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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.
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A nurse cares for a client with hepatopulmonary syndrome who is experiencing dyspnea with oxygen saturations at 92%. The client states, 'I do not want to wear the oxygen because it causes my nose to bleed. Get out of my room and leave me alone!' Which action should the nurse take?
- A. Ensure the client is in as upright a position as possible.
- B. Add humidity to the oxygen and encourage the client to wear it.
- C. Document the client's refusal, and call the health care provider.
- D. Contact the provider to request an extra dose of the client's diuretic.
Correct Answer: A
Rationale: The client with hepatopulmonary syndrome is often dyspneic. Because the oxygen saturation is not significantly low, the nurse should first allow the client to sit upright to see if that helps. If the client remains dyspneic, or if the oxygen saturation drops further, the nurse should investigate adding humidity to the oxygen and using a face mask to deliver the oxygen. The other two options may be beneficial, but they are not the best choices. If the client is comfortable, his or her agitation will decrease; this will improve respiratory status.
A nurse cares for a client who is scheduled for a paracentesis. Which intervention should the nurse delegate to an unlicensed assistive personnel (UAP)?
- A. Have the client sign the informed consent form.
- B. Help the client void just before the procedure.
- C. Help the client lie flat in bed on the right side.
- D. Get the client into a chair after the procedure.
Correct Answer: B
Rationale: For safety, the client should void just before a paracentesis. The nurse or the provider should have the client sign the consent form. The proper position for a paracentesis is sitting upright in bed or, alternatively, sitting on the edge of the bed or leaning over a bedside table. The client will be on bed rest after the procedure.
A nurse assesses a male client who has symptoms of cirrhosis. Which questions should the nurse ask to identify potential factors contributing to this disorder? (Select all that apply.)
- A. How frequently do you drink alcohol?
- B. Have you ever had sex with a man?
- C. Do you have a family history of cancer?
- D. Have you ever worked as a plumber?
- E. Were you previously incarcerated?
Correct Answer: A,B,E
Rationale: Alcohol consumption is a major cause of cirrhosis. Sexual practices, particularly unprotected sex with men, increase the risk of hepatitis B or C, which can lead to cirrhosis. Incarceration is a risk factor due to potential exposure to hepatitis C through shared needles or unsanitary conditions. Family history of cancer and working as a plumber are not directly associated with cirrhosis.
An emergency room nurse assesses a client after a motor vehicle crash. The nurse notices a steering wheel imprint across the client's chest. Which action should the nurse take?
- A. Ask the client where he or she was sitting during the crash.
- B. Assess the client by gently palpating the abdomen for tenderness.
- C. Notify the laboratory to draw blood for blood type and crossmatch.
- D. Develop a handwashing plan to prevent infection.
Correct Answer: B
Rationale: The liver is often injured by a steering wheel in a motor vehicle crash. Because the client's chest was marked by the steering wheel, the nurse should perform an abdominal assessment. Assessing the client's position in the crash is not needed because of the steering wheel imprint. The client may or may not need a blood transfusion. A handwashing plan is not relevant to this situation.
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.