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A patient with cirrhosis of the liver and ascites is scheduled for a paracentesis. What should the nurse do to prepare the patient for the procedure?
- A. Have the patient void immediately before the procedure.
- B. Position the patient flat in bed.
- C. Administer a full liquid diet.
- D. Encourage the patient to ambulate for 30 minutes.
Correct Answer: A
Rationale: The correct answer is A: Have the patient void immediately before the procedure. This step is crucial to prevent accidental puncture of the bladder during paracentesis. Voiding helps empty the bladder, reducing the risk of injury and ensuring a safer procedure.
Incorrect choices:
B: Position the patient flat in bed - Incorrect, as the patient should be in a sitting position with legs dangling over the side of the bed during the procedure.
C: Administer a full liquid diet - Incorrect, as a full liquid diet is not necessary for paracentesis preparation.
D: Encourage the patient to ambulate for 30 minutes - Incorrect, as ambulation is not relevant to preparing for paracentesis.
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The healthcare provider in the outpatient clinic has obtained health histories for these new patients. Which patient may need referral for genetic testing?
- A. 35-year-old patient whose maternal grandparents died after strokes at ages 90 and 96
- B. 18-year-old patient with a positive pregnancy test whose first child has cerebral palsy
- C. 34-year-old patient who has a sibling with newly diagnosed polycystic kidney disease
- D. 50-year-old patient with a history of cigarette smoking who is complaining of dyspnea
Correct Answer: C
Rationale: The correct answer is C. The patient with a sibling having newly diagnosed polycystic kidney disease may need a referral for genetic testing. Polycystic kidney disease has a genetic component, so there is a higher likelihood of the patient also having the condition. Referral for genetic testing can help in early diagnosis, management, and counseling for the patient and their family members.
Choice A is incorrect because strokes in maternal grandparents at advanced ages are not typically indicative of a need for genetic testing. Choice B is incorrect as cerebral palsy is not typically a genetic condition related to the patient's pregnancy test result. Choice D is incorrect as dyspnea in a smoking patient is more likely related to respiratory issues such as chronic obstructive pulmonary disease rather than a genetic condition.
A patient with a diagnosis of deep vein thrombosis (DVT) is receiving heparin therapy. Which laboratory test should the nurse monitor to evaluate the effectiveness of the heparin therapy?
- A. Prothrombin time (PT)
- B. Partial thromboplastin time (PTT)
- C. Bleeding time
- D. Platelet count
Correct Answer: B
Rationale: The correct answer is B: Partial thromboplastin time (PTT). PTT is used to monitor the effectiveness of heparin therapy because heparin primarily affects the intrinsic pathway of the coagulation cascade, which is reflected in the PTT results. Monitoring PTT helps to ensure that the patient's blood is within the therapeutic range for anticoagulation.
A: Prothrombin time (PT) is used to monitor warfarin therapy, which affects the extrinsic pathway of the coagulation cascade.
C: Bleeding time is not typically used to monitor heparin therapy effectiveness.
D: Platelet count is important to monitor for heparin-induced thrombocytopenia, but it does not directly reflect the effectiveness of heparin therapy in preventing or treating DVT.
A patient with chronic obstructive pulmonary disease (COPD) is experiencing severe dyspnea. What position should the nurse encourage the patient to assume?
- A. Supine
- B. Prone
- C. High Fowler's
- D. Trendelenburg
Correct Answer: C
Rationale: The correct answer is C: High Fowler's. This position helps improve lung expansion and breathing efficiency by maximizing chest expansion. Sitting upright reduces pressure on the diaphragm, allowing for better ventilation. Supine (A) position can worsen dyspnea by restricting lung expansion. Prone (B) position is not ideal for COPD patients as it can hinder breathing. Trendelenburg (D) position, where the patient's feet are elevated above the head, can increase pressure on the diaphragm and impair breathing, making it inappropriate for a patient experiencing severe dyspnea.
What is the primary action of a short-acting beta2-agonist (SABA) prescribed to a patient with an acute asthma exacerbation?
- A. Reduce inflammation
- B. Relieve bronchospasm
- C. Thin respiratory secretions
- D. Suppress cough
Correct Answer: B
Rationale: The correct answer is B: Relieve bronchospasm. Short-acting beta2-agonists (SABAs) like albuterol act by stimulating beta2 receptors in the airway smooth muscle, leading to bronchodilation and relieving bronchospasm. This helps to quickly open up the airways during an acute asthma exacerbation. Choice A is incorrect because SABAs do not directly reduce inflammation. Choice C is incorrect as SABAs do not affect respiratory secretions. Choice D is incorrect as SABAs do not suppress cough but rather target bronchospasm.
A patient with anemia is prescribed ferrous sulfate. What advice should the nurse give regarding the administration of this medication?
- A. Take with dairy products to increase absorption.
- B. Take on an empty stomach for best absorption.
- C. Avoid vitamin C while taking this medication.
- D. Take before bedtime.
Correct Answer: B
Rationale: The correct answer is B: Take on an empty stomach for best absorption. Ferrous sulfate is best absorbed on an empty stomach to maximize its effectiveness. When taken with food or dairy products (Choice A), the absorption of iron is reduced. Vitamin C actually enhances the absorption of iron, so avoiding it (Choice C) is not recommended. Taking the medication before bedtime (Choice D) may lead to gastrointestinal side effects and is not optimal for absorption.