Nokea
A nurse is assessing a client who has peptic ulcer disease. Which of the following findings should the nurse identify as the priority?
- A. Epigastric discomfort
- B. Dyspepsia
- C. Constipation
- D. Hematemesis
Correct Answer: D
Rationale: The correct answer is D, Hematemesis. This is the priority finding because it indicates upper gastrointestinal bleeding, which can be life-threatening. The nurse should address this immediately to prevent further complications. Epigastric discomfort (A) and dyspepsia (B) are common symptoms of peptic ulcer disease but do not indicate active bleeding. Constipation (C) is not directly related to peptic ulcer disease and does not pose an immediate threat to the client's health.
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The patient experienced a blood transfusion reaction. How should the nurse explain to the patient the cause of the hemolytic jaundice that occurred?
- A. Results from hepatocellular disease
- B. Due to a malaria parasite breaking apart red blood cells (RBCs)
- C. Results from decreased flow of bile through the liver or biliary system
- D. Due to increased breakdown of RBCs that caused elevated serum unconjugated bilirubin
Correct Answer: D
Rationale: The correct answer is D. Hemolytic jaundice in a blood transfusion reaction is due to increased breakdown of red blood cells (RBCs) causing elevated serum unconjugated bilirubin. This occurs when the patient's immune system reacts to the transfused blood, leading to destruction of RBCs. The breakdown of these cells releases hemoglobin, which is metabolized into bilirubin. This unconjugated bilirubin then accumulates in the blood, causing jaundice.
Choice A is incorrect because hepatocellular disease does not directly cause hemolytic jaundice. Choice B is incorrect as malaria parasite breaking apart RBCs leads to hemolysis, not a blood transfusion reaction. Choice C is incorrect as decreased bile flow through the liver or biliary system typically causes obstructive jaundice, not hemolytic jaundice.
In preparing a client for a colonoscopy procedure, which task is most suitable to delegate to the nursing assistant?
- A. Explain the need for clear liquids 1-3 days prior to procedure.
- B. Reinforce NPO status 8 hours prior to procedure.
- C. Administer laxatives 1-3 days prior to procedure.
- D. Administer an enema the night before the procedure.
Correct Answer: B
Rationale: Step 1: Delegation Principle - The task should be within the nursing assistant's scope of practice.
Step 2: NPO reinforcement is a basic instruction that does not require clinical judgment.
Step 3: Nursing assistant can remind the client about NPO status without interpreting medical information.
Step 4: Administering laxatives (C) and enema (D) require clinical judgment and should be done by licensed staff.
Step 5: Explaining the need for clear liquids (A) involves providing medical information, not just a reminder.
What manifestation in the patient does the nurse recognize as an early sign of hepatic encephalopathy?
- A. Manifests asterixis
- B. Becomes unconscious
- C. Has increasing oliguria
- D. Is irritable and lethargic
Correct Answer: D
Rationale: The correct answer is D: Is irritable and lethargic. Early signs of hepatic encephalopathy often include behavioral changes like irritability and lethargy due to impaired brain function from liver dysfunction. This is because the liver is unable to properly detoxify ammonia, leading to its accumulation in the bloodstream and affecting brain function. Asterixis, unconsciousness, and oliguria are more severe manifestations seen in later stages of hepatic encephalopathy. Therefore, recognizing irritability and lethargy in a patient would prompt early intervention to prevent further progression of hepatic encephalopathy.
Which of the following is not a function of the adult liver?
- A. glycogen storage
- B. detoxification
- C. synthesis of clotting proteins
- D. erythropoiesis
Correct Answer: D
Rationale: The correct answer is D: erythropoiesis. The liver does not have a primary role in the production of red blood cells (erythropoiesis), which is mainly carried out by the bone marrow.
A: The liver stores glycogen for energy regulation.
B: Detoxification is a crucial function of the liver, breaking down harmful substances.
C: The liver synthesizes clotting proteins like fibrinogen.
In summary, while the liver is vital for glycogen storage, detoxification, and clotting protein synthesis, it does not play a significant role in erythropoiesis.
A sudden decrease in blood volume would be met by increases in epinephrine, antidiuretic hormone (vasopressin) and angiotensin II. What EFFECT would the increase in these three hormones ALL HAVE IN COMMON?
- A. increased heart rate
- B. increased fluid retention and blood volume
- C. increased PNS activity
- D. vasoconstriction and increased total peripheral resistance
Correct Answer: D
Rationale: The correct answer is D: vasoconstriction and increased total peripheral resistance. Epinephrine, antidiuretic hormone, and angiotensin II all act to increase vasoconstriction, leading to an increase in total peripheral resistance. This response is crucial during a sudden decrease in blood volume to maintain blood pressure and ensure adequate perfusion to vital organs.
Choice A (increased heart rate) is not correct because while epinephrine can increase heart rate, antidiuretic hormone and angiotensin II do not directly affect heart rate.
Choice B (increased fluid retention and blood volume) is not correct because antidiuretic hormone and angiotensin II can increase fluid retention, but epinephrine does not have this effect.
Choice C (increased PNS activity) is not correct because these hormones actually stimulate the sympathetic nervous system (SNS) leading to vasoconstriction and increased blood pressure, not the parasympath