid bedside blood glucose test.

Ans: Ask the client if the weight loss was intentional. Rationale: This client has had a 12% weight loss. The nurse first determines if the weight loss was intentional. If not, then the nurse proceeds to a comprehensive nutritional assessment. Food intolerances are part of this assessment. Depending on risk factors and other findings, a blood glucose test may be warranted.

A client is in the bariatric clinic 1 month after having gastric bypass surgery. The client is crying and says "I didn't know it would be this hard to live like this." What approach by the nurse is best? Assess the client's coping and support systems. Inform the client that things will get easier. Re-educate the client on needed dietary changes. Tell the client that lifestyle changes are always hard.

Ans: Assess the client's coping and support systems. Rationale: The nurse would assess this patient's coping styles and support systems to best provide holistic care. The other options do not address the patient's distress.

The nurse is caring for a client who is scheduled for a paracentesis. Which action is appropriate for the nurse to take? Have the client sign the informed consent form. Get the patient into a chair before the procedure. Help the client lie flat in bed on the right side. Assist the client to void before the procedure.

Ans: Assist the client to void before the procedure. Rationale: For safety, the patient would void just before a paracentesis to prevent bladder damage to the procedure. The primary health care provider would have the client sign the consent form. The proper position for a paracentesis is sitting upright in bed or, alternatively, sitting on the side of the bed and leaning over the bedside table.

The nurse is teaching a client about the risk of uncontrolled or untreated the client's gastroesophageal reflux disease (GERD). What complication(s) may occur if GERD is not successfully managed? (Select all that apply.) Asthma Laryngitis Dental caries Cardiac disease Cancer

Ans: Asthma Laryngitis Dental caries Cardiac disease Cancer Rationale: Any of these complications may occur in clients who have uncontrolled or untreated GERD.

A client is awaiting bariatric surgery in the morning. What action by the nurse is most important? Answering questions the client has about surgery Beginning venous thromboembolism prophylaxis Informing the client that he or she will be out of bed tomorrow Teaching the client about needed dietary changes

Ans: Beginning venous thromboembolism prophylaxis Rationale: Morbidly obese clients are at high risk of venous thromboembolism and should be started on a regimen to prevent this from occurring as a priority. Answering questions about the surgery is done by the surgeon. Teaching is important, but safety comes first.

The nurse is caring for a client scheduled to have a transjugular intrahepatic portal-systemic shunt (TIPS) procedure. What client assessment would the nurse perform prior to this procedure? Musculoskeletal assessment Neurologic assessment Mental health assessment Cardiovascular assessment

Ans: Cardiovascular assessment Rationale: A postprocedure complication of a TIPS procedure is right-sided heart failure. Therefore, the nurse would perform a cardiovascular assessment before the procedure to determine if the client has signs and symptoms of heart failure.

A client is receiving bolus feedings through a small-bore nasoduodenal tube. What action by the nurse is the priority? Auscultate lung sounds after each feeding. Weigh the client daily on the same scale. Check tube placement every 8 hours. Check tube placement before each feeding.

Ans: Check tube placement before each feeding. Rationale: For bolus feedings, the nurse checks placement of the tube per institutional policy prior to each feeding, which is more often than every 8 hours during the day. Auscultating lung sounds is also important, but this may indicate a complication that has already occurred. Weighing the client is important to determine if nutritional goals are being met, but it is not the priority.

A nurse assesses a client who has cholecystitis. Which sign or symptom indicates that this condition is chronic rather than acute? Temperature of 100.1° F (37.8° C) Positive Murphy sign Clay-colored stools Upper abdominal pain after eating

Ans: Clay-colored stools Jaundice, clay-colored stools, and dark urine are more commonly seen with chronic cholecystitis. The other symptoms are seen in clients with either chronic or acute cholecystitis.

A nurse is reviewing laboratory values for several clients. Which value indicates a need for a nutritional assessment? Client with an albumin of 3.5 g/dL Client with a cholesterol of 142 mg/dL (3.7 mmol/L) Client with a hemoglobin of 9.8 mg/dL (98 mmol/L) Client with a prealbumin of 28 mg/dL

Ans: Client with a cholesterol of 142 mg/dL (3.7 mmol/L) Rationale: A cholesterol level below 160 mg/dL (4 mmol/L) is a possible indicator of undernutrition, so this client would be at highest priority for a nutritional assessment. The albumin and prealbumin levels are normal. The low hemoglobin could be from several problems, including dietary deficiencies, hemodilution, and bleeding.

The nurse understands that undernutrition can occur in hospitalized clients for several reasons. Which of the following factors are possible reasons for this complication to occur? (Select all that apply.) Cultural food preferences Family bringing snacks Increased need for nutrition Need for NPO status Staff shortages

Ans: Cultural food preferences Increased need for nutrition Need for NPO status Staff shortages Rationale: Many factors increase the hospitalized client's risk for nutritional deficits. Cultural food preferences may make hospital food unpalatable. Ill patients have increased nutritional needs but may be NPO for testing or treatment, or have a loss of appetite from their illness. Staff shortages impact clients who need to be fed or assisted with meals. The family may bring snacks that are either healthy or unhealthy, so without further information, the nurse cannot assume that the snacks are leading to undernutrition.

