Comprehensive - Lippincotts

A client has had an incisional cholecystec-tomy. Which of the following nursing interventions has the highest priority in postoperative care for this client? 1. Using incentive spirometry every 2 hours while awake. 2. Performing leg exercises every shift. 3. Maintaining a weight-reduction

128. 1. A major goal of postoperative care for the client who has had an incisional cholecystectomy is the prevention of respiratory complications. Because of the location of the incision, the client has a difficult time breathing deeply. Use of incentive spirometry promotes chest expansion and decreases atelectasis. Performing leg exercises each shift is not frequent enough; they should be performed hourly. Maintaining a weight reduction diet may be appropriate for the client, but it is not the highest priority in the immediate postoperative phase. Promoting wound healing is important, but respiratory complications are most common after a cholecystectomy.

An adolescent is being prepared for an emergency appendectomy. The nurse should tell the client? Select all that apply. 1. Friends can visit whenever they want. 2. The scar will be small. 3. The teen will be back in school in 1 week. 4. Antibiotics will be given to prevent an infection. 5. A dressing will stay in place for 1 week.

136. 2, 3. Teens are very concerned about their body image and knowing about the size of the scar is important to them. Typically, teens return to school in 1 week. While hospitalized, friends can visit during visiting hours. Clients are usually hospitalized for an uncomplicated appendectomy for about 24 hours. Antibiotics are not routinely given to pre¬vent an infection. The dressing is removed within a few days.

A client receives morphine for postoperative pain. Which of the following assessments should the nurse include in the client's plan of care? 1. Take apical heart rate after each dose of morphine. 2. Assess urinary output every 8 hours. 3. Assess mental status every shift. 4. Check for pedal edema every 4 hours.

137. 2. Morphine can cause urinary retention. The nurse should assess the client for urinary hesitancy or retention, and note the urinary output. It is not necessary to take the apical heart rate after each dose of morphine. Mental status should be assessed after each dose because morphine can cause such effects as sedation, delirium, and disorientation. Assessing for pedal edema is not necessary.

A male client has been diagnosed as having a low sperm count during infertility studies. After instructions by the nurse about some causes of low sperm counts, the nurse determines that the client needs further instructions when he says low sperm counts may be caused by which of the following? 1. Varicocele. 2. Frequent use of saunas. 3. Endocrine imbalances. 4. Decreased body temperature.

49. 4. Increased, not decreased, body temperature resulting from occupations or infections can contribute to low sperm counts caused by decreased sperm production. Heat can destroy sperm. Varicocele, an abnormal dilation of the veins in the spermatic cord, is an associated cause of a low sperm count. The varicosity increases the temperature within the testes, inhibiting sperm production. Frequent use of saunas or hot tubs may lead to a low sperm count. The temperature of the scrotum becomes elevated, possibly inhibiting sperm production. Endocrine imbalances (thyroid problems) are associated with low sperm counts in men because of possible interference with spermatogenesis.

When teaching unlicensed assistive personnel (UAP) about the importance of hand washing in preventing disease, the nurse should instruct the UAP that? 1. "It is not necessary to wash your hands as long as you use gloves." 2. "Handwashing is the best method for prevent¬ing cross-contamination." 3. "Waterless commercial products are not effec¬tive for killing organisms." 4. "The hands do not serve as a source of infection."

53. 2. Handwashing with the correct technique is the best method for preventing cross- contamination. The hands serve as a source of infection. Waterless commercial products containing at least 60% alcohol are as effective at killing organisms as handwashing.

The nurse assesses a client with diverticulitis and suspects peritonitis when which of the follow¬ing symptoms is noted? 1. Hyperactive bowel sounds. 2. Rigid abdominal wall. 3. Explosive diarrhea. 4. Excessive flatulence.

