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A nurse cares for a client who is scheduled for a paracentesis. Which intervention should the nurse delegate to an unlicensed assistive personnel (UAP)?
- A. Have the client sign the informed consent form.
- B. Help the client void just before the procedure.
- C. Help the client lie flat in bed on the right side.
- D. Get the client into a chair after the procedure.
Correct Answer: B
Rationale: For safety, the client should void just before a paracentesis. The nurse or the provider should have the client sign the consent form. The proper position for a paracentesis is sitting upright in bed or, alternatively, sitting on the edge of the bed or leaning over a bedside table. The client will be on bed rest after the procedure.
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A nurse cares for a client who has cirrhosis of the liver. Which action should the nurse take to decrease the presence of ascites?
- A. Monitor intake and output.
- B. Monitor vital signs and diet.
- C. Increase oral fluid intake.
- D. Weigh the client daily.
Correct Answer: B
Rationale: A low-sodium diet is one means of controlling abdominal fluid collection. Monitoring intake and output does not control fluid accumulation, nor does weighing the client. These interventions merely assess or monitor the situation. Increasing fluid intake would not be helpful.
A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for the development of carcinoma of the liver?
- A. A 25-year-old with a history of blunt liver trauma
- B. A 48-year-old with a history of diabetes mellitus
- C. A 30-year-old who has a history of cirrhosis
- D. An 82-year-old who has chronic malnutrition
Correct Answer: C
Rationale: The risk of contracting a primary carcinoma of the liver is higher in clients with cirrhosis from any cause. Blunt liver trauma, diabetes mellitus, and chronic malnutrition do not increase a person's risk for developing liver cancer.
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.
A nurse cares for a client who is prescribed lactulose (Heptalac). The client states, 'I do not want to take this medication because it causes diarrhea.' How should the nurse respond?
- A. Diarrhea is expected; that's how your body gets rid of ammonia.
- B. You may take Kaopectate liquid daily for loose stools.
- C. Do not take any more of the medication until your stools firm up.
- D. We will need to send a stool specimen to the laboratory.
Correct Answer: A
Rationale: The purpose of administering lactulose to this client is to help ammonia leave the circulatory system through the colon. Lactulose draws water into the bowel with its high osmotic gradient, thereby producing a laxative effect and subsequently evacuating ammonia from the bowel. The client must understand that this is an expected therapeutic effect for him or her to remain compliant. The nurse should not suggest administering anything that would decrease the excretion of ammonia or holding the medication. There is no need to send a stool specimen to the laboratory because diarrhea is the therapeutic response to this medication.
A nurse cares for a client with hepatopulmonary syndrome who is experiencing dyspnea with oxygen saturations at 92%. The client states, 'I do not want to wear the oxygen because it causes my nose to bleed. Get out of my room and leave me alone!' Which action should the nurse take?
- A. Ensure the client is in as upright a position as possible.
- B. Add humidity to the oxygen and encourage the client to wear it.
- C. Document the client's refusal, and call the health care provider.
- D. Contact the provider to request an extra dose of the client's diuretic.
Correct Answer: A
Rationale: The client with hepatopulmonary syndrome is often dyspneic. Because the oxygen saturation is not significantly low, the nurse should first allow the client to sit upright to see if that helps. If the client remains dyspneic, or if the oxygen saturation drops further, the nurse should investigate adding humidity to the oxygen and using a face mask to deliver the oxygen. The other two options may be beneficial, but they are not the best choices. If the client is comfortable, his or her agitation will decrease; this will improve respiratory status.