Nokea
A client has had a liver biopsy. After the procedure, the nurse should position him on his right side with a pillow under his rib cage. What is the primary reason for this position?
- A. To immobilize the diaphragm
- B. To facilitate full chest expansion
- C. To minimize the danger of aspiration
- D. To reduce the likelihood of bleeding
Correct Answer: D
Rationale: Right-side positioning with a pillow applies pressure to the biopsy site, reducing the risk of bleeding.
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The nurse is assessing a client who may have a hiatal hernia. What symptom is the client most likely to report?
- A. Projectile vomiting
- B. Crampy lower abdominal pain
- C. Burning substernal pain
- D. Bloody diarrhea
Correct Answer: C
Rationale: Burning substernal pain, often mistaken for heartburn, is a hallmark symptom of hiatal hernia due to acid reflux.
Which statement by the client diagnosed with hepatitis warrants immediate intervention by the clinic nurse?
- A. I will not drink any type of beer or mixed drink.
- B. I will get adequate rest so I don’t get exhausted.
- C. I had a big hearty breakfast this morning.
- D. I took some cough syrup for this nasty head cold.
Correct Answer: D
Rationale: Cough syrup may contain hepatotoxic ingredients (e.g., acetaminophen), posing a risk to a hepatitis patient’s liver, requiring immediate intervention. Other statements are appropriate or benign.
The 22-year-old female who is obese is discussing weight loss programs with the nurse. Which information should the nurse teach?
- A. Jog for two (2) to three (3) hours every day.
- B. Lifestyle behaviors must be modified.
- C. Eat one (1) large meal every day in the evening.
- D. Eat 1,000 calories a day and don't take vitamins.
Correct Answer: B
Rationale: Modifying lifestyle behaviors (e.g., diet, exercise, habits) is essential for sustainable weight loss. Excessive jogging, one large meal, or extreme calorie restriction are unsafe.
The client diagnosed with Crohn's disease is crying and tells the nurse, 'I can't take it anymore. I never know when I will get sick and end up here in the hospital.' Which statement is the nurse's best response?
- A. I understand how frustrating this must be for you.
- B. You must keep thinking about the good things in your life.
- C. I can see you are very upset. I'll sit down and we can talk.
- D. Are you thinking about doing anything like committing suicide?
Correct Answer: C
Rationale: Acknowledging the client's distress and offering to talk provides emotional support and opens communication to address concerns. The other responses are less therapeutic, either minimizing the issue or jumping to assumptions about suicide risk.
Which gastrointestinal assessment data should the nurse expect to find when assessing the client in end-stage liver failure?
- A. Hypoalbuminemia and muscle wasting.
- B. Oligomenorrhea and decreased body hair.
- C. Clay-colored stools and hemorrhoids.
- D. Dyspnea and caput medusae.
Correct Answer: A
Rationale: Hypoalbuminemia and muscle wasting are common in end-stage liver failure due to impaired protein synthesis and malnutrition. Other options include less specific or unrelated findings.