Nokea
A client with a history of cirrhosis is admitted with hepatic encephalopathy. The nurse should include which of the following in the plan of care?
- A. Administer lactulose as prescribed.
- B. Encourage a high-protein diet.
- C. Restrict fluid intake.
- D. Administer sedatives for agitation.
Correct Answer: A
Rationale: Lactulose reduces ammonia levels in hepatic encephalopathy.
You may also like to solve these questions
The nurse is caring for a child with sickle cell anemia who is experiencing a vaso-occlusive crisis. Which of the following interventions is the priority?
- A. Administer oxygen.
- B. Provide hydration.
- C. Apply warm compresses.
- D. Administer analgesics.
Correct Answer: B
Rationale: Hydration is the priority in vaso-occlusive crisis to reduce blood viscosity and promote circulation, preventing further sickling and complications.
The nurse is preparing to insert a urinary catheter. Which action ensures sterile technique?
- A. Cleanse the meatus with an alcohol swab
- B. Use clean gloves during insertion
- C. Apply sterile lubricant to the catheter tip
- D. Insert the catheter without a drape
Correct Answer: C
Rationale: Applying sterile lubricant to the catheter tip maintains sterile technique, reducing the risk of infection during urinary catheter insertion.
You are having a nice dinner in a fancy restaurant. As you are eating, you hear the gentleman eating at the next table start to bang the table, hold his throat and forcibly cough. What should you do?
- A. Perform the Valsalva maneuver
- B. Encourage the person to continue coughing
- C. Perform the Heimlich maneuver
- D. Begin CPR and prepare for ACLS measures
Correct Answer: B
Rationale: Forcing coughing suggests a partial airway obstruction. Encouraging the person to continue coughing is the first step to dislodge the obstruction without invasive intervention.
A client with a history of chronic lymphocytic leukemia is prescribed rituximab (Rituxan). The nurse should monitor the client for which of the following side effects during infusion?
- A. Hypotension.
- B. Hyperglycemia.
- C. Infusion reactions.
- D. Weight loss.
Correct Answer: C
Rationale: Rituximab can cause infusion reactions, such as fever or chills, requiring close monitoring during administration.
Select the arterial blood gas that you would report to the client's physician because it is not within normal parameters and it is also a significant change for the client.
- A. PaO2: 65 mm Hg
- B. PaCO2: 40 mm Hg
- C. Arterial blood pH: 7.39
- D. SaO2: 96%
Correct Answer: A
Rationale: PaO2 of 65 mm Hg is below the normal range (75-100 mm Hg), indicating hypoxemia, which requires reporting.