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A 52-year-old client with a 20-year history of alcohol abuse is hospitalized with mild ascites, jaundice, and bruising. Imaging demonstrates the presence of esophageal varices, while the client's elevated serum ammonia level indicates hepatic encephalopathy. The nurse is concerned the client's esophageal varices may rupture and proceeds to educate the client accordingly. Which item should the nurse include in the client's education session?
- A. Do not lift heavy objects.
- B. Avoid walking briskly.
- C. Avoid taking barbiturates.
- D. Avoid ingesting antacids.
Correct Answer: A
Rationale: Avoiding heavy lifting (A) reduces intra-abdominal pressure, decreasing the risk of esophageal variceal rupture. The other options are less directly related to preventing variceal bleeding.
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The emergency department (ED) nurse reviews the client's triage note. Select the findings in the triage note that require immediate follow-up.
- A. 56-year-old male reports persistent nausea and vomiting that has not improved with prescribed anti-emetic.
- B. He reports being diagnosed with viral gastroenteritis three days ago by his physician.
- C. He states that his n/v has gotten so bad that he cannot hold down food or fluids.
- D. On assessment, the client is lethargic and oriented. Unsteady gait.
- E. He reports that he can take his prescribed medications with sips of water.
- F. On assessment, the client is lethargic and oriented. Unsteady gait.
- G. Vital signs: T 99°F (37°C), P 108, RR 18, BP 132/77, pulse oximetry reading 97% on room air.
Correct Answer: A,C,D,F
Rationale: Persistent nausea/vomiting (A, C), lethargy, and unsteady gait (D, F) suggest dehydration or electrolyte imbalances requiring immediate follow-up.
The nurse is admitting a client newly diagnosed with acute pancreatitis. The nurse should anticipate a prescription for which medication?
- A. 3% saline infusion
- B. Fentanyl
- C. Diphenoxylate-atropine
- D. Sucralfate
Correct Answer: B
Rationale: Fentanyl is used for pain management in acute pancreatitis, which is often severe. 3% saline is not standard, diphenoxylate-atropine treats diarrhea (not a primary symptom), and sucralfate is for ulcers, not pancreatitis.
The nurse is caring for a client following a large volume paracentesis. To prevent hypovolemic shock, the nurse anticipates the primary healthcare provider (PHCP) to prescribe an infusion of
- A. 0.9% saline
- B. Albumin
- C. Mannitol
- D. 0.45% saline
Correct Answer: B
Rationale: Albumin is used post-paracentesis to restore intravascular volume and prevent hypovolemic shock by maintaining oncotic pressure. Saline solutions and mannitol do not effectively replace lost protein or maintain volume in this context.
The nurse is caring for a client with suspected bowel perforation. Which of the following would be contraindicated?
- A. Administering gastrografin for an upper GI x-ray.
- B. An exploratory laparotomy procedure.
- C. Administering milk of magnesia following an upper GI study.
- D. An abdominal CT scan.
Correct Answer: C
Rationale: Milk of magnesia (C) is contraindicated in suspected bowel perforation as it may worsen the condition by increasing intestinal motility or causing further leakage. Gastrografin (A), laparotomy (B), and CT scans (D) are appropriate diagnostic or therapeutic measures.
The nurse is caring for a client who has ulcerative colitis (UC). The nurse should teach the client to [Select all that apply].
- A. Eat consistent amounts of carbohydrates at mealtimes.
- B. Avoid drinking fluids with meals.
- C. Obtain recommended colon cancer screenings.
- D. Avoid taking anti-diarrheal medication.
- E. Increase the intake of non-caffeinated fluids during exacerbations.
Correct Answer: B,C,E
Rationale: For ulcerative colitis, avoiding fluids with meals (B) aids digestion, regular colon cancer screenings (C) are critical due to increased risk, and increasing non-caffeinated fluids (E) prevents dehydration during exacerbations. Consistent carbohydrates (A) are not specific, and anti-diarrheals (D) may be used cautiously.