Nokea
A client is suspected of having hepatitis. Which diagnostic test results will assist in confirming this diagnosis?
- A. Decreased erythrocyte sedimentation rate
- B. Elevated serum bilirubin
- C. Elevated hemoglobin
- D. Elevated blood urea nitrogen
Correct Answer: B
Rationale: The correct answer is B: Elevated serum bilirubin. Hepatitis is characterized by liver inflammation, which can lead to impaired bilirubin metabolism and increased levels in the blood. Elevated serum bilirubin is a common finding in hepatitis. Decreased erythrocyte sedimentation rate (Choice A) is not specific to hepatitis. Elevated hemoglobin (Choice C) and elevated blood urea nitrogen (Choice D) are not typically associated with hepatitis and are more indicative of other conditions. In summary, elevated serum bilirubin is a key diagnostic marker for confirming a diagnosis of hepatitis.
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Which of the following expected outcomes would be appropriate for the client who has ulcerative colitis?
- A. The client maintains a daily record of intake and output.
- B. The client verbalizes the importance of small, frequent feedings.
- C. The client uses a heating pad to decrease abdominal cramping.
- D. The client accepts that a colostomy is inevitable at some time in his life.
Correct Answer: B
Rationale: The correct answer is B: The client verbalizes the importance of small, frequent feedings. This is appropriate for a client with ulcerative colitis because small, frequent feedings help reduce gastrointestinal distress and maintain proper nutrition. Clients with ulcerative colitis often have difficulty tolerating large meals, so small, frequent feedings can help prevent exacerbation of symptoms.
A: Recording intake and output is important for certain conditions but not specifically for ulcerative colitis.
C: Using a heating pad may provide temporary relief for abdominal cramping but does not address the underlying issue of ulcerative colitis.
D: Accepting a colostomy is not an expected outcome for ulcerative colitis treatment unless all other options have failed.
A client returns from surgery with a sigmoid colostomy. An ostomy appliance is attached. The priority nursing diagnosis for daily observation and care is:
- A. Diarrhea related to alteration in bowel elimination.
- B. Impaired skin integrity related to seepage.
- C. Impaired nutrition: More than body requirements related to high-fat diet.
- D. Impaired physical mobility related to surgical procedure.
Correct Answer: B
Rationale: The correct answer is B: Impaired skin integrity related to seepage. This is the priority nursing diagnosis because a colostomy appliance can lead to skin breakdown due to seepage of stool, which can cause irritation and skin breakdown. Maintaining skin integrity is crucial to prevent infection and promote healing.
A: Diarrhea is not the priority as it is a common issue after colostomy surgery but can be managed with appropriate interventions.
C: Impaired nutrition is not the priority as it is not specifically related to the immediate care of the colostomy appliance.
D: Impaired physical mobility is not the priority as it is not directly related to the immediate care of the colostomy appliance.
In summary, choice B is the correct answer because maintaining skin integrity is essential for the client's well-being and to prevent complications associated with a colostomy appliance.
The nurse is preparing to discontinue a client's nasogastric tube. The client is positioned properly, and the tube has been flushed with 15 mL of air to clear secretions. Before removing the tube, the nurse makes which statement to the client?
- A. Take a deep breath when I tell you and breathe normally while I remove the tube.
- B. Take a deep breath when I tell you and bear down while I remove the tube.
- C. Take a deep breath when I tell you and slowly exhale while I remove the tube.
- D. Take a deep breath when I tell you and hold it while I remove the tube.
Correct Answer: C
Rationale: The correct answer is C because instructing the client to take a deep breath and slowly exhale while the tube is being removed helps relax the client's throat muscles, making the removal process smoother and less uncomfortable. Taking a deep breath and holding it (choice D) could lead to increased tension and resistance, while bearing down (choice B) may cause the client to push against the tube, making the removal difficult. Instructing the client to breathe normally (choice A) doesn't provide specific guidance on how to facilitate the removal process.
The nurse is caring for a client following a Billroth II procedure. On review of the postoperative orders, which of the following if prescribed, should the nurse question and verify?
- A. Irrigating the nasogastric tube
- B. Coughing and deep breathing exercises
- C. Leg exercises
- D. Early ambulation
Correct Answer: A
Rationale: The correct answer is A: Irrigating the nasogastric tube. After a Billroth II procedure, the client's stomach has been partially removed, making them prone to dumping syndrome. Irrigating the nasogastric tube can disrupt the natural digestive process and may exacerbate dumping syndrome. Instead, the focus should be on promoting slow, gradual feeding to prevent complications.
Summary:
B: Coughing and deep breathing exercises - Important for preventing respiratory complications postoperatively.
C: Leg exercises - Essential for preventing blood clots and promoting circulation.
D: Early ambulation - Encourages mobility and prevents complications such as pneumonia and blood clots.
A nurse is developing a teaching plan for the client with viral hepatitis. The nurse plans to tell the client which of the following in the teaching session?
- A. Activity should be limited to prevent fatigue
- B. The diet should be low in calories
- C. Meals should be large to conserve energy
- D. Alcohol intake should be limited to 2 oz. per day.
Correct Answer: A
Rationale: The correct answer is A. For a client with viral hepatitis, limiting activity helps prevent fatigue and aids in recovery. Excessive activity can worsen symptoms. Choice B is incorrect because a low-calorie diet may not provide enough nutrients for the body to fight the infection. Choice C is incorrect as large meals can strain the liver and worsen symptoms. Choice D is incorrect as any alcohol intake can further damage the liver in viral hepatitis. In summary, choice A is correct as it promotes rest and aids recovery, while the other choices can potentially worsen the condition.