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An infection control nurse develops a plan to decrease the number of health care professionals who contract viral hepatitis at work. Which ideas should the nurse include in this plan? (Select all that apply.)
- A. Policies related to consistent use of Standard Precautions
- B. Hepatitis vaccination mandate for workers in high-risk areas
- C. Implementation of a needleless system for intravenous therapy
- D. Hepatitis B immunity in clients at risk for hepatitis B
- E. Postexposure prophylaxis provided in a timely manner
Correct Answer: A,C,D,E
Rationale: Nurses should always use Standard Precautions for client care, and policies should reflect this. Needleless systems and reduction of sharps can help prevent hepatitis. Postexposure prophylaxis should be provided in a timely manner. Hepatitis B immunity in clients does not protect healthcare workers, but ensuring worker immunity through vaccination is critical.
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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 assesses a client who is prescribed an infusion of vasopressin (Pitressin) for bleeding esophageal varices. Which clinical manifestation should the nurse recognize as a potential complication?
- A. Nausea and vomiting
- B. Dizziness and syncope
- C. Fever and chills
- D. Mid-sternal chest pain
Correct Answer: D
Rationale: Mid-sternal chest pain is indicative of acute angina or myocardial infarction, which can be precipitated by vasopressin. Nausea, vomiting, dizziness, syncope, fever, and chills are not typical side effects of vasopressin.
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.
A nurse cares for a client who has cirrhosis of the liver. Which action should the nurse take to decrease the presence of ascites?
- A. Monitor intake and output.
- B. Monitor vital signs and diet.
- C. Increase oral fluid intake.
- D. Weigh the client daily.
Correct Answer: B
Rationale: A low-sodium diet is one means of controlling abdominal fluid collection. Monitoring intake and output does not control fluid accumulation, nor does weighing the client. These interventions merely assess or monitor the situation. Increasing fluid intake would not be helpful.
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.