PN3 final ch.51, 58, 59
A client has been discharged to home after being hospitalized with an acute episode of pancreatitis. The client, who is an alcoholic, is unwilling to participate in Alcoholics Anonymous (AA), and the client's spouse expresses frustration to the home health nurse regarding the client's refusal. What is the nurse's best response? A. "Your spouse will sign up for the meetings only when he is ready to deal with his problem." B. "Keep mentioning the AA meetings to your spouse on a regular basis." C. "I'll get you some information on the support group Al-Anon." D. "Tell me more about your frustration with your spouse's refusal to participate in AA."
"I'll get you some information on the support group Al-Anon." Putting the client's spouse in contact with an Al-Anon support group assists with the spouse's frustration. Telling the spouse that the client will sign up for AA meetings when the client is ready and telling the spouse to keep mentioning AA do not address the spouse's frustration with the client's refusal to participate in AA. Encouraging the spouse to say more about his or her frustration may allow the spouse to vent frustration, but it does not offer any options or solutions.
Which statement by a client with cirrhosis indicates that further instruction is needed about the disease? A. "Cirrhosis is a chronic disease that has scarred my liver." B. "The scars on my liver create problems with blood circulation." C. "Because of the scars on my liver, blood clotting and blood pressure are affected." D. "My liver is scarred, but the cells can regenerate themselves and repair the damage."
"My liver is scarred, but the cells can regenerate themselves and repair the damage." Although cells and tissues will attempt to regenerate, this will result in permanent scarring and irreparable damage. Cirrhosis is a chronic condition that leaves scars on the liver. Permanent scars form in response to attempts by the cells to regenerate and create problems in blood circulation moving through the liver. Liver scarring will create problems with blood clotting, cholesterol levels, and blood pressure, as well as with the metabolism of drugs and toxins.
A client has developed acute pancreatitis after also developing gallstones. Which is the highest priority instruction for this client to avoid further attacks of pancreatitis? A. "You may need a surgical consult for removal of your gallbladder." B. "See your health care provider immediately when experiencing symptoms of a gallbladder attack." C. "If you have a gallbladder attack and pain does not resolve within a few days, call your health care provider." D. "You'll need to drastically modify your alcohol intake."
"See your health care provider immediately when experiencing symptoms of a gallbladder attack." In this case, the client's pancreatitis was likely triggered by the development of gallstones. A diagnostic statement must come from the provider. Also, the client may not require removal of the gallbladder. The client must see the provider promptly when experiencing gallbladder disease and should not wait. Because this client's acute pancreatitis is likely related to gallstones, alcohol consumption need not be restricted.
The nurse is assessing a client's alcohol intake to determine whether it is the underlying cause of the client's attacks of pancreatitis. Which question does the nurse ask to elicit this information? A. "Do you usually binge drink?" B. "Do you tend to drink more on holidays or weekends?" C. "Tell me more about your alcohol intake." D. "Estimate how many episodes of binge drinking you do in a week."
"Tell me more about your alcohol intake." Asking the client about his or her alcohol intake is the only way that will allow the client to provide information in the client's own words and to the extent that the client wishes to provide it. Asking the client if he or she binge drinks or tends to drink more on holidays or weekends may put the client on the defensive rather than provide the desired information. It has not yet been determined whether the client engages in binge drinking.
A client diagnosed with acalculous cholecystitis asks the nurse how the gallbladder inflammation developed when there is no history of gallstones. What is the nurse's best response? A. "This may be an indication that you are developing sepsis." B. "The gallstones are present, but have become fibrotic and contracted." C. "This type of gallbladder inflammation is associated with hypovolemia." D. "This may be an indication of pancreatic disease."
"This type of gallbladder inflammation is associated with hypovolemia." This type of gallbladder inflammation is associated with hypovolemia. Although this type of gallbladder inflammation is associated with sepsis, it is not an indicator that sepsis is developing. Fibrotic and contracted gallstones are associated with chronic cholecystitis. The presence of acalculous cholecystitis is not an indicator that pancreatic disease has developed.
The nurse is caring for a client recently diagnosed with type 1 diabetes mellitus who has had an episode of acute pancreatitis. The client asks the nurse how he developed diabetes when the disease does not run in the family. What is the nurse's best response? A. "The diabetes could be related to your obesity." B. "What has your doctor told you about your disease?" C. "Do you consume alcohol on a frequent basis?" D. "Type 1 diabetes can occur when the pancreas is destroyed by disease."
"Type 1 diabetes can occur when the pancreas is destroyed by disease." Telling the client that type 1 diabetes can occur when the pancreas is destroyed by disease is the only response that accurately describes the relationship of the client's diabetes to pancreatic destruction. Type 2, not type 1, diabetes is usually related to obesity. Asking the client what the provider has said is an evasive response by the nurse and does not address the client's question. Many factors could produce acute pancreatitis other than alcohol consumption.
A client has just been diagnosed with pancreatic cancer. The client's upset spouse tells the nurse that they have recently moved to the area, have no close relatives, and are not yet affiliated with a church. What is the nurse's best response? A. "Maybe you should find a support group to join." B. "Would you like me to contact the hospital chaplain for you?" C. "Do you want me to try to find a therapist for you?" D. "Do you have any friends whom you want me to call?"
"Would you like me to contact the hospital chaplain for you?" It is appropriate for the nurse to suggest contacting the hospital chaplain as a counseling option for the client and family. Suggesting that the client find a support group does not assist the client and the family with the problem. It is inappropriate for the nurse to suggest that the client and the family need a therapist. The spouse has already told the nurse that they have recently moved to the area, so it is unlikely that they have already made close friends.
A client has sustained a fracture of the left tibia. The extremity is immobilized using an external fixation device. Which postoperative instruction does the nurse include in this client's teaching plan? A "Use pain medication as prescribed to control pain." B "Clean the pin site when any drainage is noticed." C "Wear the same clothing that is normally worn." D "Apply bacitracin (Neosporin) if signs or symptoms of infection develop around pin sites."
