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A telehealth nurse speaks with a client who is recovering from a liver transplant 2 weeks ago. The client states, 'I am experiencing right flank pain and have a temperature of 101 F.' How should the nurse respond?
- A. Report the client's symptoms to the responsible health care provider.
- B. You should go to the hospital immediately to have your new liver checked out.
- C. You should take an additional dose of cyclosporine today.
- D. Take acetaminophen (Tylenol) every 4 hours until you feel better.
Correct Answer: B
Rationale: Fever, right quadrant or flank pain, and jaundice are signs of liver transplant rejection; the client should be admitted to the hospital as soon as possible for intervention. Anti-rejection drugs do make a client more susceptible to infection, but this client has signs of rejection, not infection. The nurse should not advise the client to take an additional dose of cyclosporine or acetaminophen as these medications will not treat the acute rejection.
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A nurse cares for a client who is prescribed lactulose (Heptalac). The client states, 'I do not want to take this medication because it causes diarrhea.' How should the nurse respond?
- A. Diarrhea is expected; that's how your body gets rid of ammonia.
- B. You may take Kaopectate liquid daily for loose stools.
- C. Do not take any more of the medication until your stools firm up.
- D. We will need to send a stool specimen to the laboratory.
Correct Answer: A
Rationale: The purpose of administering lactulose to this client is to help ammonia leave the circulatory system through the colon. Lactulose draws water into the bowel with its high osmotic gradient, thereby producing a laxative effect and subsequently evacuating ammonia from the bowel. The client must understand that this is an expected therapeutic effect for him or her to remain compliant. The nurse should not suggest administering anything that would decrease the excretion of ammonia or holding the medication. There is no need to send a stool specimen to the laboratory because diarrhea is the therapeutic response to this medication.
A nurse cares for a client with hepatitis C. The client's brother states, 'I do not want to contract this infection, so I will not go into his room.' How should the nurse respond?
- A. If you wear a gown and gloves, you will not get this virus.
- B. Hepatitis C is not spread through casual contact.
- C. This virus is only transmitted through a fecal specimen.
- D. I can give you an update on your brother's status from here.
Correct Answer: B
Rationale: Although family members may be afraid that they will contract hepatitis C, the nurse should educate the client's family about how the virus is spread. Hepatitis C is spread via blood-to-blood transmission and is associated with illicit IV drug use, needle sharing, blood and organ transplantation, accidental needle sticks, unsanitary tattoo equipment, and sharing of intranasal cocaine paraphernalia. Wearing a gown and gloves will not decrease the transmission of this virus. Hepatitis C is not spread through casual contact or a fecal specimen. Sharing the client's status without consent would violate privacy.
A nurse cares for a client who has chronic cirrhosis from substance abuse. The client states, 'All of my family hates me.' How should the nurse respond?
- A. You should make peace with your family.
- B. This is not unusual. My family hates me too.
- C. You should find a friend or recovery group for support.
- D. You must attend Alcoholics Anonymous.
Correct Answer: C
Rationale: Clients who have chronic cirrhosis may have alienated relatives over the years because of substance abuse. The nurse should assist the client to identify a friend, neighbor, or person in his or her recovery group for support. Suggesting that the client make peace with family may not be possible and is not client-centered. Sharing personal experiences or mandating attendance at Alcoholics Anonymous is not appropriate.
After teaching a client who has been diagnosed with hepatitis A, the nurse assesses the client's understanding. Which statement by the client indicates a correct understanding of the teaching?
- A. Some medications have been known to cause hepatitis A.
- B. I may have been exposed when we ate shrimp last weekend.
- C. I was infected with hepatitis A through a recent blood transfusion.
- D. My infection with Epstein-Barr virus can co-infect me with hepatitis A.
Correct Answer: B
Rationale: The route of acquisition of hepatitis A infection is through close personal contact or ingestion of contaminated water or shellfish. Hepatitis A is not transmitted through medications. Hepatitis B can be spread through blood transfusions. Epstein-Barr virus causes a secondary infection, not a co-infection with hepatitis A.
After teaching a client who has plans to travel to a non-industrialized country, the nurse assesses the client's understanding regarding the prevention of viral hepatitis. Which statement made by the client indicates a need for further teaching?
- A. I should drink bottled water during my travels.
- B. I will not eat off others' plates or share utensils.
- C. I should eat plenty of fresh fruits and vegetables.
- D. I will wash my hands frequently and thoroughly.
Correct Answer: C
Rationale: The client should be advised to avoid fresh, raw fruits and vegetables because they can be contaminated by tap water. Drinking bottled water, not sharing plates, glasses, or eating utensils, and frequent handwashing are good ways to prevent illness.