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A nurse assesses a client who is recovering from a paracentesis 1 hour ago. Which assessment finding requires action by the nurse?
- A. Urine output via indwelling urinary catheter is 20 mL/hr.
- B. Blood pressure increases from 120/80 mm Hg to 140/90 mm Hg.
- C. Respiratory rate decreases from 18 to 14 breaths/min.
- D. A decrease in the clients weight by 6 kg
Correct Answer: A
Rationale: Rapid removal of ascitic fluid causes decreased abdominal pressure, which can contribute to hypovolemia. This can be manifested by a decrease in urine output to below 30 mL/hr. A slight increase in systolic blood pressure is insignificant. A decrease in respiratory rate indicates that breathing has been made easier by the procedure. The nurse would expect the clients weight to drop as fluid is removed. Six kilograms is less than 3 pounds and is expected.
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A nurse teaches a client with hepatitis C who is prescribed ribavirin (Copegus). Which statement should the nurse include in this client's discharge education?
- A. Use a pill organizer to ensure you take this medication as prescribed.
- B. Transient muscle aching is a common side effect of this medication.
- C. Follow up with your provider in 1 week to test your blood for toxicity.
- D. Take your radial pulse for 1 minute prior to taking this medication.
Correct Answer: A
Rationale: Treatment of hepatitis C with ribavirin takes up to 48 weeks, making compliance a serious issue. The nurse should work with the client on a strategy to remain compliant for this length of time. Muscle aching is not a common side effect. The client will be on this medication for many weeks and does not need a blood toxicity examination. There is no need for the client to assess his or her radial pulse prior to taking the medication.
An emergency room nurse assesses a client after a motor vehicle crash. The nurse notices a steering wheel imprint across the client's chest. Which action should the nurse take?
- A. Ask the client where he or she was sitting during the crash.
- B. Assess the client by gently palpating the abdomen for tenderness.
- C. Notify the laboratory to draw blood for blood type and crossmatch.
- D. Develop a handwashing plan to prevent infection.
Correct Answer: B
Rationale: The liver is often injured by a steering wheel in a motor vehicle crash. Because the client's chest was marked by the steering wheel, the nurse should perform an abdominal assessment. Assessing the client's position in the crash is not needed because of the steering wheel imprint. The client may or may not need a blood transfusion. A handwashing plan is not relevant to this situation.
A nurse obtains a clients health history at a community health clinic. Which statement alerts the nurse to a possible health threat to the client?
- A. I drink two glasses of red wine each week.
- B. I take a lot of Tylenol for my arthritis pain.
- C. I have a cousin who died of liver cancer.
- D. I got a hepatitis vaccine before traveling.
Correct Answer: B
Rationale: Acetaminophen (Tylenol) can cause liver damage if taken in large amounts. Clients should be taught not to exceed 4000 mg/day of acetaminophen. The nurse should teach the client about this limitation and should explain other drug options with the client to manage his or her arthritis pain. Two glasses of wine each week, a cousin with liver cancer, and the hepatitis vaccine do not place the client at risk for a liver disorder, and therefore do not require any health teaching.
After teaching a client who has been diagnosed with hepatitis A, the nurse assesses the client's understanding. Which statement by the client indicates a correct understanding of the teaching?
- A. Some medications have been known to cause hepatitis A.
- B. I may have been exposed when we ate shrimp last weekend.
- C. I was infected with hepatitis A through a recent blood transfusion.
- D. My infection with Epstein-Barr virus can co-infect me with hepatitis A.
Correct Answer: B
Rationale: The route of acquisition of hepatitis A infection is through close personal contact or ingestion of contaminated water or shellfish. Hepatitis A is not transmitted through medications. Hepatitis B can be spread through blood transfusions. Epstein-Barr virus causes a secondary infection, not a co-infection with hepatitis A.
A telehealth nurse speaks with a client who is recovering from a liver transplant 2 weeks ago. The client states, 'I am experiencing right flank pain and have a temperature of 101 F.' How should the nurse respond?
- A. Report the client's symptoms to the responsible health care provider.
- B. You should go to the hospital immediately to have your new liver checked out.
- C. You should take an additional dose of cyclosporine today.
- D. Take acetaminophen (Tylenol) every 4 hours until you feel better.
Correct Answer: B
Rationale: Fever, right quadrant or flank pain, and jaundice are signs of liver transplant rejection; the client should be admitted to the hospital as soon as possible for intervention. Anti-rejection drugs do make a client more susceptible to infection, but this client has signs of rejection, not infection. The nurse should not advise the client to take an additional dose of cyclosporine or acetaminophen as these medications will not treat the acute rejection.