Nokea
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.
You may also like to solve these questions
A patient with rheumatoid arthritis is prescribed methotrexate. What should the nurse include in the patient teaching?
- A. Take folic acid supplements as prescribed.
- B. Avoid alcohol completely.
- C. Expect to see immediate results.
- D. Limit fluid intake to 1 liter per day.
Correct Answer: A
Rationale: The correct answer is A: Take folic acid supplements as prescribed. Methotrexate can lead to folic acid deficiency, so supplementing with folic acid helps prevent side effects. It is important for the nurse to educate the patient on the importance of taking folic acid to maintain overall health.
Choice B is incorrect. While it is generally recommended to limit alcohol consumption with methotrexate, avoiding it completely may not be necessary for all patients.
Choice C is incorrect. Methotrexate takes time to work, often several weeks to months, so immediate results should not be expected.
Choice D is incorrect. Limiting fluid intake to 1 liter per day is not a standard recommendation for patients taking methotrexate. Adequate hydration is important for overall health.
A patient with coronary artery disease (CAD) is prescribed a statin medication. What should the nurse include in the patient education?
- A. Take the medication with food.
- B. Report any muscle pain or weakness.
- C. Increase intake of grapefruit juice.
- D. Avoid foods high in potassium.
Correct Answer: B
Rationale: Step 1: Statins can cause muscle pain or weakness as a side effect.
Step 2: Prompt reporting of muscle pain or weakness is crucial to address potential myopathy or rhabdomyolysis.
Step 3: Nurse should educate patient to report any muscle symptoms promptly for timely intervention and prevention of complications.
Summary: Option B is correct as it emphasizes the importance of monitoring and reporting potential side effects of statins. Options A, C, and D are incorrect as taking with food, increasing grapefruit juice intake, and avoiding potassium-rich foods are not relevant considerations for statin therapy.
A client with acute pancreatitis is experiencing severe abdominal pain. Which enzyme level should the nurse monitor closely?
- A. Serum amylase.
- B. Serum sodium.
- C. Serum calcium.
- D. Serum potassium.
Correct Answer: A
Rationale: The correct answer is A: Serum amylase. In acute pancreatitis, damaged pancreatic cells release amylase into the bloodstream, causing elevated serum amylase levels. Monitoring serum amylase helps in diagnosing and assessing the severity of pancreatitis.
Incorrect choices:
B: Serum sodium - Serum sodium levels are typically not directly affected by pancreatitis.
C: Serum calcium - While hypocalcemia can occur in severe pancreatitis, monitoring serum calcium is not as specific for pancreatitis diagnosis or severity assessment as serum amylase.
D: Serum potassium - Potassium levels may be affected in pancreatitis due to vomiting or dehydration, but monitoring serum potassium is not as specific to pancreatitis as serum amylase.
The patient has a calcium level of 12.1 mg/dL. Which nursing action should the nurse include on the care plan?
- A. Maintain the patient on bed rest.
- B. Auscultate lung sounds every 4 hours.
- C. Monitor for Trousseau's and Chvostek's signs.
- D. Encourage fluid intake up to 4000 mL every day.
Correct Answer: D
Rationale: The correct answer is D: Encourage fluid intake up to 4000 mL every day. High calcium levels can lead to dehydration, so encouraging fluid intake helps prevent this complication. Increased fluid intake also promotes calcium excretion through urine. Bed rest (A) is not directly related to managing high calcium levels. Auscultating lung sounds (B) every 4 hours is more relevant for respiratory issues. Monitoring for Trousseau's and Chvostek's signs (C) is associated with low calcium levels, not high levels.
The community health nurse is working in a multi-ethnic health center. In what situation should the nurse intervene?
- A. An Asian-American mother reports using cupping to treat infection, resulting in a pattern of red round marks on her toddler's back.
- B. A Hispanic pregnant client who is often late for appointments, arrives late for today's appointment.
- C. A Native-American who is being interviewed will not make direct eye contact when asked about violence in the home.
- D. An African-American infant who is spitting up milk has lost 6 ounces since last week's clinic visit.
Correct Answer: D
Rationale: The correct answer is D because an African-American infant losing weight rapidly is a sign of potential malnutrition or health issue that requires immediate intervention. The nurse should assess the infant's feeding, growth, and health status to address the problem promptly.
Choice A is incorrect as cupping is a cultural practice that may not necessarily harm the child and should be respected. Choice B is incorrect as being late for appointments is not a direct health risk that requires immediate intervention. Choice C is incorrect as avoiding direct eye contact is a cultural norm for some Native-American individuals and does not indicate a health emergency.