A "Use pain medication as prescribed to control pain." The client should be taught the correct use of prescribed pain medication to control pain adequately. Pin sites must be cleaned at least every 8 hours and as needed to reduce the risk for infection, not when any drainage is noticed. The client will have to adjust the type of clothing worn while the fixation device is in place. If signs and symptoms of infection develop around the pin sites, the client must notify the health care provider immediately. Infection at the pin sites places the client at risk for osteomyelitis.
A rock climber has sustained an open fracture of the right tibia after a 20-foot fall. The nurse plans to assess the client for which potential complications? (Select all that apply.) A Acute compartment syndrome (ACS) B Fat embolism syndrome (FES) C Congestive heart failure D Urinary tract infection (UTI) E Osteomyelitis
A Acute compartment syndrome (ACS) B Fat embolism syndrome (FES) E Osteomyelitis ACS is a serious condition in which increased pressure within one or more compartments reduces circulation to the area. A fat embolus is a serious complication in which fat globules are released from yellow bone marrow into the bloodstream within 12 to 48 hours after the injury. FES usually results from long bone fracture or fracture repair, but is occasionally seen in clients who have received a total joint replacement. Bone infection, or osteomyelitis, is most common in open fractures. Congestive heart failure is not a potential complication for this client; pulmonary embolism is a potential complication of venous thromboembolism, which can occur with fracture. The client is at risk for wound infection resulting from orthopedic trauma, not a UTI.
A client's left arm is placed in a plaster cast. Which assessment does the nurse perform before the client is discharged? A Assess that the cast is dry. B Ensure that the client has 4 × 4 gauze to take home for placement between the cast and the skin. C Check the fit of the cast by inserting a tongue blade between the cast and the skin. D Ensure that the capillary refill of the left fingernail beds is longer than 3 seconds.
A Assess that the cast is dry. The cast must be dry and free of cracking and crumbling before the client is discharged. The client should not place anything between the cast and the skin. In assessing fit, one finger should easily fit between the cast and the skin. Capillary refill longer than 3 seconds indicates impairment of the circulation in the extremity and requires the health care provider's immediate attention.
A client with a compound fracture of the left femur is admitted to the emergency department after a motorcycle crash. Which action is most essential for the nurse to take first? A Check the dorsalis pedis pulses. B Immobilize the left leg with a splint. C Administer the prescribed analgesic. D Place a dressing on the affected area.
A Check the dorsalis pedis pulses. The first action should be to assess the circulatory status of the leg because the client is at risk for acute compartment syndrome, which can begin as early as 6 to 8 hours after an injury. Severe tissue damage can also occur if neurovascular status is compromised. Immobilization will be needed, but the nurse must assess the client's condition first. Administering an analgesic and placing a dressing on the affected area should both be done after the nurse has assessed the client.
A client has undergone an elective below-the-knee amputation of the right leg as a result of severe peripheral vascular disease. In postoperative care teaching, the nurse instructs the client to notify the health care provider if which change occurs? A Observation of a large amount of serosanguineous or bloody drainage B Mild to moderate pain controlled with prescribed analgesics C Absence of erythema and tenderness at the surgical site D Ability to flex and extend the right knee
A Observation of a large amount of serosanguineous or bloody drainage A large amount of serosanguineous or bloody drainage may indicate hemorrhage or, if an incision is present, that the incision has opened. This requires immediate attention. Mild to moderate pain controlled with prescribed analgesics would be a normal finding for this client. Absence of erythema and tenderness of the surgical site would also be normal findings for this client. The client should be able to flex and extend the right knee (limb) after surgery.
The nurse anticipates providing collaborative care for a client with a traumatic amputation of the right hand with which health care team members? (Select all that apply.) A Occupational therapist Correct B Physical therapist Correct C Psychologist Correct D Respiratory therapist E Speech therapist
A Occupational therapist B Physical therapist C Psychologist An occupational therapist and a physical therapist will help to enable the client to become more independent in performing activities of daily living. An amputation can be traumatic to the client; loss of a body part should not be underestimated because the client may experience an altered self-concept, so counseling support with a psychologist should be made available to the client. The client does not have a respiratory condition that warrants collaborative care with a respiratory therapist. A speech therapist is not indicated because the client does not have speech impairment.
A client has undergone the Whipple procedure (radical pancreaticoduodenectomy) for pancreatic cancer. Which precautionary measures does the nurse implement to prevent potential complications? (Select all that apply.) A. Check blood glucose often. B. Check bowel sounds and stools. C. Ensure that drainage color is clear. D. Monitor mental status. E. Place the client in the supine position.
A. Check blood glucose often. B. Check bowel sounds and stools. D. Monitor mental status. Glucose should be checked often to monitor for diabetes mellitus. Bowels sounds and stools should be checked to monitor for bowel obstruction. A change in mental status or level of consciousness could be indicative of hemorrhage. Clear, colorless, bile-tinged drainage or frank blood with increased output may indicate disruption or leakage of a site of anastomosis. The client should be placed in semi-Fowler's position to reduce tension on the suture line and the anastomosis site and to optimize lung expansion.
When caring for a client with portal hypertension, the nurse assesses for which potential complications? (Select all that apply.) A. Esophageal varices B. Hematuria C. Fever D. Ascites E. Hemorrhoids
A. Esophageal varices D. Ascites E. Hemorrhoids Portal hypertension results from increased resistance to or obstruction (blockage) of the flow of blood through the portal vein and its branches. The blood meets resistance to flow and seeks collateral (alternative) venous channels around the high-pressure area. Veins become dilated in the esophagus (esophageal varices), rectum (hemorrhoids), and abdomen (ascites due to excessive abdominal [peritoneal] fluid). Hematuria may indicate insufficient production of clotting factors in the liver and decreased absorption of vitamin K. Fever indicates an inflammatory process.
An older adult client has had an open reduction and internal fixation of a fractured right hip. Which intervention does the nurse implement for this client? A. Keep the client's heels off the bed at all times. B. Re-position the client every 3 to 4 hours. C. Administer preventive pain medication before deep-breathing exercises. D. Prohibit the use of antiembolic stockings.
A. Keep the client's heels off the bed at all times. Because the client is an older adult and is more at risk for skin breakdown because of impaired circulation and sensation, the client's heels must be kept off the bed at all times to avoid constant pressure on this sensitive area. Re-positioning the older adult client must be done every 2 hours, not every 3 to 4 hours, to prevent skin breakdown and to inspect the skin for any signs of breakdown. Pain medication would not be administered for deep-breathing exercises because this client typically would not experience pain upon breathing. Antiembolic stockings are not contraindicated for older adults; rather, they help prevent deep vein thrombosis.