The nurse is caring for a client who was recently diagnosed with pancreatic cancer. What factors present risks for developing this type of cancer? (Select all that apply.) Diabetes mellitus Cirrhosis Smoking Female gender Family history Older age

Ans: Diabetes mellitus Cirrhosis Smoking Family history Older age Rationale: All of these choices are risk factors except that pancreatic cancer occurs most frequently in men.

A nurse assesses a client who is recovering from a Whipple procedure. Which assessment finding alerts the nurse to immediately contact the primary health care provider? Drainage from a fistula Diminished bowel sounds Pain at the incision site Nasogastric (NG) tube drainage

Ans: Drainage from a fistula Rationale: Complications of a Whipple procedure include secretions that drain from a fistula and peritonitis. Absent bowel sounds, pain at the incision site, and NG tube drainage are normal postoperative findings.

The nurse notes that the primary health care provider documented the presence of mucosal erythroplasia in a client. What does the nurse understand that this most likely means for this client? Early sign of oral cancer Fungal mouth infection Inflammation of the gums Obvious oral tumor

Ans: Early sign of oral cancer Rationale: Mucosal erythroplasia is the earliest sign of oral cancer. It is not a fungal infection, inflammation of the gums, or an obvious tumor.

A nurse assesses a client who has cirrhosis of the liver. Which laboratory findings would the nurse expect in clients with this disorder? (Select all that apply.) Elevated aspartate transaminase Elevated international normalized ratio (INR) Decreased serum globulin levels Decreased serum alkaline phosphatase Elevated serum ammonia Elevated prothrombin time (PT)

Ans: Elevated international normalized ratio (INR) Elevated serum ammonia Elevated prothrombin time (PT) Rationale: Elevated INR and PT are indications of clotting disturbances and alert the nurse to the increased possibility of hemorrhage. Elevated ammonia levels increase the client's confusion. The other values are abnormal and associated with liver disease but do not necessarily place the client at increased risk for complications.

A client just returned to the surgical unit after an open traditional gastric bypass. What action by the nurse is the priority? Assess the patient's pain. Check the surgical incision. Ensure an adequate airway. Program the morphine pump.

Ans: Ensure an adequate airway. Rationale: All actions are appropriate care measures for this patient; however, airway is always the priority. Bariatric patients tend to have short, thick necks that complicate airway management.

A nurse has delegated feeding a client to assistive personnel (AP). What action(s) does the nurse include in the directions to the AP? (Select all that apply.) Allow 30 minutes for eating so food doesn't get spoiled. Assess the patient's mouth while providing premeal oral care. Ensure that warm and cold items stay at appropriate temperatures. Remove bedpans, soiled linens, and other unpleasant items. Sit with the client, making the atmosphere more relaxed.

Ans: Ensure that warm and cold items stay at appropriate temperatures. Remove bedpans, soiled linens, and other unpleasant items. Sit with the client, making the atmosphere more relaxed. Rationale: The AP should make sure that food items remain at the appropriate temperatures for maximum palatability. Removing items such as bedpans, urinals, or soiled linens helps make the atmosphere more conducive to eating. The AP should sit, not stand, next to the client to promote a relaxing experience. The client, especially older clients who tend to eat more slowly, should not be rushed. Assessment is done by the nurse.

The nurse is caring for a client who has frequent gastric pain and dyspepsia. Which procedure would the nurse expect for the client to make an accurate diagnosis? Esophagogastroduodenoscopy (EGD) Abdominal arteriogram Nuclear medicine scan Magnetic resonance imaging (MRI)

Ans: Esophagogastroduodenoscopy (EGD) Rationale: The gold standard for diagnosing disorders of the stomach is an EGD which allows direct visualization by the endoscopist into the esophagus, stomach, and duodenum.

A client had an open traditional Whipple procedure this morning. For what priority complication would the nurse assess? Urinary tract infection Chronic kidney disease Heart failure Fluid and electrolyte imbalances

Ans: Fluid and electrolyte imbalances Rationale: Due to the length and complexity of this type of surgery, the client is at risk for fluid and electrolyte imbalances. The nurse would assess for signs and symptoms of these imbalances so they can be managed early to prevent potentially life-threatening complications.

The nurse is caring for a client with early encephalopathy due to cirrhosis of the liver. Which factors may contribute to increased encephalopathy for which the nurse would assess? (Select all that apply.) Infection GI bleeding Irritable bowel syndrome Constipation Anemia Hypovolemia

Ans: Infection GI bleeding Constipation Hypovolemia Rationale: Anemia and irritable bowel syndrome are unrelated to developing or worsening encephalopathy, which is caused by increased protein which breaks down into ammonia. Infection can cause hypovolemia which would increase serum protein concentration. Constipation and GI bleeding causes a large protein load in the intestines.

