Nokea
A nurse is admitting a client who was prescribed antibiotic therapy and now has a Clostridium difficile infection. Which of the following actions should the nurse take?
- A. Disinfect equipment in the client's room daily.
- B. Place the client in a protective environment.
- C. Use alcohol hand sanitizer after completing tasks for the client.
- D. Have the client wear a mask when out of the room.
Correct Answer: A
Rationale: The correct answer is A: Disinfect equipment in the client's room daily. This is important for preventing the spread of Clostridium difficile, a highly contagious bacterium causing severe diarrhea. Disinfecting equipment helps eliminate the bacteria from the environment, reducing the risk of transmission to other individuals.
Summary of other choices:
B: Placing the client in a protective environment is unnecessary and not recommended for Clostridium difficile infection.
C: While using alcohol hand sanitizer is important for hand hygiene, disinfecting equipment is more crucial in this case.
D: Having the client wear a mask is not necessary for preventing the transmission of Clostridium difficile.
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The patient with liver failure has had a liver transplant. What should the nurse teach the patient about care after the transplant?
- A. Alcohol intake is now okay.
- B. HBIG will be required to prevent rejection.
- C. Elevate the head 30 degrees to improve ventilation when sleeping.
- D. Monitor closely for infection because of the immunosuppressive medication.
Correct Answer: D
Rationale: The correct answer is D because patients who undergo liver transplant are put on immunosuppressive medication to prevent rejection. This medication weakens the immune system, making the patient more susceptible to infections. Monitoring closely for signs of infection is crucial to prevent complications.
Choice A is incorrect because alcohol intake is not recommended after a liver transplant as it can further damage the new liver. Choice B is incorrect because HBIG (Hepatitis B Immunoglobulin) is typically given to prevent hepatitis B recurrence, not rejection. Choice C is incorrect as elevating the head has no direct correlation with post-liver transplant care.
A tumor producing large amounts of gastrin DOES NOT include:
- A. Hyperplasia of gastric epithelium
- B. Hyperplasia of gastric mucosal lymphocytes
- C. Excessive gastric acid secretion
- D. Histamine secretion in the gastric mucosa
Correct Answer: B
Rationale: The correct answer is B: Hyperplasia of gastric mucosal lymphocytes. In a tumor producing large amounts of gastrin, hyperplasia of gastric epithelium (choice A) is expected due to increased gastrin stimulation. Excessive gastric acid secretion (choice C) is also expected as gastrin stimulates acid production. Histamine secretion in the gastric mucosa (choice D) can occur as histamine is released in response to gastrin. However, hyperplasia of gastric mucosal lymphocytes (choice B) is not a direct consequence of increased gastrin levels. Lymphocyte hyperplasia is more commonly associated with chronic inflammation or infection rather than gastrin overproduction.
The muscles of the esophagus squeeze the food downward using the process of:
- A. gravity
- B. peristalsis
- C. rugae
- D. chyme
Correct Answer: B
Rationale: The correct answer is B: peristalsis. Peristalsis is the coordinated, rhythmic muscle contractions that propel food through the esophagus and digestive tract. This process helps move food downward towards the stomach. Gravity (choice A) is not the primary mechanism for moving food through the esophagus. Rugae (choice C) refers to folds in the stomach lining, not muscle action in the esophagus. Chyme (choice D) is the partially digested food mixed with stomach acids and enzymes, not a process of moving food down the esophagus. Therefore, peristalsis is the correct answer as it accurately describes the muscle action involved in pushing food downward through the esophagus.
What role do the teeth play in digestion?
- A. chemical digestion
- B. mechanical digestion
- C. enzymatic digestion
- D. absorption
Correct Answer: B
Rationale: The correct answer is B: mechanical digestion. Teeth play a crucial role in breaking down food into smaller pieces through physical chewing, which is a form of mechanical digestion. This process increases the surface area of food particles, making it easier for enzymes to further break down nutrients during chemical digestion in the stomach and intestines. Choice A (chemical digestion) is incorrect because teeth do not directly participate in chemical breakdown of food. Choice C (enzymatic digestion) is incorrect as enzymes are not produced by teeth but by salivary glands and other digestive organs. Choice D (absorption) is incorrect as teeth are not involved in absorbing nutrients; absorption primarily occurs in the small intestine.
The patient asks why the serologic test of HBV DNA quantitation is being done. What is the best rationale for the nurse to explain the test to the patient?
- A. Indicates ongoing infection with HBV
- B. Indicates co-infection with HBV and HDV
- C. Indicates previous infection or immunization to HBV
- D. Indicates viral replication and effectiveness of therapy for chronic HBV
Correct Answer: D
Rationale: The correct answer is D because HBV DNA quantitation measures the amount of HBV genetic material in the blood, reflecting viral replication. This helps monitor the effectiveness of therapy in chronic HBV patients. Choice A is incorrect as the test does not specifically indicate ongoing infection. Choice B is incorrect as it refers to co-infection with HDV, which is not the purpose of HBV DNA quantitation. Choice C is incorrect as the test does not differentiate between previous infection and ongoing viral replication, which is crucial in managing chronic HBV.