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A healthcare professional is participating in the emergency care of a client who has just developed variceal bleeding. What intervention should the healthcare professional anticipate?
- A. Infusion of intravenous heparin
- B. IV administration of albumin
- C. STAT administration of vitamin K by the intramuscular route
- D. IV administration of octreotide
Correct Answer: D
Rationale: The correct answer is D: IV administration of octreotide. Octreotide is indicated for variceal bleeding as it reduces portal venous pressure, decreases blood flow to varices, and inhibits release of vasoactive substances. It helps control bleeding and stabilize the patient. Heparin (A) is not indicated for variceal bleeding. Albumin (B) may be used for volume resuscitation but does not address the bleeding. Vitamin K (C) is used for coagulation disorders, not variceal bleeding.
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A client with a history of deep vein thrombosis (DVT) is receiving warfarin (Coumadin). Which laboratory value indicates a therapeutic effect of the medication?
- A. INR of 2.5.
- B. PTT of 45 seconds.
- C. Hemoglobin of 12 g/dL.
- D. Platelet count of 150,000/mm³.
Correct Answer: A
Rationale: The correct answer is A: INR of 2.5. INR (International Normalized Ratio) is used to monitor the effectiveness of warfarin therapy. A target INR range for DVT treatment is typically 2.0-3.0. An INR of 2.5 indicates that the client's blood is clotting within the desired therapeutic range, preventing excessive clotting while avoiding excessive bleeding.
B: PTT measures the effectiveness of heparin, not warfarin.
C: Hemoglobin level and D: Platelet count are not specific indicators of warfarin's therapeutic effect on clotting factors.
In summary, the correct answer A is the most relevant laboratory value for monitoring the therapeutic effect of warfarin in a client with DVT.
A client admitted with acute diverticulitis has experienced a sudden increase in temperature and reports a sudden onset of exquisite abdominal tenderness. The nurse's rapid assessment reveals that the client's abdomen is uncharacteristically rigid on palpation. What is the nurse's best response?
- A. Administer a Fleet enema as prescribed and remain with the client
- B. Contact the primary care provider promptly and report these signs of perforation
- C. Position the client supine and insert an NG tube
- D. Page the primary provider and report that the client may be obstructed
Correct Answer: B
Rationale: The correct answer is B: Contact the primary care provider promptly and report these signs of perforation.
Rationale:
1. Sudden increase in temperature, sudden onset of exquisite abdominal tenderness, and uncharacteristically rigid abdomen are signs of perforation in diverticulitis.
2. Promptly contacting the primary care provider allows for immediate evaluation and intervention.
3. Perforation is a serious complication that requires urgent medical attention to prevent further complications like sepsis.
Summary of other choices:
A: Administering a Fleet enema is not appropriate and can worsen the condition of a perforated diverticulum.
C: Inserting an NG tube is not indicated for a perforated diverticulum and may exacerbate the situation.
D: Reporting the client may be obstructed is not accurate based on the signs presented and does not address the urgency of perforation.
A client has developed hepatic encephalopathy secondary to cirrhosis and is receiving care on the medical unit. The client's current medication regimen includes lactulose four times daily. What desired outcome should the nurse relate to this pharmacologic intervention?
- A. Two to three soft bowel movements daily
- B. Significant increase in appetite and food intake
- C. Absence of nausea and vomiting
- D. Absence of blood or mucus in stool
Correct Answer: A
Rationale: The correct answer is A: Two to three soft bowel movements daily. Lactulose is a laxative commonly used to manage hepatic encephalopathy by reducing ammonia levels through promoting bowel movements. The desired outcome of this medication is to prevent the buildup of ammonia in the bloodstream, which can exacerbate hepatic encephalopathy. Soft bowel movements indicate that the medication is effectively promoting bowel motility and reducing ammonia levels. Choices B, C, and D are incorrect as lactulose is not directly associated with increasing appetite, resolving nausea and vomiting, or eliminating blood or mucus in the stool in this context.
The preceptor is orienting a new graduate nurse to the critical care unit. The preceptor asks the new graduate to state symptoms that most likely indicate the beginning of a shock state in a critically ill client. What findings should the new graduate nurse identify?
- A. Warm skin, hypertension, and constricted pupils.
- B. Bradycardia, hypotension, and respiratory acidosis.
- C. Mottled skin, tachypnea, and hyperactive bowel sounds.
- D. Tachycardia, mental status change, and low urine output.
Correct Answer: D
Rationale: The correct answer is D: Tachycardia, mental status change, and low urine output. In the early stages of shock, the body compensates by increasing heart rate (tachycardia) to maintain perfusion. Mental status change can indicate decreased cerebral perfusion. Low urine output is a sign of decreased renal perfusion.
A: Warm skin, hypertension, and constricted pupils are not indicative of shock. In shock, skin becomes cool and clammy, blood pressure drops, and pupils dilate.
B: Bradycardia, hypotension, and respiratory acidosis are not early signs of shock. Bradycardia and hypotension occur in the late stages of shock. Respiratory acidosis is a complication of shock, not an early symptom.
C: Mottled skin, tachypnea, and hyperactive bowel sounds are signs of shock but not early indicators. Mottled skin appears in the late stages of shock, tach
A healthcare provider is providing dietary teaching to a client with cholecystitis. Which type of diet should the healthcare provider recommend?
- A. High-fiber, low-fat diet
- B. Low-fiber, high-protein diet
- C. Low-fat, low-cholesterol diet
- D. High-protein, high-fat diet
Correct Answer: C
Rationale: The correct answer is C: Low-fat, low-cholesterol diet. For cholecystitis, which is inflammation of the gallbladder, a low-fat, low-cholesterol diet is essential to prevent exacerbation of symptoms. High-fat diets can trigger gallbladder attacks, while low-fat and low-cholesterol diets help reduce the workload on the gallbladder. High-fiber (choice A) may be too harsh on the digestive system. Low-fiber, high-protein (choice B) and high-protein, high-fat (choice D) diets can exacerbate symptoms due to the high-fat content.