58. 2. Diverticular rupture causes peritonitis from the release of intestinal contents (chemicals and bacteria) into the peritoneal cavity. A rigid abdominal wall results from a diverticular cavity. The inflammatory response of the peritoneal tissue produces severe abdominal rigidity and pain, diminished intestinal motility, and retention of intestinal contents (air, fluid, and stool). Hyperactive bowel sounds, explosive diarrhea, and excessive flatulence do not indicate peritonitis.

A nurse is assessing a client who has a poten¬tial diagnosis of pancreatitis. Which risk factors predispose the client to pancreatitis? Select all that apply. 1. Excessive alcohol use. 2. Gallstones. 3. Abdominal trauma. 4. Hypertension. 5. Hyperlipidemia with excessive triglycerides. 6. Hypothyroidism.

59. 1, 2, 3, 5. Pancreatitis, a chronic or acute inflammation of the pancreas, is a potentially life-threatening condition. Excessive alcohol intake and gallstones are the greatest risk factors. Abdominal trauma can potentiate inflammation. Hyperlipidemia is a risk factor for recurrent pancreatitis. Hypertension and hypothyroidism are not associated with pancreatitis.

63. A client is trying to lose weight at a moderate pace. If the client eliminates 1,000 calories per day from his normal intake, how many pounds would he lose in 1 week? ________lb.

63. 2 lb. One pound of weight is approximately equivalent to 3,500 calories. Removing 1,000 calories per day results in a 2-lb weight loss per week (7,000 calories divided by 7 days). If a client wanted to lose 1 lb in a 7-day period, he would need to cut out 500 calories per day (3,500 calories divided by 7 days). It is unsafe to try to lose more than 2 lb/ week.

A client needs surgery to relieve an intestinal obstruction. The nurse receives the following set of orders for the client. Which of the following orders should the nurse question before performing? 1. Tap water enemas until clear. 2. Out of bed as tolerated. 3. Neomycin sulfate 1 g P.O. every 4 hours. 4. Betadine scrub to abdomen.

72. 1. High colonic irrigation can increase the risk of perforation in a distended and inflamed colon. Tap water is hypotonic in the bowel and would draw increased fluid into the area. The other orders are part of standard preparation for intestinal surgery. CN: Reduction of risk potential; CL: Synthesize

After teaching a client about collecting a stool sample for occult testing, which client state¬ment indicates effective teaching? Select all that apply. 1. "I will avoid eating meat for 1 to 3 days before getting a stool sample." 2. "I need to eat foods low in fiber a few days before collecting the sample." 3. "I'll take the sample from different areas of the stool that I have passed." 4. "I need to send the stool sample to the lab in a covered container right away." 5. "I can continue to take all of my regular medi¬cations at home."

73. 1, 3. When a client collects stool for occult blood, the nurse should instruct him to avoid eating meat, especially red meat, for 1 to 3 days before the sample collection because meat eliminated in the stool can lead to false-positive results. Eating foods high in fiber a few days before sample collection may be recommended because doing so improves the chances of finding occult blood if a lesion is present. The client should take stool samples from different sites of the stool for a better sample. The stool sample should be covered to protect every¬one from body secretions. The specimen does not have to be sent to the laboratory immediately. Some medications, herbs, foods, and activities can lead to false results of the occult testing. For example, iron pills, turnips, and horseradish lead to false-positive results. Vitamin C leads to false-negative results. Some anti-inflammatory drugs and aspirin should be avoided due to antiplatelet properties that increase the risk of gastrointestinal bleeding.

A client who is on nothing-by-mouth status is constantly asking for a drink. Which of the follow¬ing is the most appropriate nursing intervention? 1. Reexplain to the client why she cannot drink. 2. Offer ice chips every hour to decrease thirst. 3. Offer the client frequent oral hygiene care. 4. Divert the client's attention by turning on the television.