The nurse documents the vital signs of a client diagnosed with acute pancreatitis: Apical pulse = 116 beats/min Respirations = 28 breaths/min Blood pressure = 92/50. What complication of acute pancreatitis would the nurse suspect that the client might have? Electrolyte imbalance Pleural effusion Internal bleeding Pancreatic pseudocyst

Ans: Internal bleeding Rationale: The client is exhibiting signs of hypovolemia most likely due to internal bleeding or hemorrhage. Due to decreased blood volume, the blood pressure is low and the heart rate increases to compensate for hypovolemia to ensure organ perfusion. Respirations often increase to increase oxygen in the blood.

The nurse assesses a client who has possible gastritis. Which assessment finding(s) indicate(s) that the client has chronic gastritis? (Select all that apply.) Anorexia Dyspepsia Intolerance of fatty foods Pernicious anemia Nausea and vomiting

Ans: Intolerance of fatty foods Pernicious anemia Rationale: Intolerance of fatty or spicy foods and pernicious anemia are signs of chronic gastritis. Anorexia and nausea/vomiting can be seen in both conditions. Dyspepsia is seen in acute gastritis.

The nurse is caring for a client who has late-stage (advanced) cirrhosis. What assessment findings would the nurse expect? (Select all that apply.) Jaundice Clay-colored stools Icterus Ascites Petechiae Dark urine

Ans: Jaundice Clay-colored stools Icterus Ascites Dark urine Rationale: FAll of these assessment findings are very common for a client who has late-stage cirrhosis due to biliary obstruction and poor liver function. The client has vascular lesions and excess fluid from portal hypertension.

The nurse plans care for a patient who has hepatopulmonary syndrome. Which interventions would the nurse include in this client's plan of care? (Select all that apply.) Oxygen therapy Prone position Feet elevated on pillows Daily weights Physical therapy Respiratory therapy

Ans: Oxygen therapy Feet elevated on pillows Daily weights Respiratory therapy Rationale: Care for a client who has hepatopulmonary syndrome would include oxygen therapy, the head of bed elevated at least 30 degrees or as high as the client wants to improve breathing, elevated feet to decrease dependent edema, and daily weights. There is no need to place the patient in a prone position, on the patient's stomach. Although physical therapy may be helpful to a patient who has been hospitalized for several days, physical therapy is not an intervention specifically for hepatopulmonary syndrome. However, respiratory support from a specialized therapist may be needed.

The nurse is caring for a client diagnosed with oral cancer. What is the nurse's priority for client care? Encourage fluids to liquefy the client's secretions. Place the client on Aspiration Precautions. Remind the client to use an incentive spirometer. Manage the client's pain and inflammation.

Ans: Place the client on Aspiration Precautions. Rationale: The client who has oral cancer often has difficulty swallowing and is at risk for aspiration and possibly aspiration pneumonia. Therefore, the most important nursing action is to place the client on precautions to prevent aspiration. The nurse would implement the other actions but they are not as vital to promote client safety.

The nurse is caring for a client who is recovering from an open traditional Whipple surgical procedure. What action would the nurse take? Clamp the nasogastric tube. Place the patient in semi-Fowler position. Assess vital signs once every shift. Provide oral rehydration.

Ans: Place the patient in semi-Fowler position. Rationale: Postoperative care for a patient recovering from an open Whipple procedure would include placing the client in a semi-Fowler position to reduce tension on the suture line and anastomosis sites and promote breathing, setting the nasogastric tube to low continuous suction to remove free air buildup and pressure, assessing vital signs frequently to assess fluid and electrolyte complications, and providing intravenous fluids.

The nurse is assessing a client who has hepatitis C. What extrahepatic complications would the nurse anticipate? (Select all that apply.) Pancreatitis Polyarthritis Heart disease Myalgia Peptic ulcer disease Ulcerative colitis

Ans: Polyarthritis Heart disease Myalgia Rationale: The client who has hepatitis C has complications that do not relate to the liver, including polyarthritis, myalgia, heart disease and vasculitis, renal disease, and cognitive impairment.

The nurse plans care for a client who has acute pancreatitis and is prescribed nothing by mouth (NPO). With which health care team members would the nurse collaborate to provide appropriate nutrition to this client? (Select all that apply.) Registered dietitian nutritionist Nursing assistant Clinical pharmacist Certified herbalist Primary health care provider

Ans: Registered dietitian nutritionist Clinical pharmacist Primary health care provider Rationale: Clients who are prescribed NPO while experiencing an acute pancreatitis episode may need enteral or parenteral nutrition. The nurse would collaborate with the registered dietitian nutritionist, clinical pharmacist, and primary health care provider to plan and implement the more appropriate nutritional interventions. The nursing assistant and certified herbalist would not assist with this clinical decision.

