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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.
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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 assesses clients on the medical-surgical unit. Which client is at greatest risk for the development of carcinoma of the liver?
- A. A 25-year-old with a history of blunt liver trauma
- B. A 48-year-old with a history of diabetes mellitus
- C. A 30-year-old who has a history of cirrhosis
- D. An 82-year-old who has chronic malnutrition
Correct Answer: C
Rationale: The risk of contracting a primary carcinoma of the liver is higher in clients with cirrhosis from any cause. Blunt liver trauma, diabetes mellitus, and chronic malnutrition do not increase a person's risk for developing liver cancer.
A nurse delegates hygiene care for a client who has advanced cirrhosis to an unlicensed nursing personnel (UAP). Which statements should the nurse include when delegating this task to the UAP? (Select all that apply.)
- A. Apply lotion to the client's dry skin areas.
- B. Use a basin with warm water to bathe the client.
- C. For oral care, use a soft toothbrush.
- D. Provide supplemental warm water for gargles.
- E. Bathe with antibacterial and water-based soaps.
Correct Answer: A,C,D
Rationale: Clients with advanced cirrhosis often have pruritus. Lotion will help decrease itchiness from dry skin. A soft toothbrush should be used to prevent gum bleeding, and the client's nails should be trimmed short to prevent scratching. Clients should use cool, not warm, water on their skin and should not use excessive amounts of soap.
A nurse assesses a client who is recovering from a paracentesis 1 hour ago. Which assessment finding requires action by the nurse?
- A. Urine output via indwelling urinary catheter is 20 mL/hr.
- B. Blood pressure increases from 120/80 mm Hg to 140/90 mm Hg.
- C. Respiratory rate decreases from 18 to 14 breaths/min.
- D. A decrease in the clients weight by 6 kg
Correct Answer: A
Rationale: Rapid removal of ascitic fluid causes decreased abdominal pressure, which can contribute to hypovolemia. This can be manifested by a decrease in urine output to below 30 mL/hr. A slight increase in systolic blood pressure is insignificant. A decrease in respiratory rate indicates that breathing has been made easier by the procedure. The nurse would expect the clients weight to drop as fluid is removed. Six kilograms is less than 3 pounds and is expected.
After teaching a client who has alcohol-induced cirrhosis, a nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching?
- A. I cannot drink any alcohol at all anymore.
- B. I need to avoid protein in my diet.
- C. I should not take over-the-counter medications.
- D. I should not take any prescription medications.
Correct Answer: B
Rationale: Based on the degree of liver involvement and decreased function, protein intake may have to be decreased. However, some protein is necessary for the synthesis of albumin and normal healing. The other statements indicate accurate understanding of self-care measures for this client.