74. 3. The most appropriate intervention is to offer the client frequent mouth care to moisten the dry oral mucosa. Reexplaining why the client can¬not drink may be helpful but will not relieve her thirst. Ice chips cannot be given to a client who is on nothing-by-mouth status. Diverting the client's attention does not treat her complaint. CN: Basic care and comfort; CL: Synthesize

A female client is admitted with fatigue, cold intolerance, weight gain, and muscle weakness. The initial nursing assessment reveals brittle nails, dry hair, constipation, and possible goiter. The client is most likely experiencing signs and symptoms of: 1. Cushing's disease. 2. Hypothyroidism. 3. Hyperthyroidism. 4. A pituitary tumor.

75. 2. This client is demonstrating classic symp¬toms of hypothyroidism. Primary hypothyroid¬ism results from pathologic changes in the thyroid gland. In this case, the thyroid gland cannot secrete sufficient amounts of thyroid hormone, leading to a decrease in cellular metabolic activity, decreased oxygen consumption, and decreased heat production. Cushing's disease is manifested by a buffalo hump, moonface, hypertension, fatigability, and weakness, resulting from the inappropriate release of cortisol. Hyperthyroidism, or Graves' disease, is manifested by increased appetite with weight loss, increased anxiety, hand tremors, palpitations, heat intolerance, and insomnia. A pituitary tumor can have many symptoms, depending on the location.

The nurse is preparing a discharge plan for a 16-year-old who has fractured her femur and ulna. The client asks the nurse how quickly her fractures will heal so she can return to her normal activities. Which of the following responses is most appropriate for the nurse to make? 1. "The healing of your leg will be delayed because you have had skeletal traction." 2. "It will take your arm about 12 weeks to heal completely, but it will take your leg about 24 weeks." 3. "Because you are young and healthy, your bones should heal in less than 12 weeks." 4. "You will require long-term rehabilitation and should expect it to take at least 8 months for your bones to heal."

81. 2. In an emergency in which the neonate's head is already delivering, the first action by the nurse should be to check for the presence of a cord around the neonate's neck. If the cord is present, the nurse should gently remove it from around the neck. The mother should be told to breathe gently and avoid forceful bearing-down efforts, which could lead to lacerations. Although blood and bodily fluid precautions are always present in client care, this is an emergency. If possible, the nurse should put on gloves. Suctioning the mouth can be done after the nurse has checked that the cord is not around the neonate's neck. Telling the mother that help is on the way is not reassuring because emergency medical technicians may take some time to arrive. Delivery is imminent because the neonate's head is delivering.

Which of the following nursing diagnoses should the nurse identify as a priority after surgical repair of a cleft lip? 1. Acute pain. 2. Risk for infection. 3. Impaired physical mobility. 4. Impaired parenting.

87. 2. After surgery, the most important nursing diagnosis is Risk for infection. Surgery involves an incision, which places the infant at risk for infection. The infant with this type of procedure does have discomfort, which can be relieved with acetaminophen (Tylenol). Acute pain is an important nursing diagnosis but not the priority. The infant may be in arm restraints or have the cuff of the sleeve pinned to the diaper or pants. It is important that the infant not touch the incision line or disrupt the sutures. There is no indication for a nursing diagnosis of Impaired parenting. The parents would be reacting normally with a first reaction of shock.

Which of the following is an appropriate outcome for a client with rheumatoid arthritis? 1. The client will manage joint pain and fatigue to perform activities of daily living. 2. The client will maintain full range of motion in joints. 3. The client will prevent the development of further pain and joint deformity. 4. The client will take anti-inflammatory medications as indicated by the presence of disease symptoms.

88. 1. An appropriate outcome for the client with rheumatoid arthritis is that he will adopt self-care behaviors to manage joint pain, stiffness, and fatigue and be able to perform activities of daily living. Range-of-motion (ROM) exercises can help maintain mobility, but it may not be realistic to expect the client to maintain full ROM. Depending on the disease progression, there may be further development of pain and joint deformity, even with appropriate therapy. It is important for the client to understand the importance of taking the prescribed drug therapy even if symptoms have abated.

A client has his leg immobilized in a long leg cast. Which of the following assessments indicates the early beginning of circulatory impairment? 1. Inability to move toes. 2. Cyanosis of toes. 3. Complaints of cast tightness. 4. Tingling of toes.