After teaching a client who has a history of cholelithiasis, the nurse assesses the client's understanding. Which menu selection indicates that the client understands the dietary teaching? Lasagna tossed salad with Italian dressing, and low-fat milk Grilled cheese sandwich, tomato soup, and coffee with cream Cream of potato soup, Caesar salad with chicken, and a diet cola Roasted chicken breast, baked potato with chives, and orange juice

Ans: Roasted chicken breast, baked potato with chives, and orange juice Rationale: Clients with cholelithiasis should avoid foods high in fat and cholesterol, such as whole milk, butter, and fried foods. Lasagna, low-fat milk, grilled cheese, cream, and cream of potato soup all have high levels of fat. The meal with the least amount of fat is the chicken breast dinner.

A client is admitted with acute pancreatitis. What priority problem would the nurse expect the client to report? Nausea and vomiting Severe boring abdominal pain Jaundice and itching Elevated temperature

Ans: Severe boring abdominal pain Rationale: The client who has acute pancreatitis reports severe boring abdominal pain that is often rated by clients as a 10+ on a 0-10 pain scale. Nausea, vomiting, and fever may also occur, but that is not the client's priority for care.

A nurse assesses a client who is recovering from an open traditional Whipple surgical procedure. Which assessment finding(s) alert(s) the nurse to a complication from this surgery? (Select all that apply.) Clay-colored stools Substernal chest pain Shortness of breath Lack of bowel sounds or flatus Urine output of 20 mL/6 hr

Ans: Substernal chest pain Shortness of breath Lack of bowel sounds or flatus Urine output of 20 mL/6 hr Rationale: Myocardial infarction (chest pain), pulmonary embolism (shortness of breath), adynamic ileus (lack of bowel sounds or flatus), and acute kidney injury (urine output of 20 mL/6 hr) are common complications for which the nurse must assess the client after the Whipple procedure. Clay-colored stools are associated with cholecystitis and are not a complication of a Whipple procedure.

A client who had minimally invasive bypass gastric surgery 2 days ago reports new-onset of severe abdominal pain. What is the nurse's best action as this time? Listen to the client's bowel sounds. Call the Rapid Response Team. Take the client's vital signs. Contact the primary health care provider.

Ans: Take the client's vital signs. Rationale: The client may be experiencing either bleeding or anastomosis leak(s). Clients having these complications have severe abdominal, back, or shoulder pain, tachycardia, and hypotension.

The nurse is caring for a client who has been diagnosed with peptic ulcer disease. For which complication would the nurse monitor? Large bowel obstruction Dyspepsia Upper gastrointestinal (GI) bleeding Gastric cancer

Ans: Upper gastrointestinal (GI) bleeding Rationale: Peptic ulcer disease (PUD) can cause gastric mucosal damage or perforation, which causes upper GI bleeding. Dyspepsia is a symptom of PUD, gastritis, and gastric cancer. PUD affects the stomach and/or duodenum, not the colon.

The nurse assesses a client who is recovering from a paracentesis 1 hour ago. Which assessment finding would require immediate action by the nurse? Urine output via indwelling urinary catheter is 20 mL/hr Blood pressure increases from 110/58 to 120/62 mm Hg Respiratory rate decreases from 22 to 16 breaths/min A decrease in the client's weight by 3 lb (1.4 kg)

Ans: Urine output via indwelling urinary catheter is 20 mL/hr Rationale: A rapid removal of ascitic fluid causes decreased abdominal pressure, which can contribute to hypovolemia. This can be manifested by a decrease in urine output to below 30 mL/hr. A slight increase in systolic blood pressure is insignificant. A decrease in respiratory rate indicates that breathing has been made easier by the procedure. The nurse would expect the client's weight to drop as fluid is removed. To prevent hypovolemic shock, no more than 2000 mL are usually removed from the abdomen at one time. The patient's weight typically only decreases by less than 2 kg or 4.4 lb.

During an interview, the client tells the nurse that the client has a duodenal ulcer. Which assessment finding would the nurse expect? Hematemesis Pain when eating Melena Weight loss

Ans: (Prof. G mentioned this) (study guide) Melena Rationale: All of the other assessment findings are more commonly seen in clients who have gastric ulcers rather than duodenal ulcers.

The nurse assesses a newly admitted client and documents a body mass index (BMI) of 31.2. What does this value indicate to the nurse? The client has a healthy weight. The client is underweight. The client is obese. The client is overweight.

Ans: (Quiz#4) (study guide) The client is obese. Rationale: A BMI of over 30 indicates that the client is obese.

A nurse knows that job-related risks for developing oral cancer include which occupations? (Select all that apply.) Coal miner Electrician Metal worker Plumber Textile worker

Ans: (Quiz#4) (study guide) Coal miner Metal worker Plumber Textile worker Rationale: The occupations of coal mining, metal working, plumbing, and textile work produce exposure to polycyclic aromatic hydrocarbons (PAHs), which are known carcinogens. Electricians do not have this risk.

The nurse recalls that the risk factors for acute gastritis include which of the following? (Select all that apply.) Alcohol Caffeine Corticosteroids Fruit juice Nonsteroidal anti-inflammatory drugs (NSAIDs)

Ans: (quiz #4) Alcohol Caffeine Corticosteroids Nonsteroidal anti-inflammatory drugs (NSAIDs) Rationale: Risk factors for acute gastritis include alcohol, caffeine, corticosteroids, and chronic NSAID use. Fruit juice is not a risk factor, although in some people it does cause distress.