What is the nurse's priority when doing an admission for a client who returned directly from the operating suite after a carpal tunnel repair? A. Monitor vital signs, including pulse oximetry. B. Check the surgical dressing to ensure that it is intact. C. Assess neurovascular assessment in the affected arm. D. Monitor intake and output.
A. Monitor vital signs, including pulse oximetry.
When caring for a client with Laennec's cirrhosis, which of these does the nurse expect to find on assessment? (Select all that apply.) A. Prolonged partial thromboplastin time B. Icterus of skin C. Swollen abdomen D. Elevated magnesium E. Currant jelly stool F. Elevated amylase level
A. Prolonged partial thromboplastin time B. Icterus of skin C. Swollen abdomen The liver produces clotting factors; when it is damaged, prolonged coagulation times and bleeding may result. Icterus, or jaundice, results from cirrhosis. The client with cirrhosis may develop ascites, or fluid in the abdominal cavity. Elevated magnesium is not related to cirrhosis. The client with cirrhosis may develop hypocalcemia and/or hypokalemia. Currant jelly stool is consistent with intussusception, a type of bowel obstruction. Cirrhosis is consistent with elevations of aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase; amylase is typically elevated in pancreatitis.
Which intervention does the nurse suggest to a client with a leg amputation to help cope with loss of the limb? A. Talking with an amputee close to the client's age who has had the same type of amputation B Drawing a picture of how the client sees him- or herself C Talking with a psychiatrist about the amputation D Engaging in diversional activities to avoid focusing on the amputation
A. Talking with an amputee close to the client's age who has had the same type of amputation Meeting with someone of a comparable age who has gone through a similar experience will help the client cope better with his or her own situation. Drawing a picture is not therapeutic and may cause more harm than good. Unless the client is having serious maladjustment problems or has a coexisting psychological disorder, meeting with a psychiatrist should not be necessary. Diversional activities do not help the client deal with loss of the limb.
A client is experiencing an attack of acute pancreatitis. Which nursing intervention is the highest priority for this client? A. Measure intake and output every shift. B. Do not administer food or fluids by mouth. C. Administer opioid analgesic medication. D. Assist the client to assume a position of comfort.
Administer opioid analgesic medication. For the client with acute pancreatitis, pain relief is the highest priority. Although measuring intake and output, NPO status, and positioning for comfort are all important, they are not the highest priority.
When assessing a client for hepatic cancer, the nurse anticipates finding an elevation in which laboratory test result? A. Hemoglobin and hematocrit B. Leukocytes C. Alpha-fetoprotein D. Serum albumin
Alpha-fetoprotein Fetal hemoglobin (alpha-fetoprotein) is abnormal in adults; it is a tumor marker indicative of cancers. Although anemia may be present, elevated hemoglobin and hematocrit are not diagnostic of hepatic cancer. White blood cells (leukocytes) are not used to specifically diagnose cancers. Serum albumin levels may be low in liver cancer and in malnutrition.
The nurse asks a client with liver disease to raise the arms to shoulder level and dorsiflex the hands. A few moments later, the hand begins to flap upward and downward. How does the nurse correctly document this in the medical record? A. Positive Babinski's sign B. Hyperreflexia C. Kehr's sign D. Asterixis
Asterixis Liver flap or asterixis is related to increased serum ammonia levels—the dorsiflexed hands begin to flap upward and downward when outstretched for a few moments. Babinski's sign is positive when, as the sole of the foot is stroked, the great toe points up and the toes fan out. Hyperreflexia refers to deep tendon reflexes that are overactive. Kehr's sign is reflected by increased abdominal pain, exaggerated by deep breathing, and referred to the right shoulder.
Which statement indicates to the nursing instructor that the nursing student understands the normal healing process of bone after a fracture? A "A callus is quickly deposited and transformed into bone." B "A hematoma forms at the site of the fracture." C "Calcium and vascular proliferation surround the fracture site." D "Granulation tissue reabsorbs the hematoma and deposits new bone."
B "A hematoma forms at the site of the fracture." In stage 1, within 24 to 72 hours after a fracture, a hematoma forms at the site of the fracture because bone is extremely vascular. This then prompts the formation of fibrocartilage, providing the foundation for bone healing. Stage 2 of bone healing occurs within 3 days to 2 weeks after the fracture, when granulation tissue begins to invade the hematoma. Stage 3 of bone healing occurs as a result of vascular and cellular proliferation. In stage 4 of a healing fracture, callus is gradually reabsorbed and transformed into bone.
The client has sustained a traumatic amputation of the left arm after a machine accident. In what order should the following nursing actions be taken? 1. Apply direct pressure to the amputated site. 2. Elevate the extremity above the client's heart. 3. Assess the client for breathing problems. 4. Examine the amputation site. A 2, 4, 3, 1 B 3, 4, 1, 2 C 1, 4, 3, 2 D 4, 1, 2, 3
B 3, 4, 1, 2 First, the airway must be assessed for breathing problems. Second, the nurse should examine the amputation site. Third, the nurse should apply direct pressure to the amputated site. Finally, the extremity should be elevated above the client's heart to decrease bleeding.
The nurse admits an older adult client who sustained a left hip fracture and is in considerable pain. The nurse anticipates that the client will be placed in which type of traction? A Balanced skin traction B Buck's traction C Overhead traction D Plaster traction
B Buck's traction Buck's traction may be applied before surgery to help decrease pain associated with muscle spasm. Balanced skin traction is indicated for fracture of the femur or pelvis. Overhead traction is indicated for fracture of the humerus with or without involvement of the shoulder and clavicle. Plaster traction is indicated for wrist fracture.
Which information about a client who was admitted with pelvic and bilateral femoral fractures after being crushed by a tractor is most important for the nurse to report to the health care provider? A Thighs have multiple oozing abrasions. B Serum potassium level is 7 mEq/L. C The client is describing pain as level 4 (0-to-10 scale). D Hemoglobin level is 12.0 g/dL.