98. 4. Tingling and numbness of the toes would be the earliest indication of circulatory impairment. Inability to move the toes and cyanosis are later indicators. Complaints of cast tightness should be investigated because cast tightness can lead to circu¬latory impairment; it is not, however, an indicator of impairment.

A client tells the nurse that she has had sexual contact with someone whom she suspects has genital herpes. Which of the following instructions should the nurse give the client in response to this information? 1. Anticipate lesions within 25 to 30 days. 2. Continue sexual activity unless lesions are present. 3. Report any difficulty urinating. 4. Drink extra fluids to prevent lesions from forming.

99. 3. The client should be encouraged to report painful urination or urinary retention. Lesions may appear 2 to 12 days after exposure. The client is capable of transmitting the infection even when asymptomatic, so a barrier contraceptive should be used. Drinking extra fluids will not stop the lesions from forming.

Which of the following is an adverse effect of vancomycin (Vancocin) and needs to be reported promptly? 1. Vertigo. 2. Tinnitus. 3. Muscle stiffness. 4. Ataxia.

46. 2. The client should report tinnitus because vancomycin can affect the acoustic branch of the eighth cranial nerve. Vancomycin does not affect the vestibular branch of the acoustic nerve; vertigo and ataxia would occur if the vestibular branch were involved. Muscle stiffness is not associated with vancomycin.

The nurse is preparing to administer blood to a client who requires postoperative blood replace¬ment. The nurse should use a blood administration set that has a: 1. Micron mesh filter. 2. Nonfiltered blood administration set. 3. Special leukocyte-poor filter. 4. Microdrip administration set.

1. All blood products should be administered through a micron mesh filter. Blood is never administered without a filter. Leukocytes can be removed by using leukocyte-poor filters, and this is recommended to decrease reactions in clients, such as hemophiliacs, who require frequent transfusions. Blood is too concentrated to administer through a microdrip set.

A client asks the nurse how long she has to take her medicine for hypothyroidism. The nurse's response is based on the knowledge that: 1. Lifelong daily medicine is necessary. 2. The medication is expensive, and the dose can be reduced in a few months. 3. The medication can be gradually withdrawn in 1 to 2 years. 4. The medication can be discontinued after the client's thyroid-stimulating hormone level is normal.

1. Thyroid replacement is a lifelong maintenance therapy. The medication is usually given as one dose in the morning. It cannot be tapered or discontinued because the client needs thyroid supplementation to maintain health. The medication cannot be discontinued after the thyroid-stimulating hormone (TSH) level is normal; the dose will be maintained at the level that normalizes the TSH concentration.

When infusing total parenteral nutrition (TPN), the nurse should assess the client for which of the following complications? 1. Essential amino acid deficiency. 2. Essential fatty acid deficiency. 3. Hyperglycemia. 4. Infection.

138. 4. Infection is the greatest concern to the nurse. Infection occurs more frequently because of the number of procedures performed on clients that require this therapy and people they come in contact with in the hospital. Infection can be reduced if proper infection control techniques are used and human contact is reduced. Deficiencies and toxicities of nutrients are rare because of the use of standard protocols and orders for TPN formulas. Hyperglycemia can occur with TPN administration; however, all clients receiving TPN have their serum glucose concentration monitored frequently, and the hyperglycemia can easily be managed by adding insulin to the TPN solution. An infection is a much more serious complication.

The nurse is assessing a client with irreversible shock. The nurse should document which of the following? 1. Increased alertness. 2. Circulatory collapse. 3. Hypertension. 4. Diuresis.

101. 2. Severe hypoperfusion to all vital organs results in failure of the vital functions and then circulatory collapse. Hypotension, anuria, respiratory distress, and acidosis are other symptoms associated with irreversible shock. The client in irreversible shock will not be alert.