A client has dumping syndrome after a partial gastrectomy. Which action by the nurse would be appropriate? Arrange a dietary consult. Increase fluid intake. Limit the client's foods. Make the client NPO.

Ans: (quiz #4) Arrange a dietary consult. Rationale: The client with dumping syndrome after a gastrectomy has multiple dietary needs. A referral to a registered dietitian nutritionist will be extremely helpful. Food and fluid intake is complicated and needs planning. The client should not be NPO.

A nurse participates in a community screening event for oral cancer. What client is the highest priority for referral to a primary health care provider? Client who has poor oral hygiene practices. Client who smokes and drinks daily. Client who tans for an upcoming vacation. Client who occasionally uses illicit drugs.

Ans: (quiz #4) Client who smokes and drinks daily. Rationale: Smoking and alcohol exposure create a high risk for this client. Poor oral hygiene is not related to the etiology of cancer but may cause a tumor to go unnoticed. Tanning is a risk factor, but short-term exposure does not have the same risk as daily exposure to tobacco and alcohol.

The nurse is caring for a client who has a risk gene for developing cirrhosis. Which racial/ethnic group has this gene most often? Blacks Asian/Pacific Islanders Latinos French

Ans: (quiz #4) Latinos Rationale: The Patatin-like phospholipase domain containing 3 gene (PNPLA3) has been identified as a risk gene for cirrhosis, which occurs most often in Latinos when compared to other populations.

Which of these client assessment findings is typically associated with oral cancer? Dry sticky oral membranes Increased appetite Itchy rash in oral cavity Painless red or raised lesion

Ans: (quiz #4) Painless red or raised lesion Rationale: A painless red or raised lesion often indicates a diagnosis of oral cancer. The client usually has a decreased appetite and thick secretions. Itchiness is not a common finding associated with oral cancer.

A client has a nasogastric (NG) tube as a result of an upper gastrointestinal (GI) hemorrhage. What comfort measure would the nurse remind assistive personnel (AP) to provide? Lavaging the tube with ice water Performing frequent oral care Re-positioning the tube every 4 hours Taking and recording vital signs

Ans: (quiz #4) Performing frequent oral care Rationale: Clients with NG tubes need frequent oral care both for comfort and to prevent infection. Lavaging the tube is done by the nurse. Repositioning the tube, if needed, is also done by the nurse. They can take vital signs, but this is not a comfort measure.

The nurse caring for clients with gastrointestinal disorders would recall that omeprazole is a drug in which classification? Gastric acid inhibitor Histamine receptor blocker Mucosal barrier fortifier Proton pump inhibitor

Ans: (quiz #4) Proton pump inhibitor Rationale: Omeprazole is a proton pump inhibitor.

The nurse is caring for a client experiencing upper gastrointestinal (GI) bleeding. What is the priority action for the client's care? Maintain airway, breathing, and circulation. Monitor vital signs, including orthostatic blood pressure. Draw blood for hemoglobin and hematocrit immediately. Insert a nasogastric (NG) tube and connect to intermittent suction.

Ans: (quiz #4) (study guide) Maintain airway, breathing, and circulation. Rationale: The priority action for any client experiencing deterioration or an emergent situation is to monitor and maintain airway, breathing, and circulation (ABCs). Taking orthostatic blood pressure would not be appropriate, but the nurse would monitor vital signs carefully and draw blood for hemoglobin and hematocrit. An NG tube would also need to be inserted and connected to gastric suction to rest the GI tract. However, none of these actions take priority over maintaining ABCs.

The nurse is preparing to teach a client with chronic hepatitis B about lamivudine therapy. What health teaching would the nurse include? "Follow up on all appointments to monitor your lab values." "Do not take amiodorone at any time while on this drug." "Monitor for jaundice, rash, and itchy skin while on this drug." "Report any changes in urinary elimination while on this drug."

Ans: (quiz #4) (study guide) "Report any changes in urinary elimination while on this drug." Rationale: Lamivudine can cause renal impairment and the nurse would remind the client of changes that may indicate kidney damage.

The nurse is preparing a client who has chronic pancreatitis about how to prevent exacerbations of the disease. Which health teaching will the nurse include? (Select all that apply.) "Avoid alcohol ingestion." "Be sure and balance rest with activity." "Avoid caffeinated beverages." "Avoid green, leafy vegetables." "Eat small meals and high-calorie snacks."

Ans: (quiz#4) "Avoid alcohol ingestion." "Be sure and balance rest with activity." "Avoid caffeinated beverages." "Eat small meals and high-calorie snacks." Rationale: Clients who have chronic pancreatitis need to avoid GI stimulants, including alcohol, caffeine, and nicotine. Food and snacks need to be high-calorie to prevent additional weight loss. Green vegetables can be consumed if tolerated by the client.