B Serum potassium level is 7 mEq/L. The elevated potassium level may indicate that the client has rhabdomyolysis and acute tubular necrosis caused by the crush injury. Further assessment and treatment are needed immediately to prevent further kidney damage or cardiac dysrhythmias. Thighs having multiple oozing abrasions with a pain level of 4 are not unusual for a client with this type of injury. A hemoglobin level of 12.0 g/dL is a normal finding.
2.ID: 4615491959 The nurse refers a client with an amputation and the client's family to which community resource? A. American Amputee Society (AAS) B. Amputee Coalition of America (ACA) C. Community Workers for Amputees (CWA) D. National Amputee of America Society (NAAS)
B. Amputee Coalition of America (ACA) The ACA is an available resource for clients with amputations and supports them and their families. The AAS, CWA, and NAAS do not exist.
A client has a grade III compound fracture of the right tibia. To prevent infection, which intervention does the nurse implement? A. Apply bacitracin (Neosporin) ointment to the site daily with a sterile cotton swab. B. Use strict aseptic technique when cleaning the site. C. Leave the site open to the air to keep it dry. D. Assist the client to shower daily and pat the wound site dry.
B. Use strict aseptic technique when cleaning the site. Using aseptic technique is the best way to prevent infection. Chlorhexidine (Hibiclens), 2 mg/mL solution, is the better cleansing solution for pin site care, not Neosporin ointment. A wound of this type should be kept covered, not left open to the air. The wound site of a compound fracture must not be exposed to a shower; this practice violates maintaining aseptic technique.
It is essential that the nurse monitor the client returning from hepatic artery embolization for hepatic cancer for which potential complication? A. Right shoulder pain B. Polyuria C. Bone marrow suppression D. Bleeding
Bleeding When monitoring a client post hepatic artery embolization, an arterial approach is taken; therefore, prompt detection of hemorrhage is the priority. Discomfort may be present, but the priority is to assess for hemorrhage. The nurse must assess for signs of shock, not polyuria. Embolization does not suppress the bone marrow; if chemotherapy or immune modulators are used, the nurse then assesses for bone marrow suppression.
A client has sustained a rotator cuff tear while playing baseball. The nurse anticipates that the client will receive which immediate conservative treatment? A Surgical repair of the rotator cuff B Prescribed exercises of the affected arm C Immobilizer for the affected arm D Patient-controlled analgesia with morphine
C Immobilizer for the affected arm The conservative treatment for this client is to place the injured arm in an immobilizer. Surgical intervention is not considered conservative treatment. Exercises are prohibited immediately after a rotator cuff injury. The client with a rotator cuff injury is treated primarily with nonsteroidal anti-inflammatory drugs to manage pain.
A client is in skeletal traction. Which nursing intervention ensures proper care of this client? A Ensure that weights are attached to the bed frame or placed on the floor. B Ensure that pins are not loose, and tighten as needed. C Inspect the skin at least every 8 hours. D Remove the traction weights only for bathing.
C Inspect the skin at least every 8 hours. The client's skin should be inspected every 8 hours for signs of irritation, inflammation, or actual skin breakdown. Weights are not allowed to be placed on the floor; weights should hang freely at all times. Pin sites should be checked for signs and symptoms of infection and for security in their position to the fixation and the client's extremity. However, the nurse does not adjust the pins. Any loose pin site or alteration must be reported to the health care provider. Weights must never be removed without a request from the health care provider.
The nurse is instructing a local community group about ways to reduce the risk for musculoskeletal injury. What information does the nurse include in the teaching plan? A. "Avoid contact sports." B. "Avoid rigorous exercise." C. "Wear helmets when riding a motorcycle." D. "Avoid driving in inclement weather."
C. "Wear helmets when riding a motorcycle." Those who ride motorcycles or bicycles should wear helmets to prevent head injury. Telling the general public to avoid contact sports or to avoid driving in inclement weather is not realistic. Telling the general public to avoid rigorous exercise is not only unrealistic, it is also opposed to what many health care professionals recommend to maintain health.
When assessing a client with hepatitis B, the nurse anticipates which assessment findings? (Select all that apply.) A. Recent influenza infection B. Brown stool C. Tea-colored urine D. Right upper quadrant tenderness E. Itching
C. Tea-colored urine D. Right upper quadrant tenderness E. Itching The urine may be brown, tea-, or cola-colored in clients with hepatitis. Inflammation of the liver may cause right upper quadrant pain. Deposits of bilirubin on the skin, secondary to high bilirubin levels, and jaundice irritate the skin and cause itching. Hepatitis B virus, not the influenza virus, causes hepatitis B, which is spread by blood and body fluids. The stool in hepatitis may be tan or clay-colored.
The nursing team consists of an RN, an LPN/LVN, and a nursing assistant. Which client should be assigned to the RN? A. Client who is taking lactulose and has diarrhea B. Client with hepatitis C who requires a dressing change C. Client with end-stage cirrhosis who needs teaching about a low-sodium diet D. Obtunded client with alcoholic encephalopathy who needs a blood draw
Client with end-stage cirrhosis who needs teaching about a low-sodium diet The RN is responsible for client teaching; therefore, the client with end-stage cirrhosis should be assigned to the RN. Assisting a client with toileting and recording stool number and amount can be accomplished by nonprofessional staff. The LPN/LVN can provide dressing changes. Ancillary staff can perform venipuncture.
The RN has just received the change-of-shift report for the medical unit. Which client should the RN see first? A. Client with ascites who had a paracentesis 2 hours ago and is reporting a headache B. Client with portal-systemic encephalopathy (PSE) who has become increasingly difficult to arouse C. Client with hepatic cirrhosis and jaundice who has hemoglobin of 10.9 g/dL and thrombocytopenia D. Client with hepatitis A who has elevated alanine aminotransferase (ALT) and aspartate aminotransferase (AST)
Client with portal-systemic encephalopathy (PSE) who has become increasingly difficult to arouse A change in the level of consciousness (LOC) of the client with PSE is the greatest concern; actions to improve the client's LOC should be rapidly implemented. Although uncomfortable, a headache in the client with ascites is not likely related to liver disease and does not pose an immediate threat or complication. A hemoglobin of 10.9 g/dL and thrombocytopenia are expected findings in a client with cirrhosis and do not pose an immediate threat. Elevated ALT and AST levels are expected for the client with hepatitis A and do not indicate a risk for severe complications.
