Nokea
After an unimmunized individual is exposed to hepatitis B through a needle-stick injury, which of the following actions should the nurse plan to take?
- A. Administer hepatitis B vaccine.
- B. Test for antibodies to hepatitis B.
- C. Teach about ?±-interferon therapy.
- D. Give hepatitis B immune globulin.
- E. Educate about oral antiviral therapy.
Correct Answer: A,B,D
Rationale: The recommendations for hepatitis B exposure include both vaccination and immune globulin administration. In addition, baseline testing for hepatitis B antibodies will be needed. Interferon and oral antivirals are not used for hepatitis B prophylaxis.
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The nurse is caring for a patient with cirrhosis and esophageal varices who has a new prescription for propranolol. Which of the following assessment findings is the best indicator that the medication has been effective?
- A. The apical pulse rate is 68 beats/minute.
- B. Stools test negative for occult blood.
- C. The patient denies complaints of chest pain.
- D. Blood pressure is less than 140/90 mm Hg.
Correct Answer: B
Rationale: Since the purpose of β-blocker therapy for patients with esophageal varices is to decrease the risk for bleeding from esophageal varices, the best indicator of the effectiveness for propranolol is the lack of blood in the stools. Although propranolol is used to treat hypertension, angina, and tachycardia, the purpose for use in this patient is to decrease the risk for bleeding from esophageal varices.
A patient contracts hepatitis from contaminated food. During the acute (icteric) phase of the patient's illness, which of the following serological findings should the nurse expect?
- A. Antibody to hepatitis D virus (anti-HDV)
- B. Hepatitis B surface antigen (HBsAg)
- C. Anti-hepatitis A virus immunoglobulin G (anti-HAV IgG)
- D. Anti-hepatitis A virus immunoglobulin M (anti-HAV IgM)
Correct Answer: D
Rationale: Hepatitis A is transmitted through the oral-fecal route, and antibody to HAV IgM appears during the acute phase of hepatitis A. The patient would not have antigen for hepatitis B or antibody for hepatitis D. Anti-HAV IgG would indicate past infection and lifelong immunity.
The nurse is caring for a patient with cirrhosis who has 4+ pitting edema of the feet and legs. Which of the following assessments is priority for the nurse to monitor?
- A. Hemoglobin
- B. Temperature
- C. Activity level
- D. Albumin
Correct Answer: D
Rationale: The low oncotic pressure caused by hypoalbuminemia is a major pathophysiological factor in the development of edema. The other parameters also should be monitored, but they are not directly associated with the patient's current symptoms.
The nurse is caring for a patient with severe cirrhosis who has an episode of bleeding esophageal varices. Which of the following laboratory tests should the nurse monitor to detect possible complications of the bleeding episode?
- A. Bilirubin
- B. Ammonia
- C. Potassium
- D. Prothrombin time
Correct Answer: B
Rationale: The blood in the gastrointestinal (GI) tract will be absorbed as protein and may result in an increase in ammonia level because the liver cannot metabolize protein well. The prothrombin time, bilirubin, and potassium levels also should be monitored, but these will not be affected by the bleeding episode.
The nurse is caring for a patient with acute pancreatitis. Which of the following findings is of most concern?
- A. Absent bowel sounds
- B. Abdominal tenderness
- C. Left upper quadrant pain
- D. Palpable abdominal mass
Correct Answer: D
Rationale: A palpable abdominal mass in acute pancreatitis may indicate a pancreatic pseudocyst or abscess, which are serious complications requiring urgent intervention. Absent bowel sounds, abdominal tenderness, and left upper quadrant pain are common findings in acute pancreatitis but are less concerning unless accompanied by other critical symptoms.