After teaching a client who is prescribed pancreatic enzyme replacement therapy, the nurse assesses the client's understanding. Which statement by the client indicates a need for further teaching? "The capsules can be opened and the powder sprinkled on applesauce if needed." "I will wipe my lips carefully after I drink the enzyme preparation." "The best time to take the enzymes is immediately after I have a meal or a snack." "I will not mix the enzyme powder with food or liquids that contain protein."

Ans: (quiz#4) "The best time to take the enzymes is immediately after I have a meal or a snack." Rationale: The enzymes must be taken immediately before eating meals or snacks. If the client cannot swallow the capsules whole, they can be opened up and the powder sprinkled on applesauce, mashed fruit, or rice cereal. The client should wipe his or her lips carefully after drinking the enzyme preparation because the liquid could damage the skin. Protein items will be dissolved by the enzymes if they are mixed together.

A client with peptic ulcer disease is in the emergency department and reports gastric pain that has gotten much worse over the last 24 hours. The client's blood pressure when lying down is 112/68 mm Hg and when standing is 98/52 mm Hg. What action by the nurse is most appropriate? Administer a proton pump inhibitor (PPI). Call the Rapid Response Team. Start a large-bore IV with normal saline. Tell the patient to remain lying down.

Ans: (quiz#4) Start a large-bore IV with normal saline. Rationale: This client has orthostatic changes to the blood pressure, indicating fluid volume loss. The nurse would start a large-bore IV with an isotonic solution. PPIs are not a treatment for an ulcer. The Rapid Response Team is not needed at this point. The client should be put on safety precautions, which includes staying in bed, but this is not the most appropriate action at this time.

A client has an external percutaneous transhepatic biliary catheter inserted for a biliary obstruction. What health teaching about catheter care would the nurse provide for the client? "Cap the catheter drain at night to prevent leakage and skin damage." "Position the drainage bag lower than the catheter insertion site." "Irrigate the catheter with an ounce of saline every night." "Pierce a hole in the top of the drainage bag to get rid of odors."

Ans: (quiz#4) (study guide) "Position the drainage bag lower than the catheter insertion site." Rationale: An external temporary or permanent catheter drains bile by gravity into a bag that collects bile. Therefore, the drainage bag should be lower that the catheter insertion site. The catheter should not be capped or irrigated, and no holes should be made in the bag to prevent bile from having contact with the skin.

A client who has peptic ulcer disease is prescribed quadruple drug therapy for Helicobacter pylori infection. What health teaching related to bismuth would the nurse include? "Report stool changes to your primary health care provider immediately." "Do not take aspirin or aspirin products of any kind while on bismuth." "Take bismuth about 30 minutes before each meal and at bedtime." "Be aware that bismuth can cause frequent vomiting and diarrhea."

Ans: (study guide) "Do not take aspirin or aspirin products of any kind while on bismuth." Rationale: Bismuth is a salicylate drug and causes stool discoloration but not vomiting and diarrhea. It does not have to be taken at a specific time relative to meals. Clients taking bismuth should not take other salicylates, such as aspirin or aspirin-containing products.

The nurse is caring for a client with hepatitis C. The client's brother states, "I do not want to get this infection, so I'm not going into his hospital room." How would the nurse respond? "Hepatitis C is not spread through casual contact." "If you wear a gown and gloves, you will not get this virus." "This virus is only transmitted through a fecal specimen." "I can give you an update on your brother's status from here."

Ans: (study guide) "Hepatitis C is not spread through casual contact." Rationale: Although family members may be afraid that they will contract hepatitis C, the nurse would educate them about how the virus is spread. Hepatitis C is spread via blood-to-blood transmission and is associated with illicit IV drug needle sharing, blood and organ transplantation, accidental needlesticks, unsanitary tattoo equipment, and sharing of intranasal drug paraphernalia. Wearing a gown and gloves will not decrease the transmission of this virus. Hepatitis C is not spread through casual contact or a fecal specimen. The nurse would be violating privacy laws by sharing the client's status with the brother.

The nurse is caring for a client with hepatic portal-systemic encephalopathy (PSE). The client is thin and cachectic, and the family expresses distress that the patient is receiving little dietary protein. How would the nurse respond? "A low-protein diet will help the liver rest and will restore liver function." "Less protein in the diet will help prevent confusion associated with liver failure." "Increasing dietary protein will help the patient gain weight and muscle mass." "Low dietary protein is needed to prevent fluid from leaking into the abdomen."

Ans: (study guide) "Less protein in the diet will help prevent confusion associated with liver failure." Rationale: A low-protein diet is prescribed when serum ammonia levels increase and/or the client shows signs of PSE. A low-protein diet helps reduce excessive breakdown of protein into ammonia by intestinal bacteria. Encephalopathy is caused by excess ammonia. A low-protein diet has no impact on restoring liver function. Increasing the patient's dietary protein will cause complications of liver failure and would not be suggested. Increased intravascular protein will help prevent ascites, but clients with liver failure are not able to effectively synthesize dietary protein.