The nurse is caring for clients in the outpatient clinic. Which of these phone calls should the nurse return first? A. Client with hepatitis A reporting severe and ongoing itching B. Client with severe ascites who has a temperature of 101.4° F (38° C) C. Client with cirrhosis who has had a 3-pound weight gain over 2 days D. Client with esophageal varices and mild right upper quadrant pain
Client with severe ascites who has a temperature of 101.4° F (38° C) The client with ascites and an elevated temperature may have spontaneous bacterial peritonitis; the nurse should call this client first. Itching is anticipated with jaundice, this client may be called last. Weight gain with cirrhosis is not uncommon owing to low albumin levels. Cirrhosis may cause mild right upper quadrant pain; this client should be called after the client with severe ascites.
A client who was awaiting liver transplantation is excluded from the procedure after the presence of which condition is discovered? A. Colon cancer with metastasis to the liver B. Hypertension C. Hepatic encephalopathy D. Ascites and shortness of breath
Colon cancer with metastasis to the liver Transplantation is performed for hepatitis and primary (not secondary) liver cancers. Hypertension is a controllable factor and would not preclude the client from a liver transplant. Encephalopathy is a consequence of advanced liver disease, consistent with the condition of a client awaiting transplantation; it can be treated with lactulose and nonabsorbable antibiotics. Ascites and resulting shortness of breath are also consequences of advanced liver disease, consistent with the client awaiting transplantation; they can be managed with diuretics and paracentesis.
When providing dietary teaching to a client with hepatitis, what practice does the nurse recommend? A. Having a larger meal early in the morning B. Consuming increased carbohydrates and moderate protein C. Restricting fluids to 1500 mL/day D. Limiting alcoholic beverages to once weekly
Consuming increased carbohydrates and moderate protein To repair the liver, the client should have a high-carbohydrate and moderate-protein diet; fats may cause dyspepsia. The client with hepatitis feels full easily and should have four to six small meals daily. Fluids are restricted with ascites caused by cirrhosis; not all clients with hepatitis progress to cirrhosis. Complete abstention from alcohol is necessary until the liver enzymes return to normal.
A client with a fracture asks the nurse about the difference between a compound fracture and a simple fracture. Which statement by the nurse is correct? A "Simple fracture involves a break in the bone, with skin contusions." B "Compound fracture does not extend through the skin." C "Simple fracture is accompanied by damage to the blood vessels." D "Compound fracture involves a break in the bone, with damage to the skin."
D "Compound fracture involves a break in the bone, with damage to the skin." A compound fracture involves a break in the bone with damage to the skin. A simple fracture does not extend through the skin. A compound fracture is accompanied by damage to blood vessels.
The nurse prepares to perform a neurovascular assessment on a client with closed multiple fractures of the right humerus. Which technique does the nurse use? A Inspect the abdomen for tenderness and bowel sounds. B Auscultate lung sounds. C Assess the level of consciousness and ability to follow commands. D Assess sensation of the right upper extremity.
D Assess sensation of the right upper extremity. Assessing sensation of the right upper extremity is part of a focused neurovascular assessment for the client with multiple fractures of the right humerus. Inspecting the abdomen and auscultating lung sounds of the client with multiple fractures are not part of a focused neurovascular assessment. Because the client does not have a head injury, assessing the client's level of consciousness and ability to follow commands is not part of a focused neurovascular assessment.
An older adult client has multiple tibia and fibula fractures of the left lower extremity after a motor vehicle crash. Which pain medication does the nurse anticipate will be requested for this client? A Cyclobenzaprine (Flexeril) B Ibuprofen (Advil) C Meperidine (Demerol) D Patient-controlled analgesia (PCA) with morphine
D Patient-controlled analgesia (PCA) with morphine Morphine is an opioid narcotic analgesic; given through PCA, it is the most appropriate mode of pain management for this type of acute pain associated with multiple injuries. Muscle relaxants such as cyclobenzaprine are effective for treating pain related to muscle spasms, but they are not adequate for this type of acute pain. Ibuprofen is a nonsteroidal anti-inflammatory drug that is used to treat mild to moderate pain; bone pain is very acute, so ibuprofen would not be sufficient. Meperidine should never be used for older adults because it has toxic metabolites that can cause seizures.
A client is recovering from an above-the-knee amputation resulting from peripheral vascular disease. Which statement indicates that the client is coping well after the procedure? A. "My spouse will be the only person to change my dressing." B. "I can't believe that this has happened to me. I can't stand to look at it." C. "I do not want any visitors while I'm in the hospital." D. "It will take me some time to get used to this.
D. "It will take me some time to get used to this. Acknowledging that it will take time to get used to the amputation indicates that the client is expressing acceptance and effective coping. Stating that the spouse will change the dressing indicates the client does not want to participate in self-care. Expressing disbelief and disgust over the amputation indicates the client is unwilling to address what has happened. The client who does not want to receive visitors is having difficulty coping with the change in body image.
1.ID: 4615491966 Which nursing action does the nurse on the orthopedic unit plan to delegate to unlicensed assistive personnel (UAP)? A. Remove the wound drain for a client who had an open reduction of a hip fracture 3 days ago. B. Assess for bruising on a client who is receiving warfarin (Coumadin) to prevent deep vein thrombosis. C. Teach a client with a right ankle fracture how to use crutches when transferring and ambulating. D. Check the vital signs for a client who was admitted after a total knee replacement 3 hours ago.
D. Check the vital signs for a client who was admitted after a total knee replacement 3 hours ago. Correct Vital sign assessment is a skill that is within the role of the UAP. Removing a wound drain, assessment, and client teaching are nursing actions that require broader education and are within the scope of practice of licensed nursing staff.
A client is brought to the emergency department via ambulance after a motor vehicle crash. What condition does the nurse assess for first? A. Bleeding B. Head injury C. Pain D. Respiratory distress
D. Respiratory distress The client should first be assessed for respiratory distress, and any oxygen interventions instituted accordingly. Bleeding is the second assessment priority, head injury is the third assessment priority, and pain is the fourth assessment priority in this case.