The nurse is assigned to a client with jaundice and collects the following data: poor appetite, nausea, and two episodes of emesis in the past 2 hours. The nurse should make which of the following nursing diagnoses? 1. Imbalanced nutrition: Less than body requirements. 2. Acute pain related to abdominal muscle spasms. 3. Adult failure to thrive. 4. Ineffective health maintenance.

113. 1. Nausea and anorexia, and in some situations weight loss, are symptoms experienced by clients with jaundice. Jaundice is associated with high levels of bilirubin in the blood. Causes include hepatitis, yellow fever, and alcoholism. The nursing diagnoses of Acute pain related to muscle spasms and Ineffective health maintenance are not supported by the data. Adult failure to thrive is a possible nursing diagnosis; however, more data is needed to support it.

A client has a total hip replacement. Which of the following client statements indicates a need for further teaching before discharge? 1. "I will implement my exercise program as soon as I get home." 2. "I will be careful not to cross my legs." 3. "I will need an elevated toilet seat." 4. "I can't wait to take a tub bath when I get home."

145. 4. The client will need to avoid extremes of motion in the hip to avoid dislocation. The hip should not be flexed more than 90 degrees, internally rotated, or legs crossed. It is not possible to safely sit in the bathtub without flexing the hip beyond the recommended 90 degrees. The client can implement the prescribed exercise program at the time of discharge home. The client should take care not to stress the hip for 3 to 6 months after surgery. An elevated toilet seat will be necessary during the recovery from surgery.

To help prevent hip flexion deformities associated with rheumatoid arthritis, the nurse should help the client assume which of the following positions in bed several times a day? 1. Prone. 2. Very low Fowler's. 3. Modified Trendelenburg. 4. Side-lying.

150. 1. To help prevent flexion deformities, a client with rheumatoid arthritis should lie in a prone position in bed for about 1/2 hour several times a day. This positioning helps keep the hips and knees in an extended position and prevents joint flexion. Low Fowler's, modified Trendelenburg, and side-lying positions do not prevent hip flexion.

The nurse is instructing an unlicensed assis-tive personnel on the prevention of postoperative pulmonary complications. Which of the following statements indicates that the assistant has under-stood the nurse's instructions? 1. "I will turn the client every 4 hours." 2. "I will keep the client's head elevated." 3. "I should suction the client every 2 hours." 4. "I will have the client take 5 to 10 deep breaths every hour."

164. 4. Having the client deep-breathe hourly is the most appropriate action for the assistant to take to help prevent pulmonary complications. The client should be turned at least every 2 hours. Keeping the client's head elevated will not prevent pulmonary complications. Suctioning the client is not an assistant's responsibility, nor does it prevent pulmonary complications.

The infusion rate of total parenteral nutrition is tapered before being discontinued. This is done to prevent which of the following complications? 1. Essential fatty acid deficiency. 2. Dehydration. 3. Rebound hypoglycemia. 4. Malnutrition.

166. 3. When dextrose is abruptly discontinued, rebound hypoglycemia can occur. The nurse should assess the client for symptoms of hypoglycemia. Essential fatty acid deficiency is very unlikely to occur because some of these fatty acids are stored. Preventing dehydration or malnutrition is not the reason for tapering the infusion rate; the client's hydration and nutritional status and ability to maintain adequate intake must be established before total parenteral nutrition is discontinued.

The mother of a child with bronchial asthma tells the nurse that the child wants a pet. Which of the following pets is most appropriate? 1. Cat. 2. Fish. 3. Gerbil. 4. Canary.

2. Pets are discouraged when parents are try ing to allergy-proof a home for a child with bronchial asthma, unless the pets are kept outside. Pets with hair or feathers are especially likely to trigger asthma attacks. A fish is a satisfactory pet for this child, but the parents should be taught to keep the fish tank clean to prevent it from harboring mold.

A client with human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome confides that he is homosexual and his employer does not know his HIV status. Which response by the nurse is best? 1. "Would you like me to help you tell them?" 2. "The information you confide in me is confidential." 3. "I must share this information with your family." 4. "I must share this information with your employer."

