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After an unimmunized individual is exposed to hepatitis B through a needle-stick injury, which actions will the nurse plan to take (select one that does not apply)?
- A. Administer hepatitis B vaccine.
- B. Test for antibodies to hepatitis B.
- C. Teach about alpha-interferon therapy.
- D. Give hepatitis B immune globulin.
Correct Answer: C
Rationale: In the case of exposure to hepatitis B, the nurse should plan to administer hepatitis B vaccine to provide active immunity. Testing for antibodies to hepatitis B is essential to determine the individual's immune status. Giving hepatitis B immune globulin is necessary for passive immunity in cases of exposure. However, teaching about alpha-interferon therapy is not part of the standard management for hepatitis B exposure. Interferon therapy and oral antivirals are typically used in the treatment of chronic hepatitis B infections, not for prophylaxis after exposure.
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A man is receiving heparin subcutaneously. The patient has dementia and lives at home with a part-time caretaker. The nurse is most concerned about which side effect of heparin?
- A. Back Pain
- B. Fever and Chills
- C. Risk for Bleeding
- D. Dizziness
Correct Answer: C
Rationale: The correct answer is 'Risk for Bleeding.' A patient with dementia may have impaired judgment and may be prone to falls or injuries, increasing the risk of bleeding while on heparin therapy. Monitoring for signs of bleeding is crucial in this situation. Choice A, 'Back Pain,' is not a common side effect of heparin. Choice B, 'Fever and Chills,' is not a typical side effect of heparin but may indicate other underlying conditions. Choice D, 'Dizziness,' is not a common side effect of heparin and is not the primary concern in this scenario.
A 34-year-old patient with chronic hepatitis C infection has several medications prescribed. Which medication requires further discussion with the healthcare provider before administration?
- A. Ribavirin (Rebetol, Copegus) 600 mg PO bid
- B. Pegylated α-interferon (PEG-Intron, Pegasys) SQ weekly
- C. Diphenhydramine (Benadryl) 25 mg PO every 4 hours PRN itching
- D. Dimenhydrinate (Dramamine) 50 mg PO every 6 hours PRN nausea
Correct Answer: B
Rationale: The correct answer is B: Pegylated α-interferon (PEG-Intron, Pegasys) SQ weekly. Pegylated α-interferon is typically administered once weekly, not daily. Therefore, this medication requires further discussion with the healthcare provider before administration to ensure the correct dosing frequency. Ribavirin, choice A, is appropriate for chronic hepatitis C treatment. Choices C and D, Diphenhydramine and Dimenhydrinate, are commonly used for symptomatic relief in patients with hepatitis C and do not require further discussion with the healthcare provider in this context.
A client with asthma has low-pitched wheezes present in the final half of exhalation. One hour later, the client has high-pitched wheezes extending throughout exhalation. This change in assessment indicates to the nurse that the client:
- A. Has increased airway obstruction.
- B. Has improved airway obstruction.
- C. Needs to be suctioned.
- D. Exhibits hyperventilation.
Correct Answer: B
Rationale: The change from low-pitched wheezes to high-pitched wheezes indicates a shift from larger to smaller airway obstruction, suggesting increased narrowing of the airways. This change signifies a progression or worsening of the airway obstruction. The absence of evidence of secretions does not support the need for suctioning. Hyperventilation is characterized by rapid and deep breathing, which is not indicated by the information provided in the question.
A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). The nurse knows that a PTCA is
- A. Surgical repair of a diseased coronary artery.
- B. Placement of an automatic internal cardiac defibrillator.
- C. Procedure that compresses plaque against the wall of the diseased coronary artery to improve blood flow.
- D. Non-invasive radiographic examination of the heart.
Correct Answer: C
Rationale: Percutaneous transluminal coronary angioplasty (PTCA) is a procedure that involves compressing plaque against the wall of a diseased coronary artery to improve blood flow. It is a minimally invasive procedure performed during a cardiac catheterization to open blockages in the coronary arteries. Surgical repair of a diseased coronary artery refers to procedures like coronary artery bypass grafting (CABG), not PTCA. Placement of an automatic internal cardiac defibrillator is a different intervention used for managing cardiac arrhythmias, not for improving coronary blood flow. A non-invasive radiographic examination of the heart would typically refer to procedures like a cardiac CT scan or an MRI, not PTCA.
A 30-year-old man is being admitted to the hospital for elective knee surgery. Which assessment finding is most important to report to the healthcare provider?
- A. Tympany on percussion of the abdomen
- B. Liver edge 3 cm below the costal margin
- C. Bowel sounds of 20/minute in each quadrant
- D. Aortic pulsations visible in the epigastric area
Correct Answer: B
Rationale: The correct answer is 'Liver edge 3 cm below the costal margin.' Normally, the lower border of the liver is not palpable below the ribs, so this finding suggests hepatomegaly, which could indicate an underlying health issue. Tympany on percussion of the abdomen, bowel sounds of 20/minute in each quadrant, and aortic pulsations visible in the epigastric area are all within normal limits for a physical assessment and do not require immediate reporting to the healthcare provider.