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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.
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A client with a new diagnosis of diabetes mellitus is learning to self-administer insulin. Which instruction should the nurse include?
- A. Store the insulin in the freezer.
- B. Administer the insulin at the same site each time.
- C. Rotate injection sites within the same region.
- D. Shake the vial vigorously before drawing up the insulin.
Correct Answer: C
Rationale: The correct answer is C: Rotate injection sites within the same region. This is important to prevent lipohypertrophy and ensure proper insulin absorption. Administering insulin at the same site each time (B) can lead to tissue damage. Storing insulin in the freezer (A) can alter its effectiveness. Shaking the vial vigorously (D) can cause air bubbles and affect insulin dosage accuracy. Rotation of injection sites within the same region is crucial for consistent absorption and preventing complications.
A client with liver cirrhosis is prescribed lactulose. What is the purpose of this medication?
- A. To lower blood sugar levels
- B. To reduce ammonia levels
- C. To treat liver inflammation
- D. To improve bile flow
Correct Answer: B
Rationale: Rationale: Lactulose is prescribed for liver cirrhosis to reduce ammonia levels. It works by promoting the excretion of ammonia in the stool, preventing its accumulation in the bloodstream. This helps prevent hepatic encephalopathy, a serious complication of cirrhosis. Other choices are incorrect because lactulose does not directly affect blood sugar levels, liver inflammation, or bile flow in the context of liver cirrhosis.
A patient with severe anemia is prescribed erythropoietin. What is the primary action of this medication?
- A. Stimulate white blood cell production
- B. Increase platelet count
- C. Promote red blood cell production
- D. Enhance clotting factor production
Correct Answer: C
Rationale: The correct answer is C: Promote red blood cell production. Erythropoietin is a hormone that stimulates the bone marrow to produce more red blood cells, helping to treat anemia. It does not stimulate white blood cell production (A), increase platelet count (B), or enhance clotting factor production (D). White blood cells are involved in the immune response, platelets are responsible for clotting, and clotting factors are proteins involved in the blood clotting process. Therefore, the primary action of erythropoietin is to specifically target red blood cell production to address anemia.
What skin care instructions should the nurse give to a patient receiving external beam radiation therapy for cancer treatment?
- A. Use a heating pad to relieve any pain in the treated area.
- B. Apply alcohol-based lotions to the treated area daily.
- C. Avoid exposing the treated area to sunlight.
- D. Wash the treated area with hot water and strong soap.
Correct Answer: C
Rationale: The correct answer is C: Avoid exposing the treated area to sunlight. This is important because radiation therapy can make the skin more sensitive to sunlight, leading to increased risk of sunburn and skin damage. Sun exposure can worsen skin reactions and delay healing. Choice A is incorrect because heat sources like heating pads can exacerbate skin irritation. Choice B is incorrect as alcohol-based lotions can further irritate the skin. Choice D is incorrect as hot water and strong soap can be too harsh on the sensitive skin. Overall, protecting the treated area from sunlight is crucial for optimal skin care during radiation therapy.
A patient with deep vein thrombosis (DVT) is prescribed warfarin. Which dietary instruction should the nurse provide?
- A. Avoid foods high in vitamin K.
- B. Increase intake of dairy products.
- C. Limit intake of citrus fruits.
- D. Avoid high-sodium foods.
Correct Answer: A
Rationale: The correct answer is A: Avoid foods high in vitamin K. Warfarin is a vitamin K antagonist, so consuming high-vitamin K foods can counteract its effects. By avoiding such foods, the medication can work effectively in preventing further blood clot formation. Choice B is incorrect because dairy products do not directly interact with warfarin. Choice C is incorrect as citrus fruits do not have a significant impact on warfarin therapy. Choice D is incorrect as sodium intake is not directly related to the action of warfarin.