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A nurse assesses a client who is prescribed an infusion of vasopressin (Pitressin) for bleeding esophageal varices. Which clinical manifestation should the nurse recognize as a potential complication?
- A. Nausea and vomiting
- B. Dizziness and syncope
- C. Fever and chills
- D. Mid-sternal chest pain
Correct Answer: D
Rationale: Mid-sternal chest pain is indicative of acute angina or myocardial infarction, which can be precipitated by vasopressin. Nausea, vomiting, dizziness, syncope, fever, and chills are not typical side effects of vasopressin.
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A nurse cares for a client with hepatitis C. The client's brother states, 'I do not want to contract this infection, so I will not go into his room.' How should the nurse respond?
- A. If you wear a gown and gloves, you will not get this virus.
- B. Hepatitis C is not spread through casual contact.
- C. This virus is only transmitted through a fecal specimen.
- D. I can give you an update on your brother's status from here.
Correct Answer: B
Rationale: Although family members may be afraid that they will contract hepatitis C, the nurse should educate the client's family about how the virus is spread. Hepatitis C is spread via blood-to-blood transmission and is associated with illicit IV drug use, needle sharing, blood and organ transplantation, accidental needle sticks, unsanitary tattoo equipment, and sharing of intranasal cocaine paraphernalia. Wearing a gown and gloves will not decrease the transmission of this virus. Hepatitis C is not spread through casual contact or a fecal specimen. Sharing the client's status without consent would violate privacy.
After teaching a client who has plans to travel to a non-industrialized country, the nurse assesses the client's understanding regarding the prevention of viral hepatitis. Which statement made by the client indicates a need for further teaching?
- A. I should drink bottled water during my travels.
- B. I will not eat off others' plates or share utensils.
- C. I should eat plenty of fresh fruits and vegetables.
- D. I will wash my hands frequently and thoroughly.
Correct Answer: C
Rationale: The client should be advised to avoid fresh, raw fruits and vegetables because they can be contaminated by tap water. Drinking bottled water, not sharing plates, glasses, or eating utensils, and frequent handwashing are good ways to prevent illness.
A nurse assesses clients at a community health fair. Which client is at greatest risk for the development of hepatitis B?
- A. A 20-year-old college student who has had several sexual partners
- B. A 46-year-old woman who takes acetaminophen daily for headaches
- C. A 63-year-old businessman who travels frequently across the country
- D. An 18-year-old woman who recently ate raw shellfish for dinner
Correct Answer: A
Rationale: Hepatitis B can be spread through sexual contact, needle sharing, needle sticks, blood transfusions, hemodialysis, acupuncture, and the maternal-fetal route. A person with multiple sexual partners has more opportunities to contract the infection. Hepatitis B is not transmitted through medications, casual contact with other travelers, or raw shellfish. Although an overdose of acetaminophen can cause liver cirrhosis, this is not associated with hepatitis B. Hepatitis A is spread through ingestion of contaminated shellfish.
A nurse delegates hygiene care for a client who has advanced cirrhosis to an unlicensed nursing personnel (UAP). Which statements should the nurse include when delegating this task to the UAP? (Select all that apply.)
- A. Apply lotion to the client's dry skin areas.
- B. Use a basin with warm water to bathe the client.
- C. For oral care, use a soft toothbrush.
- D. Provide supplemental warm water for gargles.
- E. Bathe with antibacterial and water-based soaps.
Correct Answer: A,C,D
Rationale: Clients with advanced cirrhosis often have pruritus. Lotion will help decrease itchiness from dry skin. A soft toothbrush should be used to prevent gum bleeding, and the client's nails should be trimmed short to prevent scratching. Clients should use cool, not warm, water on their skin and should not use excessive amounts of soap.
After teaching a client who has alcohol-induced cirrhosis, a nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching?
- A. I cannot drink any alcohol at all anymore.
- B. I need to avoid protein in my diet.
- C. I should not take over-the-counter medications.
- D. I should not take any prescription medications.
Correct Answer: B
Rationale: Based on the degree of liver involvement and decreased function, protein intake may have to be decreased. However, some protein is necessary for the synthesis of albumin and normal healing. The other statements indicate accurate understanding of self-care measures for this client.