A telehealth nurse speaks with a client who is recovering from a liver transplant 2 weeks ago. The client states, "I'm having right belly pain and have a temperature of 101° F (38.3° C)." How would the nurse respond? "The anti-rejection drugs you are taking make you susceptible to infection." "You should go to the hospital immediately to get checked out." "You should take an additional dose of cyclosporine today." "Take acetaminophen every 4 hours until you feel better soon."

Ans: (study guide) "You should go to the hospital immediately to get checked out." Rationale: Fever, right abdominal quadrant pain, and jaundice are signs of possible liver transplant rejection; the client would be admitted to the hospital as soon as possible for intervention. Antirejection drugs do make a client more susceptible to infection, but this client has signs of rejection, not infection. The nurse would not advise the client to take an additional dose of cyclosporine or acetaminophen as these medications will not treat the acute rejection.

A client is scheduled for a hepatobiliary iminodiacetic acid (HIDA) scan. What would the nurse include in the client's teaching about this diagnostic test? "You'll have to drink a contrast medium right before the test." "You'll need to do a bowel prep the nursing before the test." "You'll be able to drink liquids up until the test begins." "You'll have a large camera close to you during the test."

Ans: (study guide) "You'll have a large camera close to you during the test." Rationale: Clients having a HIDA scan are NPO and receive an injectable nuclear medicine contrast. No bowel preparation is required. A large camera is close to the client for most of the test which can be a problem for clients who are claustrophobic.

A client is receiving total parenteral nutrition (TPN). On assessment, the nurse notes that the client's pulse is 128 beats/min, blood pressure is 98/56 mm Hg, skin is dry, and skin turgor is poor. What action should the nurse perform next? Assess the 24-hour intake and output. Assess the client's oral cavity. Prepare to hang a normal saline bolus. Increase the infusion rate of the TPN.

Ans: (study guide) Assess the 24-hour intake and output. Rationale: This client has clinical indicators of dehydration, so the nurse calculates the patient's 24-hour intake, output, and fluid balance. This information is then reported to the health care provider. The client's oral cavity assessment may or may not be consistent with dehydration. The nurse may need to give the client a fluid bolus, but not as an independent action. The client's dehydration is most likely due to fluid shifts from the TPN, so increasing the infusion rate would make the problem worse, and is not done as an independent action for clients receiving TPN.

The nurse is managing care for a client receiving feeding through a gastrostomy tube (G-tube). What assessment would the nurse perform? Check the skin around the tube insertion site. Weigh the client every shift with the same scale. Draw blood to assess albumin every shift. Irrigate the tube at least once a day.

Ans: (study guide) Check the skin around the tube insertion site. Rationale: The most important assessment would be to observe the skin around the tube for irritation, redness, and skin breakdown. The skin should be cleaned frequently to keep it free of drainage and moisture which can lead to excoriation or other type of skin breakdown. For a client who is undernourished, he or she is usually weighed every day and prealbumin is a more sensitive indicator of over nutritional health. The G-tube is not routinely irrigated.

The nurse is caring for a client with a long history of peptic ulcer disease. What assessment findings would the nurse anticipate if the client experiences upper gastrointestinal (GI) bleeding? (Select all that apply.) Decreased heart rate Decreased blood pressure Bounding radial pulse Dizziness Hematemesis Decreased urinary output

Ans: (study guide) Decreased blood pressure Dizziness Hematemesis Decreased urinary output Rationale: The client who has upper GI bleeding would likely have vomiting that contains blood (hematemesis), and would have signs and symptoms of dehydration such as decreased blood pressure, dizziness, and/or decreased urinary output. The heart rate increases rather than decreases and the pulse is weak rather than bounding in clients who are dehydrated.

A client's small-bore feeding tube has become occluded after the nurse administered medications. What actions by the nurse are appropriate? (Select all that apply.) Attempt to dissolve the clog by instilling a cola product. Determine if any of the medications come in liquid form. Flush the tube before and after administering medications. Mix all medications in the formula and use a feeding pump. Try to flush the tube with 30 mL of water and gentle pressure.

Ans: (study guide) Determine if any of the medications come in liquid form. Flush the tube before and after administering medications. Try to flush the tube with 30 mL of water and gentle pressure. Rationale: If the tube is obstructed, use a 50-mL syringe and gentle pressure to attempt to open the tube. Cola products should not be used unless water is not effective. To prevent future problems, determine if any of the medications can be dispensed in liquid form and flush the tube with water before and after medication administration. Do not mix medications with the formula.

The nurse is caring for a client diagnosed with probable gastroesophageal reflux disease (GERD). What assessment finding(s) would the nurse expect? (Select all that apply.) Dyspepsia Regurgitation Belching Coughing Chest discomfort Dysphagia

Ans: (study guide) Dyspepsia Regurgitation Belching Coughing Chest discomfort Dysphagia Rationale: All of these signs and symptoms are commonly seen in clients who have GERD.

