Nokea
A client with primary sclerosing cholangitis has received a liver transplant. The nurse should give priority to assessing the client for complications. Which findings are associated with an acute rejection of the new liver?
- A. Increased jaundice and prolonged prothrombin time
- B. Fever and foul-smelling bile drainage
- C. Abdominal distention and clay-colored stools
- D. Increased uric acid and increased creatinine
Correct Answer: A
Rationale: Increased jaundice and prolonged prothrombin time indicate liver dysfunction, consistent with acute liver transplant rejection.
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While terminating the therapeutic nurse-client relationship, which action should be avoided?
- A. raise a new issue with the client
- B. review accomplishments of the relationship
- C. refer the client to a community support group
- D. allow the client to express his feelings about ending the relationship
Correct Answer: A
Rationale: Raising a new issue at termination can disrupt closure and hinder the client’s ability to process the end of the relationship.
The nurse is caring for an adolescent with a 5-year history of bulimia. A common clinical finding in the client with bulimia is:
- A. Extreme weight loss
- B. Dental caries
- C. Hair loss
- D. Decreased temperature
Correct Answer: B
Rationale: Dental caries are common in bulimia due to frequent vomiting, which exposes teeth to stomach acid, causing enamel erosion.
The nurse must administer in one syringe a combined dose of two different insulins from two vials. Place the steps (Roman numerals) in the correct order.
- A. Cleanse tops of vials.
- B. Inject air into vial 1.
- C. Withdraw medication from vial 1.
- D. Change needles.
- E. Withdraw medication from vial 2.
- F. Inject air into vial 2.
Correct Answer: A,B,F,C,E
Rationale: The correct order is: Cleanse vials (I), inject air into vial 1 (II), inject air into vial 2 (VI), withdraw from vial 1 (III), withdraw from vial 2 (V). Changing needles (IV) is not standard.
The client is having electroconvulsive therapy for treatment of severe depression. Prior to the ECT the nurse should:
- A. Apply a tourniquet to the client's arm.
- B. Administer an anticonvulsant medication.
- C. Ask the client if he is allergic to shell fish.
- D. Apply a blood pressure cuff to the arm.
Correct Answer: D
Rationale: Applying a blood pressure cuff allows monitoring of vital signs during ECT, which is a standard safety measure.
A client with a deep decubitus ulcer is receiving therapy in the hyperbaric oxygen chamber. Before therapy, the nurse should:
- A. Apply a lanolin-based lotion to the skin
- B. Wash the skin with water and pat dry
- C. Cover the area with a petroleum gauze
- D. Apply an occlusive dressing to the site
Correct Answer: B
Rationale: Washing the skin with water and patting dry ensures cleanliness and prevents irritation during hyperbaric oxygen therapy.