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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.
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A nurse cares for a client who is hemorrhaging from bleeding esophageal varices and has an esophagogastric tube. Which action should the nurse take first?
- A. Sedate the client to prevent tube dislodgement.
- B. Maintain balloon pressure at 15 to 25 mm Hg.
- C. Irrigate the gastric lumen with normal saline.
- D. Assist the client for airway patency.
Correct Answer: D
Rationale: Maintaining airway patency is the primary nursing intervention for this client. The nurse suctions oral secretions to prevent aspiration. The client should be sedated, and balloon pressure should be maintained between 15 and 25 mm Hg. Irrigation with saline may be performed, but these actions are not a higher priority than airway patency.
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.
An infection control nurse develops a plan to decrease the number of health care professionals who contract viral hepatitis at work. Which ideas should the nurse include in this plan? (Select all that apply.)
- A. Policies related to consistent use of Standard Precautions
- B. Hepatitis vaccination mandate for workers in high-risk areas
- C. Implementation of a needleless system for intravenous therapy
- D. Hepatitis B immunity in clients at risk for hepatitis B
- E. Postexposure prophylaxis provided in a timely manner
Correct Answer: A,C,D,E
Rationale: Nurses should always use Standard Precautions for client care, and policies should reflect this. Needleless systems and reduction of sharps can help prevent hepatitis. Postexposure prophylaxis should be provided in a timely manner. Hepatitis B immunity in clients does not protect healthcare workers, but ensuring worker immunity through vaccination is critical.
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.
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.