In caring for a client who has undergone paracentesis, which changes in the client's status should be promptly reported to the provider? A. Increased blood pressure, increased respiratory rate B. Decreased blood pressure, increased heart rate C. Increased respiratory rate, increased apical pulse, pallor D. Tachypnea, diaphoresis, increased blood pressure
Decreased blood pressure, increased heart rate Decreased blood pressure and increased heart rate are indicative of shock. Increased blood pressure, increased respiratory rate, increased apical pulse, pallor, tachypnea, and diaphoresis are all indicative of anxiety on the client's part.
The nurse suspects that a client may have acute pancreatitis as evidenced by which group of laboratory results? A. Deceased calcium, elevated amylase, decreased magnesium B. Elevated bilirubin, elevated alkaline phosphatase C. Elevated lipase, elevated white blood cell count, elevated glucose D. Decreased blood urea nitrogen (BUN), elevated calcium, elevated magnesium
Elevated lipase, elevated white blood cell count, elevated glucose Elevated lipase is more specific to a diagnosis of acute pancreatitis. Many pancreatic and nonpancreatic disorders can cause increased serum amylase levels. Bilirubin and alkaline phosphatase levels will be increased only if pancreatitis is accompanied by biliary dysfunction. Usually, calcium and magnesium will be increased and BUN increased, not decreased, in acute pancreatitis.
Which activity by the nurse will best relieve symptoms associated with ascites? A. Administering oxygen B. Elevating the head of the bed C. Monitoring serum albumin levels D. Administering intravenous fluids
Elevating the head of the bed The enlarged abdomen of ascites limits respiratory excursion; Fowler's position will increase excursion and reduce shortness of breath. The client may need oxygen, but first the nurse should raise the head of the bed to improve respiratory excursion and oxygenation. Monitoring will detect anticipated decreased serum albumin levels associated with cirrhosis and hepatic failure but does not relieve the symptoms of ascites. Administering IV fluids will contribute to fluid volume excess and fluid shifts into the peritoneal cavity, worsening ascites.
Which intervention is important for the nurse to include in the plan of care for a client who is to undergo paracentesis later today? A. Measure and record drainage. B. Monitor aspartate aminotransferase, alanine aminotransferase, and alkaline phosphatase. C. Obtain informed consent for the procedure. D. Have the client void before the procedure is performed.
Have the client void before the procedure is performed. Voiding before the procedure prevents bladder injury. The drainage color and amount will be recorded after the procedure. Liver enzymes are expected to be elevated; this is the purpose of the procedure. The health care provider performing the procedure should discuss the intervention and potential complications with the client and obtain informed consent.
Which diagnostic results lead the nurse to suspect that a client may have gallbladder disease? A. Increased white blood cell (WBC) count, visualization of calcified gallstones, edema of the gallbladder wall B. Decreased WBC count, visualization of calcified gallstones, increased alkaline phosphatase C. Increased WBC count, visualization of noncalcified gallstones, edema of the gallbladder wall D. Decreased WBC count, visualization of noncalcified gallstones, increased alkaline phosphatase
Increased white blood cell (WBC) count, visualization of calcified gallstones, edema of the gallbladder wall An increased WBC count is evidence of inflammation. Only calcified gallstones will be visualized on abdominal x-ray. Ultrasonography of the right upper quadrant is the best diagnostic test for cholecystitis. Acute cholecystitis is seen as edema of the gallbladder wall and pericholecystic fluid. Alkaline phosphatase will be elevated if liver function is abnormal; this is not common in gallbladder disease.
Which set of assessment findings indicates to the nurse that a client may have acute pancreatitis? A. Absence of jaundice, pain of gradual onset B. Absence of jaundice, pain in right abdominal quadrant C. Presence of jaundice, pain worsening when sitting up D. Presence of jaundice, pain worsening when lying supine
Presence of jaundice, pain worsening when lying supine Pain that worsens when lying supine and the presence of jaundice are the only assessment findings indicative of acute pancreatitis. Pain associated with acute pancreatitis usually has an abrupt onset, is located in the mid-epigastric or upper left quadrant, and lessens with sitting up; also, jaundice is present.
A client is scheduled to undergo a liver transplantation. Which nursing intervention is most likely to prevent the complications of bile leakage and abscess formation? A. Preventing hypotension B. Keeping the T-tube in a dependent position C. Administering antibiotic vaccinations D. Administering immune-suppressant drugs
Keeping the T-tube in a dependent position Keeping the T-tube in a dependent position and secured to the client is likely to prevent bile leakage, abscess formation, and hepatic thrombosis. Preventing hypotension will help to prevent the complication of acute kidney injury. Administering antibiotic vaccinations will help to prevent infection. Administering immune-suppressant drugs will help to prevent graft rejection.
When caring for a client with hepatic encephalopathy, in which situation does the nurse question the use of neomycin (Mycifradin)? A. Kidney failure B. Refractory ascites C. Fetor hepaticus D. Paracentesis scheduled for today
Kidney failure The aminoglycoside drugs, which include neomycin, are nephrotoxic and ototoxic, and should not be taken by the client with hepatic encephalopathy. Cirrhosis and hepatic failure cause both ascites and encephalopathy; no contraindication for neomycin is known. Fetor hepaticus causes an ammonia smell to the breath when serum ammonia levels are elevated; neomycin is used to decrease serum ammonia levels. The client may be NPO for a few hours before paracentesis, but may take neomycin when the procedure is complete, or with less than 30 mL of water, depending on hospital policy.
A client who had been hospitalized with pancreatitis is being discharged with home health services. The client is severely weakened after this illness. Which nursing intervention is the highest priority in conserving the client's strength? A. Limiting the client's activities to one floor of the home B. Instructing the client to take an as-needed (PRN) sleeping medication at night C. Arranging for the client to have a nutritional consult to assess the client's diet D. Asking the health care provider for a request for PRN nasal oxygen
Limiting the client's activities to one floor of the home Limiting the client's activities to one floor of the home will prevent tiring the client with stair climbing. Taking a PRN sleeping medication may not necessarily increase the client's strength level or conserve strength; also, the client may not be experiencing difficulty sleeping. Arranging for a nutritional consult or placing the client on PRN nasal oxygen will not necessarily result in an increase in the client's strength level or conserve strength; no information suggests that the client has any history of breathing difficulties.
