Nokea
A client with cirrhosis is at risk for bleeding. Which laboratory test is most important to monitor?
- A. Blood glucose
- B. Serum creatinine
- C. Prothrombin time (PT)
- D. Electrolytes
Correct Answer: C
Rationale: The correct answer is C: Prothrombin time (PT). In cirrhosis, the liver's ability to produce clotting factors is impaired, leading to a higher risk of bleeding. Monitoring PT helps assess the liver's synthetic function and the blood's ability to clot. Abnormal PT values indicate a higher bleeding risk and guide interventions like vitamin K or blood products. Blood glucose (A), serum creatinine (B), and electrolytes (D) do not directly reflect the liver's synthetic function or clotting status in cirrhosis, making them less relevant for monitoring bleeding risk.
You may also like to solve these questions
The community mental health nurse is planning to visit four clients with schizophrenia today. Which client should the nurse see first?
- A. The mother who took her children from school because aliens were after them.
- B. The young man who has a history of substance abuse and no telephone.
- C. The newly diagnosed client who needs to be evaluated for medication compliance.
- D. The young woman who believes she is to blame for her recent miscarriage.
Correct Answer: A
Rationale: The correct answer is A: The mother who took her children from school because aliens were after them should be seen first. This choice indicates potential harm to the children due to the mother's delusions, posing an immediate safety concern. The nurse needs to assess the situation and ensure the children's safety. Choices B, C, and D do not present immediate safety risks. B is a history of substance abuse but no current immediate danger. C is newly diagnosed and can wait for evaluation, as can D who may need support but is not in immediate danger. Prioritizing safety is crucial in mental health nursing.
A client with acute pancreatitis is experiencing severe abdominal pain. Which enzyme level should the nurse monitor closely?
- A. Serum amylase.
- B. Serum sodium.
- C. Serum calcium.
- D. Serum potassium.
Correct Answer: A
Rationale: The correct answer is A: Serum amylase. In acute pancreatitis, damaged pancreatic cells release amylase into the bloodstream, causing elevated serum amylase levels. Monitoring serum amylase helps in diagnosing and assessing the severity of pancreatitis.
Incorrect choices:
B: Serum sodium - Serum sodium levels are typically not directly affected by pancreatitis.
C: Serum calcium - While hypocalcemia can occur in severe pancreatitis, monitoring serum calcium is not as specific for pancreatitis diagnosis or severity assessment as serum amylase.
D: Serum potassium - Potassium levels may be affected in pancreatitis due to vomiting or dehydration, but monitoring serum potassium is not as specific to pancreatitis as serum amylase.
A client with liver cirrhosis is being educated about managing their condition. Which statement by the client indicates a need for further teaching?
- A. I will avoid drinking alcohol
- B. I need to limit my salt intake
- C. I can take acetaminophen for pain
- D. I should eat a balanced diet
Correct Answer: C
Rationale: The correct answer is C: "I can take acetaminophen for pain." Acetaminophen can be harmful to the liver, especially in individuals with liver cirrhosis. The liver is responsible for metabolizing acetaminophen, and in cirrhosis, its function is impaired, leading to potential toxicity. Choice A is correct as alcohol can worsen liver damage. Choice B is correct as excess salt can lead to fluid retention and complications. Choice D is correct as a balanced diet is important for overall health. Therefore, the statement about taking acetaminophen indicates a need for further teaching.
What instructions should the nurse give to a patient with cervical cancer who is planned to receive external-beam radiation to prevent complications from the effects of the radiation?
- A. Test all stools for the presence of blood.
- B. Maintain a high-residue, high-fiber diet.
- C. Clean the perianal area carefully after every bowel movement.
- D. Inspect the mouth and throat daily for the appearance of thrush.
Correct Answer: C
Rationale: The correct answer is C: Clean the perianal area carefully after every bowel movement. This is important to prevent skin breakdown and infection due to the potential side effect of radiation-induced diarrhea. By maintaining good hygiene in the perianal area, the patient can reduce the risk of complications such as skin irritation and infection.
Choice A is incorrect because testing stools for the presence of blood is not directly related to preventing complications from external-beam radiation.
Choice B is incorrect because while a high-residue, high-fiber diet may be beneficial for some cancer patients, it is not specifically recommended to prevent complications from radiation therapy in this case.
Choice D is incorrect because inspecting the mouth and throat daily for thrush is more relevant for patients receiving chemotherapy or immunosuppressive therapy, not specifically for those undergoing external-beam radiation.
Prior to elective surgery, a patient taking warfarin should receive which instruction regarding warfarin therapy?
- A. Continue taking warfarin until the day of surgery.
- B. Stop taking warfarin three days before surgery.
- C. Switch to aspirin before surgery.
- D. Stop taking warfarin one week before surgery.
Correct Answer: D
Rationale: The correct answer is D because stopping warfarin one week before surgery reduces the risk of excessive bleeding during the procedure. Warfarin's anticoagulant effect can persist for several days, so stopping it earlier allows time for its effects to diminish. Choice A is incorrect because continuing warfarin until the day of surgery increases bleeding risk. Choice B is incorrect as stopping warfarin only three days before surgery may not provide enough time for the anticoagulant effect to wear off. Choice C is incorrect as aspirin is not a suitable substitute for warfarin in most cases.