Nokea
A diagnosis of hepatitis C is confirmed by a male client's physician. The nurse should be knowledgeable of the differences between hepatitis A, B, and C. Which of the following are characteristics of hepatitis C?
- A. The potential for chronic liver disease is minimal.
- B. The onset of symptoms is abrupt.
- C. The incubation period is 2-26 weeks.
- D. There is an effective vaccine for hepatitis B, but not for hepatitis C.
Correct Answer: C
Rationale: Hepatitis C has an incubation period of 2-26 weeks. It has a high potential for chronic liver disease, an insidious onset, and no effective vaccine, unlike hepatitis B.
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A client with a history of a stroke is receiving Plavix (clopidogrel). The nurse should monitor the client for:
- A. Bleeding
- B. Hypertension
- C. Hypoglycemia
- D. Fever
Correct Answer: A
Rationale: Clopidogrel, an antiplatelet, increases bleeding risk, requiring monitoring for signs like bruising or epistaxis. Hypertension, hypoglycemia, and fever are not primary concerns.
The patient states, 'My stomach hurts about two hours after I eat.' Based upon this information, the nurse suspects the patient likely has a:
- A. Gastric ulcer
- B. Duodenal ulcer
- C. Peptic ulcer
- D. Curling's ulcer
Correct Answer: B
Rationale: Pain 2–3 hours after eating is characteristic of a duodenal ulcer, as acid irritates the ulcerated mucosa in the duodenum post-digestion. Gastric ulcer pain typically occurs sooner after meals, peptic ulcer is a general term, and Curling’s ulcer is stress-related.
Which of the following instructions should be included in the nurse's teaching regarding oral contraceptives?
- A. Weight gain should be reported to the physician.
- B. An alternate method of birth control is needed when taking antibiotics.
- C. If the client misses one or more pills,two pills should be taken per day for one week.
- D. Changes in the menstrual flow should be reported to the physician.
Correct Answer: B
Rationale: Antibiotics can reduce the effectiveness of oral contraceptives by altering gut flora necessitating an alternate birth control method during antibiotic use. Weight gain and menstrual changes are common and doubling pills is not the correct protocol for missed doses.
A client has been admitted to the nursing unit with the diagnosis of severe anemia. She is slightly short of breath, has episodes of dizziness, and complains her heart sometimes feels like it will 'beat out of her chest.' The physician has ordered her to receive 2 U of packed red blood cells. The most important nursing action to be taken is:
- A. Starting an 18-gauge IV infusion
- B. Having the consent form on the chart
- C. Administering the correct blood product to the correct client
- D. Transfusing the blood in a 2-hour time frame
Correct Answer: C
Rationale: An 18-gauge IV is an appropriate size for administering blood; however, client safety demands that the right blood product must be administered. The consent form is legally necessary to be on the chart, but client safety is maintained by giving the correct blood component to the correct client. Administering the correct blood product to the correct client will maintain physiological safety and minimize transfusion reactions. The blood administration should take place over the ordered time frame designated by the physician.
A client with a history of a kidney transplant is being discharged. The nurse should teach the client to:
- A. Monitor for signs of infection
- B. Eat a high-sodium diet
- C. Limit physical activity
- D. Take antibiotics daily
Correct Answer: A
Rationale: Immunosuppression post-kidney transplant increases infection risk, requiring vigilant monitoring. High-sodium diets, activity limits, and daily antibiotics are not standard.