What teaching does the home health nurse give the family of a client with hepatitis C to prevent the spread of the infection? A. The client must not consume alcohol. B. Avoid sharing the bathroom with the client. C. Members of the household must not share toothbrushes. D. Drink only bottled water and avoid ice.
Members of the household must not share toothbrushes. Toothbrushes, razors, towels, and items that may spread blood and body fluids should not be shared. The client should not consume alcohol, but abstention will not prevent spread of the virus. The client may share a bathroom if he or she is continent. To prevent hepatitis A when traveling to foreign countries, bottled water should be consumed and ice made from tap water should be avoided.
When providing community education, the nurse emphasizes that which group should receive immunization for hepatitis B? A. Clients who work with shellfish B. Men who prefer sex with men C. Clients traveling to a third-world country D. Clients with elevations of aspartate aminotransferase and alanine aminotransferase
Men who prefer sex with men Men who prefer sex with men are at increased risk for hepatitis B, which is spread by the exchange of blood and body fluids during sexual activity. Consuming raw or undercooked shellfish may cause hepatitis A, not hepatitis B. Travel to third-world countries exposes the traveler to contaminated water and risk for hepatitis A; hepatitis B is not of concern, unless the client is exposed to blood and body fluids during travel. Clients who have liver disease should receive the vaccine, but men who have sex with men are at higher risk for contracting hepatitis B.
The nurse administers lactulose (Evalose) to a client with cirrhosis for which purpose? A. Provides enzymes necessary to digest dairy products B. Reduces portal pressure C. Promotes gastrointestinal (GI) excretion of ammonia D. Decreases GI bleeding
Promotes gastrointestinal (GI) excretion of ammonia Lactulose reduces serum ammonia levels by excreting ammonia through the GI tract. Lactase is the enzyme that digests dairy products. The mechanism of action of lactulose is not to reduce portal pressure. Lactulose does not affect bleeding.
The nurse expects that which client will be discharged to the home environment first? A. Older obese adult who has had a laparoscopic cholecystectomy B. Middle-aged thin adult who has had a laparoscopic cholecystectomy C. Middle-aged thin adult with a heart murmur who has had a traditional cholecystectomy D. Older obese adult with chronic obstructive pulmonary disease (COPD) who has had a traditional cholecystectomy
Middle-aged thin adult who has had a laparoscopic cholecystectomy The combination of client age, a thin frame, and the type of procedure performed will determine that the middle-aged thin client who had a laparoscopic cholecystectomy will be discharged first. Although the older obese client who had a laparoscopic cholecystectomy will have a faster discharge time than one with a traditional cholecystectomy, the client's obesity and age probably will require a longer stay. A traditional cholecystectomy will always require a longer recovery time. The older obese client with a history of COPD will likely have a more lengthy recovery because of associated breathing problems.
When providing discharge teaching to a client with cirrhosis, it is essential for the nurse to emphasize avoidance of which of these? A. Vitamin K-containing products B. Potassium-sparing diuretics C. Nonabsorbable antibiotics D. Nonsteroidal anti-inflammatory drugs (NSAIDs)
Nonsteroidal anti-inflammatory drugs (NSAIDs) Clients who have cirrhosis should not take NSAIDs because they may predispose to bleeding. The client with cirrhosis is prone to bleeding; vitamin K can decrease bleeding, so it is not necessary to restrict this in the diet. Potassium-sparing diuretics are used to reduce ascites. Nonabsorbable antibiotics are used to decrease ammonia levels.
The nurse suspects that which client is at highest risk for developing gallstones? A. Obese male with a history of chronic obstructive pulmonary disease B. Obese female on hormone replacement therapy C. Thin male with a history of coronary artery bypass grafting D. Thin female who has recently given birth
Obese female on hormone replacement therapy Both obesity and altered hormone levels increase a woman's risk for developing gallstones. Men are at lower risk than women for developing gallstones. Although pregnancy increases the risk for a woman to develop gallstones, this woman's thin frame lessens that risk.
A client with a history of esophageal varices has just been admitted to the emergency department after vomiting a large quantity of blood. Which action does the nurse take first? A. Obtain the charts from the previous admission. B. Listen for bowel sounds in all quadrants. C. Obtain pulse and blood pressure. D. Ask about abdominal pain.
Obtain pulse and blood pressure. The nurse should assess vital signs to detect hypovolemic shock caused by hemorrhage. Obtaining charts, assessing bowel sounds, and pain assessment can be delayed until the client has stabilized. Assessment for adequate perfusion is the highest priority at this time.
A client with acute cholecystitis is admitted to the medical-surgical unit. Which nursing activity associated with the client's care will be best for the nurse to delegate to unlicensed assistive personnel (UAP)? A. Assessing dietary risk factors for cholecystitis B. Checking for bowel sounds and distention C. Determining precipitating factors for abdominal pain D. Obtaining the admission weight, height, and vital signs
Obtaining the admission weight, height, and vital signs Obtaining height, weight, and vital signs is included in the education for UAP and usually is included in the job description for these staff members. Assessment, checking bowel sounds, and determining precipitating factors for abdominal pain require broader education and are within the scope of practice of licensed nursing staff.
The RN is caring for a client with end-stage liver disease that has resulted in ascites. Which action does the RN delegate to unlicensed assistive personnel (UAP)? A. Assessing skin integrity and abdominal distention B. Drawing blood from a central venous line for electrolyte studies C. Evaluating laboratory study results for the presence of hypokalemia D. Placing the client in a semi-Fowler's position
Placing the client in a semi-Fowler's position Positioning the client in a semi-Fowler's position is included within UAP education and scope of practice, although the RN will need to supervise the UAP in providing care and will evaluate the effect of the semi-Fowler's position on client comfort and breathing. Assessment of skin integrity and abdominal distention, obtaining blood from a central line, and evaluation of laboratory results should be done by the RN.