2. The nurse is responsible for maintaining confidentiality of this disclosure by the client.

An elderly client is being admitted to same-day surgery for cataract extraction. The client has several diamond rings. The nurse should explain to the client that: 1. Her rings will be taped before the surgery. 2. She will sign a valuables envelope that will be placed in a safe. 3. The rings will be locked in the narcotics box. 4. The nursing supervisor will hold onto the rings during the surgery.

2. Under the policy for valuables, the nurse documents the description on an envelope with the client, the client and nurse sign the envelope, and the valuables envelope is locked in the safe. The other options increase the risk of loss or damage to the client's valuables.

A client admitted with a gastric ulcer has been vomiting bright red blood. His hemoglo-bin level is 5.11 g/dL, and his blood pressure is 100/50 mm Hg. The client and his family state that their religious beliefs do not support the use of blood products and refuse blood transfusions as a treatment for the bleeding. The nurse should col¬laborate with the physician and family to next: 1. Discontinue all measures. 2. Notify the hospital attorney. 3. Attempt to stabilize the client through the use of fluid replacement. 4. Give enough blood to keep the client from dying.

3. The most appropriate response is to continue all treatments and attempt to stabilize the client using fluid replacement without administering blood or blood products. It is imperative that the health care team respect the client's religious beliefs and wishes, even if they are not those of the health care team. Discontinuing all measures is not an option. The health care team should continue to provide the best care possible and does not need to notify the attorney.

A client with a fractured leg has been instructed to ambulate without weight bearing on the affected leg. The nurse evaluates that the client is ambulating correctly if she uses which of the fol¬lowing crutch-walking gaits? 1. Two-point gait. 2. Four-point gait. 3. Three-point gait. 4. Swing-to gait.

3. The three-point gait, in which the client advances the crutches and the affected leg at the same time while weight is supported on the unaffected extremity, is the appropriate gait of choice. This allows for non-weight-bearing on the affected extremity. The two-point, four-point, and swing-to gaits require some weight bearing on both legs, which is contraindicated for this client.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used in the treatment of musculoskeletal conditions. It is important for the nurse to remind the client to: 1. Take NSAIDs at least three times per day. 2. Exercise the joints at least 1 hour after taking the medication. 3. Take antacids 1 hour after taking NSAIDs. 4. Take NSAIDs with food.

36. 4. NSAIDs irritate the gastric mucosa and should be taken with food. NSAIDs are usually taken once or twice daily. Joint exercise is not related to the drug administration. Antacids may interfere with the absorption of NSAIDs.

The nurse holds the gauze pledget against an I.M. injection site while removing the needle from the muscle. This technique helps to: 1. Seal off the track left by the needle in the tissue. 2. Speed the spread of the medication in the tissue. 3. Avoid the discomfort of the needle pulling on the skin. 4. Prevent organisms from entering the body through the skin puncture.

38. 3. Holding the gauze pledget against an I.M. injection site while removing the needle from the muscle avoids the discomfort of the needle pulling on the skin.

Which of the following statements indicates that the client with a peptic ulcer understands the dietary modifications he needs to follow at home? 1. "I should eat a bland, soft diet." 2. "It is important to eat six small meals a day." 3. "I should drink several glasses of milk a day." 4. "I should avoid alcohol and caffeine."

47. 4. Caffeinated beverages and alcohol should be avoided because they stimulate gastric acid production and irritate gastric mucosa. The client should avoid foods that cause discomfort; however, there is no need to follow a soft, bland diet. Eating six small meals daily is no longer a common treatment for peptic ulcer disease. Milk in large quantities is not recommended because it actually stimulates further production of gastric acid.

The nurse is teaching a client about using topical gentamicin sulfate (Garamycin). Which of the following comments by the client indicates the need for additional teaching? 1. "I will avoid being out in the sun for long periods." 2. "I should stop applying it once the infected area heals." 3. "I'll call the physician if the condition worsens." 4. "I should apply it to large open areas."