The nurse is caring for a client who has possible acute pancreatitis. What serum laboratory findings would the nurse expect for this client? (Select all that apply.) Elevated amylase Elevated lipase Elevated glucose Decreased calcium Elevated bilirubin Elevated leukocyte count

Ans: (study guide) Elevated amylase Elevated lipase Elevated glucose Decreased calcium Elevated bilirubin Elevated leukocyte count Rationale: All of these choices are correct. Amylase and lipase are pancreatic enzymes that are released during pancreatic inflammation and injury. Leukocytes also increased due to his inflammatory response. Pancreatic injury affects the ability of insulin to be released causing increased glucose levels. Bilirubin is also typically increased due to hepatobiliary obstruction. Calcium and magnesium levels decrease because fatty acids bind free calcium and magnesium causing a lowered serum level; these changes occur in the presence of fat necrosis.

The nurse is caring for a client who has cirrhosis of the liver. Which risk factor is the leading cause of cirrhosis? Metabolic syndrome Liver cancer Nonalcoholic fatty liver disease Hepatitis C

Ans: (study guide) Hepatitis C Rationale: Hepatitis C is the leading cause of cirrhosis and also causes liver cancer. Clients with nonalcoholic fatty liver disease often have metabolic syndrome and can also develop cirrhosis.

A client receiving continuous tube feeding to provide total enteral nutrition begins vomiting. What action by the nurse is most appropriate? Administer an antiemetic. Check the patient's gastric residual. Hold the feeding until the vomiting subsides. Reduce the rate of the tube feeding by half.

Ans: (study guide) Hold the feeding until the vomiting subsides. Rationale: The nurse would stop the feeding until the vomiting subsides and consult with the registered dietitian nutritionist or primary health care provider about the rate at which to restart the feeding. Giving an antiemetic is not appropriate. After vomiting, a gastric residual will not be accurate. The nurse would not continue to feed the patient while he or she is vomiting.

A client has an open traditional hiatal hernia repair this morning. What is the nurse's priority for client care at this time? Managing surgical pain Ambulating the client early Preventing respiratory complications Managing the nasogastric tube

Ans: (study guide) Preventing respiratory complications Rationale: The client who has traditional surgery (rather than minimally invasive surgery) is at risk for respiratory complications such as atelectasis and pneumonia because he or she has an incision that may prevent the client from taking deep breaths or using an incentive spirometer. Therefore, the nurse's priority is to prevent these potentially life-threatening respiratory problems.

The nurse is caring for a client who has cirrhosis of the liver. What nursing action is appropriate to help control ascites? Monitor intake and output. Provide a low-sodium diet. Increase oral fluid intake. Weigh the patient daily.

Ans: (study guide) Provide a low-sodium diet. Rationale: A low-sodium diet is one means of controlling abdominal fluid collection. Monitoring intake and output does not control fluid accumulation, nor does weighing the client. These interventions merely assess or monitor the situation. Increasing fluid intake would not be helpful.

The nurse is caring for a client who had an open traditional esophagectomy. Which assessment findings would the nurse report immediately to the primary health care provider? (Select all that apply.) Nausea Wound dehiscence Fever Tachycardia Moderate pain Fatigue

Ans: (study guide) Wound dehiscence Fever Tachycardia Rationale: Wound dehiscence is a serious, potentially life-threatening problem that needs immediate attention of the primary health care provider, typically the surgeon. Fever and tachycardia may indicate that the client has a postoperative infection, another serious, potentially life-threatening complication. Indications of both of these problems need to be documented and reported by the nurse. Nausea, fatigue, and moderate pain are expected postoperative assessment findings.

The nurse is caring for an older client receiving total enteral nutrition via a small-bore nasoduodenal tube. For what priority complication would the nurse assess? Intermittent diarrhea Cholecystitis Aspiration pneumonia Peptic ulcer disease

Ans: (study guide) Aspiration pneumonia Rationale: Aspiration pneumonia is one of the most common complications in older adults who have enteral nutrition via a nasoduodenal tube because their gag reflex is often decreased. Intermittent diarrhea may also occur, but that is not potentially life threatening if the client does not become dehydrated.

The nurse is teaching a client about taking Elbasvir for hepatitis C. What information in the client's history would the nurse need prior to drug administration? History of hepatitis B History of kidney disease History of cardiac disease History of rectal bleeding

Ans: (study guide) History of Hepatitis B Rationale: Elbasvir can cause liver toxicity and therefore the nurse would assess for a history of or current hepatitis B.

A client is admitted with a large oral tumor. What assessment by the nurse takes priority? a. Airway b. Breathing c. Circulation d. Nutrition

Ans: (this was in the quiz #4) a. Airway Rationale: Airway always takes priority. Airway must be assessed first and any problems managed if present.

The nurse inserts a small-bore nasoduodenal tube for a client who is undernourished. What priority nursing action is required prior to starting the continuous tube feeding to confirm correct tube placement? Assess for carbon dioxide using capnometry. Perform pH testing of gastric fluid. Auscultate over the epigastric area. Request an x-ray before starting the feeding.

ans: (quiz#4) Request an x-ray before starting the feeding. Rationale: The most reliable assessment to determine correct feeding tube placement in to have an x-ray to visualize where the tip of the tube is located.