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A nurse is caring for a client who has cirrhosis. Which of the following laboratory findings should the nurse expect?
- A. Increased bilirubin levels
- B. Decreased albumin levels
- C. Increased prothrombin time
- D. Decreased serum glucose levels
Correct Answer: A
Rationale: Corrected Rationale: Increased bilirubin levels are expected in clients with cirrhosis due to impaired liver function. Elevated bilirubin levels are commonly seen in cirrhosis as the liver's ability to process bilirubin is compromised. Decreased albumin levels and increased prothrombin time are also associated with cirrhosis, but the most specific finding related to liver dysfunction among the choices provided is increased bilirubin levels. Decreased serum glucose levels are not typically associated with cirrhosis.
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A nurse is performing a gastric lavage for a client who has upper gastrointestinal bleeding. Which of the following actions should the nurse take?
- A. Instill 500 ml of solution through the NG tube
- B. Insert a large-bore NG tube
- C. Use a cold irrigation solution
- D. Instruct the client to lie on his right side
Correct Answer: B
Rationale: The correct answer is B: 'Insert a large-bore NG tube.' When performing a gastric lavage for a client with upper gastrointestinal bleeding, a large-bore NG tube is used to effectively remove gastric contents and blood. Option A is incorrect because the amount of solution to instill depends on the specific situation and should be guided by the healthcare provider's order. Option C is incorrect because using a cold irrigation solution can lead to hypothermia and is not recommended. Option D is incorrect as there is no need to instruct the client to lie on his right side specifically for gastric lavage.
A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following laboratory values indicates the TPN is effective?
- A. Albumin 3.5 g/dL
- B. Hemoglobin 8 g/dL
- C. WBC count 15,000/mm3
- D. Blood glucose 110 mg/dL
Correct Answer: D
Rationale: The correct answer is D. A blood glucose level of 110 mg/dL indicates that the TPN is effective in maintaining normal glucose levels. Hemoglobin level (choice B) is related to anemia and not directly indicative of TPN effectiveness. Albumin level (choice A) is a marker of nutritional status over a longer term and may not reflect immediate TPN effectiveness. White blood cell count (choice C) is related to infection or inflammation and is not a direct indicator of TPN effectiveness.
A client is being discharged with a new prescription for metoprolol. Which of the following instructions should the nurse include?
- A. Do not discontinue this medication suddenly.
- B. Take this medication in the evening to decrease the risk of falls.
- C. Monitor your heart rate before taking this medication.
- D. Avoid grapefruit juice while taking this medication.
Correct Answer: C
Rationale: The correct instruction for a client prescribed metoprolol is to monitor their heart rate before taking the medication. Metoprolol is a beta-blocker that can cause bradycardia (slow heart rate), so it is essential for clients to check their heart rate before each dose. Choice A is incorrect because abruptly stopping metoprolol can lead to adverse effects, so it should not be discontinued suddenly. Choice B is incorrect because there is no specific recommendation to take metoprolol at night to reduce falls. Choice D is incorrect because grapefruit juice can interact with metoprolol, affecting its absorption, and should be avoided.
A client with a new prescription for furosemide should increase intake of which of the following?
- A. You should take this medication on an empty stomach.
- B. You should increase your intake of potassium-rich foods.
- C. You should take this medication at bedtime.
- D. You should avoid taking this medication with food.
Correct Answer: B
Rationale: The correct answer is B: 'You should increase your intake of potassium-rich foods.' Furosemide is a potassium-wasting diuretic, which means it can lead to low potassium levels in the body. Increasing intake of potassium-rich foods helps counteract this effect. Choices A, C, and D are incorrect because furosemide should not necessarily be taken on an empty stomach, at bedtime, or specifically avoided with food.
A charge nurse is teaching a group of newly licensed nurses about the correct use of restraints. Which of the following should the nurse include in the teaching?
- A. Placing a belt restraint on a school-age child who has seizures.
- B. Securing wrist restraints to the bed rails for an adolescent.
- C. Applying elbow immobilizers to an infant receiving cleft lip injury.
- D. Keeping the side rails of a toddler's crib elevated.
Correct Answer: D
Rationale: The correct answer is D. Keeping the side rails of a toddler's crib elevated is an appropriate use of restraints to prevent the child from falling, which is an essential safety measure. Placing a belt restraint on a school-age child with seizures (choice A) is not recommended as it can be dangerous during a seizure. Securing wrist restraints to the bed rails for an adolescent (choice B) may cause harm and should not be done routinely. Applying elbow immobilizers to an infant receiving a cleft lip injury (choice C) is not a standard practice for managing this condition and would not be appropriate.