Nokea
A healthcare professional is educating a group of recent nursing graduates about their risks for contracting hepatitis B. What preventative measure should the professional promote?
- A. Immunization
- B. Chronic tonsillitis
- C. Consumption of a vitamin-rich diet
- D. Annual vitamin K injections
Correct Answer: A
Rationale: The correct answer is A: Immunization. Hepatitis B is a viral infection transmitted through exposure to infected blood or body fluids. Immunization with the hepatitis B vaccine is the most effective preventative measure, providing long-term protection against the virus. Chronic tonsillitis (B) is unrelated to hepatitis B prevention. Consumption of a vitamin-rich diet (C) and annual vitamin K injections (D) do not offer protection against hepatitis B. Immunization is the best choice due to its proven efficacy in preventing hepatitis B transmission.
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After a client with ascites due to liver cirrhosis undergoes a paracentesis, what should the nurse do post-procedure?
- A. Encourage the client to drink plenty of fluids
- B. Monitor the client's blood pressure and heart rate
- C. Position the client flat on their back
- D. Administer a dose of furosemide
Correct Answer: B
Rationale: The correct answer is B: Monitor the client's blood pressure and heart rate. Post-paracentesis, there is a risk of hypotension due to sudden fluid shift. Monitoring BP and HR is crucial to detect and manage any hemodynamic changes promptly. Encouraging fluid intake (choice A) may exacerbate ascites. Positioning flat (choice C) may lead to hypotension. Administering furosemide (choice D) without monitoring vital signs can worsen hypotension.
A client with portal hypertension who has developed ascites is scheduled for a paracentesis. What pre-procedure nursing intervention is essential?
- A. Encourage the client to empty the bladder
- B. Administer a laxative to clear the bowels
- C. Restrict the client's fluid intake
- D. Place the client in a supine position
Correct Answer: A
Rationale: The correct answer is A: Encourage the client to empty the bladder. Before a paracentesis, it's crucial to ensure the bladder is empty to prevent accidental puncture during the procedure. This reduces the risk of injury and complications. Options B and C are incorrect because they are not directly related to the safety of the paracentesis procedure. Option D is incorrect as placing the client in a supine position does not address the need to empty the bladder.
When creating a care plan for a 70-year-old obese client admitted to the postsurgical unit following a colon resection, the client's age and increased body mass index put them at increased risk for which complication in the postoperative period?
- A. Hyperglycemia
- B. Azotemia
- C. Falls
- D. Infection
Correct Answer: D
Rationale: The correct answer is D: Infection. Postoperative obese patients are at higher risk for surgical site infections due to impaired wound healing, decreased tissue oxygenation, and increased tissue pressure. Obesity also compromises the immune system, further increasing susceptibility to infections. Age is a risk factor for infection as well, as older adults may have weakened immune responses. Hyperglycemia (choice A) is a common issue in obese patients but not specifically related to postoperative complications. Azotemia (choice B) refers to elevated levels of nitrogen-containing compounds in the blood and is not directly related to obesity or age. Falls (choice C) are more related to mobility issues and environmental factors, not specifically to age and obesity in the postoperative period.
An older adult with a diagnosis of Alzheimer's disease has been experiencing fecal incontinence, with no recent change in stool character noted by the nurse. What is the nurse's most appropriate intervention?
- A. Keep a food diary to identify foods that worsen the client's symptoms
- B. Provide the client with a bland, low-residue diet
- C. Toilet the client on a frequent, scheduled basis
- D. Collaborate with the primary provider to secure an order for loperamide
Correct Answer: C
Rationale: The correct answer is C: Toilet the client on a frequent, scheduled basis. This intervention is appropriate for managing fecal incontinence in individuals with Alzheimer's disease. By establishing a routine for toileting, the nurse can help the client maintain continence and reduce the risk of accidents. This approach also promotes dignity and independence for the client.
A: Keeping a food diary may be helpful for identifying triggers of fecal incontinence, but it is not the most immediate intervention in this case.
B: Providing a bland, low-residue diet may not directly address the issue of fecal incontinence and may not be necessary if there has been no recent change in stool character.
D: Securing an order for loperamide may be appropriate in some cases, but it is not the first-line intervention for managing fecal incontinence in this scenario.
The nurse is providing an educational workshop about coronary artery disease (CAD) and its risk factors. The nurse explains to participants that CAD has many risk factors, some that can be controlled and some that cannot. What risk factors should the nurse list that can be controlled or modified?
- A. Gender, obesity, family history, and smoking
- B. Inactivity, stress, gender, and smoking
- C. Cholesterol levels, hypertension, and smoking
- D. Stress, family history, and obesity
Correct Answer: C
Rationale: The correct answer is C because cholesterol levels, hypertension, and smoking are modifiable risk factors for CAD. High cholesterol levels can be controlled through diet and medication. Hypertension can be managed through lifestyle changes and medication. Smoking is a behavior that can be modified.
A is incorrect because gender and family history are non-modifiable risk factors. Obesity can be controlled but is not listed in the correct answer.
B is incorrect because inactivity and stress are modifiable risk factors, but gender is not modifiable.
D is incorrect because stress and family history are non-modifiable risk factors, and obesity is not listed in the correct answer.