4. The aminoglycoside antibiotic gentamicin sulfate should not be applied to large denuded areas because toxicity and systemic absorption are possible. The nurse should instruct the client to avoid excessive sun exposure because gentamicin sulfate can cause photosensitivity. The client should be instructed to apply the cream or ointment for only the length of time prescribed because a superinfection can occur from overuse. The client should contact the physician if the condition worsens after use.

The nurse coordinates with the laboratory staff to have the gentamicin trough serum level drawn. At what time should the blood be drawn in relation to the administration of the I.V. dose of gentamicin sulfate (Garamycin)? 1. 2 hours before the administration of the next I.V. dose. 2. 3 hours before the administration of the next I.V. dose. 3. 4 hours before the administration of the next I.V. dose. 4. Just before the administration of the next I.V. dose.

4. To determine how low the gentamicin serum level drops between doses, the trough serum level should be drawn just before the administration of the next I.V. dose of gentamicin sulfate.

The client with a nasogastric (NG) tube begins to complain of abdominal distention. Which of the following measures should the nurse implement first? 1. Call the physician. 2. Irrigate the NG tube. 3. Check the function of the suction equipment. 4. Reposition the NG tube.

48. 3. When a client with a NG tube exhibits abdominal distention, the nurse should first check the suction machine. If the suction equipment is functioning properly, then the nurse should take other steps, such as repositioning the tube or checking tube patency by irrigating it. If these steps are not effective, then the physician should be called.

The nurse applies warm compresses to apply to a client's leg. To determine effectiveness of the compresses, the nurse should determine if there is: 1. Less scaling on the skin. 2. Decreased bruising. 3. Improved circulation to the area. 4. Decreased swelling in the area.

122. 3. Heat applications cause vasodilation, which promotes circulation to the area, and increase tissue metabolism and leukocyte mobility. Heat applications do not prevent swelling; applications of cold are used to prevent swelling by causing vasoconstriction. Moist heat applications do not reduce bruising or scaling on the skin.

Which of the following abnormal serum chemistry values is present in a client with cirrhosis who has developed ascites? 1. Decreased aspartate aminotransferase. 2. Hypoalbuminemia. 3. Hyperkalemia. 4. Decreased alanine aminotransferase.

125. 2. Hypoalbuminemia occurs in cirrhosis because the liver cannot synthesize albumin. This causes a decrease in colloidal osmotic pressure, resulting in ascites. Hyperkalemia is not an expected electrolyte imbalance of cirrhosis. The aspartate aminotransferase and alanine aminotransferase values are increased in liver disease.

A client who had a transurethral resection of the prostate (TURP) 1 day earlier has a three-way Foley catheter inserted for continuous bladder irrigation. Which of the following statements best explains why continuous irrigation is used after TURP? 1. To control bleeding in the bladder. 2. To instill antibiotics into the bladder. 3. To keep the catheter free from clot obstruction. 4. To prevent bladder distention.

130. 3. Continuous irrigation, usually consisting of sterile normal saline, is used after TURP to keep blood clots from obstructing the catheter and impeding urine flow. Antibiotics may be instilled in the bladder with the use of an irrigating solution, but this is not the primary reason for using continuous irrigation in TURP. The irrigating solution may secondarily help prevent bladder distention because it keeps the catheter from becoming obstructed.

A health care provider has been exposed to hepatitis B through a needlestick. Which of the fol¬lowing drugs should the nurse anticipate adminis¬tering as postexposure prophylaxis? 1. Hepatitis B immune globulin. 2. Interferon. 3. Hepatitis B surface antigen. 4. Amphotericin B.

90. 1. Hepatitis B immune globulin is given as prophylactic therapy to individuals who have been exposed to hepatitis B. Interferon has been approved to treat hepatitis B. Hepatitis B surface antigen is a diagnostic test used to detect current infection. Amphotericin B is an antifungal.