Which problem for a client with cirrhosis takes priority? A. Insufficient knowledge related to the prognosis of the disease process B. Discomfort related to the progression of the disease process C. Potential for injury related to hemorrhage D. Inadequate nutrition related to an inability to tolerate usual dietary intake
Potential for injury related to hemorrhage Potential for injury related to hemorrhage is the priority client problem because this complication could be life-threatening. Insufficient knowledge, discomfort, and inadequate nutrition are not priorities because these issues are not immediately life-threatening.
A client has been placed on enzyme replacement for treatment of chronic pancreatitis. In teaching the client about this therapy, the nurse advises the client not to mix enzyme preparations with foods containing which element? A. Carbohydrates B. High fat C. High fiber D. Protein
Protein Enzyme preparations should not be mixed with foods containing protein because the enzymes will dissolve the food into a watery substance. No evidence suggests that enzyme preparations should not be mixed with carbohydrates, food with high fat content, and food with high fiber content.
A health care worker believes that he may have been exposed to hepatitis A. Which intervention is the highest priority to prevent him from developing the disease? A. Requesting vaccination for hepatitis A B. Using a needleless system in daily work C. Getting the three-part hepatitis B vaccine D. Requesting an injection of immunoglobulin
Requesting an injection of immunoglobulin The administration of immunoglobulin, antibodies to hepatitis A, may prevent development of the disease. The vaccine for hepatitis A will take several weeks to stimulate the development of antibodies; passive immunity in the form of immunoglobulin is needed. Implementing a needleless system and getting the three-part vaccine may prevent the development of hepatitis B, not hepatitis A.
The nurse is teaching a client with gallbladder disease about diet modification. Which meal does the nurse suggest to the client? A. Steak and French fries B. Fried chicken and mashed potatoes C. Turkey sandwich on wheat bread D. Sausage and scrambled eggs
Turkey sandwich on wheat bread Turkey is an appropriate low-fat selection for this client. Steak, French fries, fried chicken, and sausage are too fatty, and eggs are too high in cholesterol for a client with gallbladder disease.
How does the home care nurse best modify the client's home environment to manage side effects of lactulose (Evalose)? A. Provides small frequent meals for the client B. Suggests taking daily potassium supplements C. Elevates the head of the bed in high-Fowler's position D. Requests a bedside commode for the client
Requests a bedside commode for the client Lactulose therapy increases the frequency of stools, so a bedside commode should be made available to the client, especially if he or she has difficulty reaching the toilet. Small frequent meals and elevating the head of the bed will not have any effect on the side effects of lactulose. Although lactulose produces excessive stools and could potentially result in loss of potassium, it is inappropriate for the nurse to suggest that the client take potassium supplements.
The nurse is attempting to position a client having an acute attack of pancreatitis in the most comfortable position possible. In which position does the nurse place this client? A. Supine, with a pillow supporting the abdomen B. Up in a chair between frequent periods of ambulation C. High-Fowler's position, with pillows used as needed D. Side-lying position, with knees drawn up to the chest
Side-lying position, with knees drawn up to the chest The side-lying position with the knees drawn up has been found to relieve abdominal discomfort related to acute pancreatitis. No evidence suggests that supine position, sitting up in a chair, or high-Fowler's position have any effect on abdominal discomfort related to acute pancreatitis.
Following paracentesis, during which 2500 mL of fluid was removed, which assessment finding is most important to communicate to the heath care provider? A. The dressing has a 2-cm area of serous drainage. B. The client's platelet count is 135,000/mm3. C. The client's albumin level is 2.8 mg/dL. D. The client's heart rate is 122 beats/min.
The client's heart rate is 122 beats/min. Rapid removal of fluid may cause symptoms of shock; tachycardia, especially when associated with hypotension, should be reported to the provider. A small amount of serous fluid may leak; the dressing should be reinforced. Platelets will be checked before the procedure; these are slightly low, but this is not a cause for concern. An albumin level of 2.8 mg/dL is an expected finding for a client with cirrhosis; it is not life threatening. Awarded 1.0 points out of 1.0 possible points.
The nurse is preparing to instruct a client with chronic pancreatitis who is to begin taking pancrelipase (Cotazym). Which instruction does the nurse include when teaching the client about this medication? A. Administer pancrelipase before taking an antacid. B. Chew tablets before swallowing. C. Take pancrelipase before meals. D. Wipe your lips after taking pancrelipase.
Wipe your lips after taking pancrelipase. Pancrelipase is a pancreatic enzyme used for enzyme replacement for clients with chronic pancreatitis. To avoid skin irritation and breakdown from residual enzymes, the lips should be wiped. Pancrelipase should be administered after antacids or histamine2 blockers are taken. It should not be chewed to minimize oral irritation and allow the drug to be released more slowly. It should be taken with meals and snacks and followed with a glass of water.
After receiving change-of-shift report on these clients, which client does the nurse plan to assess first? A. Young adult client with acute pancreatitis who is dyspneic and has a respiratory rate of 34 to 38 breaths/min B. Adult client admitted with cholecystitis who is experiencing severe right upper quadrant abdominal pain C. Middle-aged client who has an elevated temperature after undergoing endoscopic retrograde cholangiopancreatography D. Older adult client who is receiving total parenteral nutrition after a Whipple procedure and has a glucose level of 235 mg/dL
Young adult client with acute pancreatitis who is dyspneic and has a respiratory rate of 34 to 38 breaths/min Acute respiratory distress syndrome is a possible complication of acute pancreatitis. The dyspneic client is at greatest risk for rapid deterioration and requires immediate assessment and intervention. The client with cholecystitis and the client with an elevated temperature will require further assessment and intervention, but these are not medical emergencies requiring the nurse's immediate attention. The older adult client's glucose level will require intervention but, again, is not a medical emergency.
Health Promotion Activities to Prevent Carpal Tunnel Syndrome
• Become familiar with federal and state laws regarding workplace requirements to prevent repetitive stress injuries such as carpal tunnel syndrome (CTS). • When using equipment or computer workstations that can contribute to developing CTS, assess that they are ergonomically appropriate, including: • Specially designed wrist rest devices • Geometrically designed computer keyboards • Chair height that allows good posture • Take regular short breaks away from activities that cause repetitive stress, such as working at computers. • Stretch fingers and wrists frequently during work hours. • Stay as relaxed as possible when using equipment that causes repetitive stress
