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A client admitted with a diagnosis of sepsis has a central venous pressure (CVP) of 15 mm Hg. What should the nurse do first?
- A. Administer a fluid bolus of 500 ml.
- B. Notify the healthcare provider immediately.
- C. Administer a diuretic.
- D. Continue to monitor the CVP.
Correct Answer: B
Rationale: The correct answer is B: Notify the healthcare provider immediately. A CVP of 15 mm Hg in a client with sepsis may indicate fluid overload or cardiac dysfunction, which require prompt medical intervention. Notifying the healthcare provider allows for timely assessment and appropriate management. Administering a fluid bolus (A) without further evaluation can exacerbate fluid overload. Administering a diuretic (C) without knowing the underlying cause can be harmful. Continuing to monitor the CVP (D) is important, but immediate action is required due to the high CVP level.
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A client with rheumatoid arthritis is prescribed methotrexate. Which instruction should the nurse include in the client's teaching?
- A. Avoid alcohol while taking this medication.
- B. Take the medication with a full meal.
- C. Increase your intake of high-fiber foods.
- D. Avoid exposure to sunlight.
Correct Answer: A
Rationale: The correct answer is A: Avoid alcohol while taking this medication. Methotrexate can cause liver toxicity, and alcohol consumption can exacerbate this risk. It is important for the client to avoid alcohol to prevent potential harm to the liver.
B: Taking the medication with a full meal is not a necessary instruction for methotrexate. It is typically recommended to take methotrexate on an empty stomach.
C: Increasing intake of high-fiber foods is not directly related to methotrexate therapy. It is important for overall health but not specifically for this medication.
D: Avoiding exposure to sunlight is not a common instruction for methotrexate. While some medications can increase sensitivity to sunlight, this is not a typical concern with methotrexate.
The nurse is providing an educational workshop about coronary artery disease (CAD) and its risk factors. The nurse explains to participants that CAD has many risk factors, some that can be controlled and some that cannot. What risk factors should the nurse list that can be controlled or modified?
- A. Gender, obesity, family history, and smoking
- B. Inactivity, stress, gender, and smoking
- C. Cholesterol levels, hypertension, and smoking
- D. Stress, family history, and obesity
Correct Answer: C
Rationale: The correct answer is C because cholesterol levels, hypertension, and smoking are modifiable risk factors for CAD. High cholesterol levels can be controlled through diet and medication. Hypertension can be managed through lifestyle changes and medication. Smoking is a behavior that can be modified.
A is incorrect because gender and family history are non-modifiable risk factors. Obesity can be controlled but is not listed in the correct answer.
B is incorrect because inactivity and stress are modifiable risk factors, but gender is not modifiable.
D is incorrect because stress and family history are non-modifiable risk factors, and obesity is not listed in the correct answer.
A client reports recent exposure to hepatitis A. What is a common mode of transmission for this virus?
- A. Blood transfusion
- B. Fecal-oral route
- C. Needle sharing
- D. Sexual contact
Correct Answer: B
Rationale: The correct answer is B: Fecal-oral route. Hepatitis A is commonly transmitted through ingestion of contaminated food or water. The virus is present in the feces of infected individuals and can be spread through inadequate sanitation practices. Blood transfusion (A) is not a common mode of transmission for hepatitis A. Needle sharing (C) is more associated with hepatitis B and C transmission. Sexual contact (D) is not a primary mode of transmission for hepatitis A. In summary, the fecal-oral route is the most common mode of transmission for hepatitis A due to contamination of food or water with the virus.
A client has developed hepatic encephalopathy secondary to cirrhosis and is receiving care on the medical unit. The client's current medication regimen includes lactulose four times daily. What desired outcome should the nurse relate to this pharmacologic intervention?
- A. Two to three soft bowel movements daily
- B. Significant increase in appetite and food intake
- C. Absence of nausea and vomiting
- D. Absence of blood or mucus in stool
Correct Answer: A
Rationale: The correct answer is A: Two to three soft bowel movements daily. Lactulose is a laxative commonly used to manage hepatic encephalopathy by reducing ammonia levels through promoting bowel movements. The desired outcome of this medication is to prevent the buildup of ammonia in the bloodstream, which can exacerbate hepatic encephalopathy. Soft bowel movements indicate that the medication is effectively promoting bowel motility and reducing ammonia levels. Choices B, C, and D are incorrect as lactulose is not directly associated with increasing appetite, resolving nausea and vomiting, or eliminating blood or mucus in the stool in this context.
A 55-year-old woman presents with fatigue, pruritus, and jaundice. Laboratory tests reveal elevated bilirubin and alkaline phosphatase levels. Imaging shows dilated intrahepatic bile ducts and a normal common bile duct. What is the most likely diagnosis?
- A. Primary biliary cirrhosis
- B. Primary sclerosing cholangitis
- C. Gallstones
- D. Pancreatic cancer
Correct Answer: A
Rationale: The most likely diagnosis is A: Primary biliary cirrhosis. This is supported by the patient's symptoms of fatigue, pruritus, jaundice, elevated bilirubin and alkaline phosphatase levels, and dilated intrahepatic bile ducts. Primary biliary cirrhosis is an autoimmune liver disease that primarily affects middle-aged women, leading to destruction of intrahejson hepatic bile ducts. The normal common bile duct rules out obstruction from gallstones or pancreatic cancer. Primary sclerosing cholangitis typically presents with strictures in the bile ducts, which is not seen in this case. Therefore, the combination of symptoms, lab findings, and imaging results point towards primary biliary cirrhosis as the most likely diagnosis.