Nokea
The client asks how he contracted hepatitis A. He reports all of the following. Which one is most likely related to hepatitis A?
- A. He ate home-canned corn.
- B. He ate oysters his roommate brought home from a fishing trip.
- C. He stepped on a nail two weeks ago.
- D. He donated blood two weeks before he got sick.
Correct Answer: B
Rationale: Hepatitis A is transmitted via the fecal-oral route, often through contaminated food like oysters. Oysters from unsafe waters are a common source.
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The nurse is preparing a client diagnosed with GERD for surgery. Which information warrants notifying the HCP?
- A. The client's Bernstein esophageal test was positive.
- B. The client's abdominal x-ray shows a hiatal hernia.
- C. The client's WBC count is 14,000/mm3.
- D. The client's hemoglobin is 13.8 g/dL.
Correct Answer: C
Rationale: An elevated WBC count (14,000/mm3) suggests infection or inflammation, which could complicate surgery and requires immediate attention. A positive Bernstein test and hiatal hernia are expected in GERD, and a hemoglobin of 13.8 g/dL is within normal limits.
The nurse is teaching the American Diabetes Association diet to a client diagnosed with diabetes mellitus type 2. Which should the nurse teach the client?
- A. Instruct the client to weigh all food before cooking it.
- B. Teach the client to eat only carbohydrates if the blood glucose is low.
- C. Demonstrate how to determine the amount of carbohydrates being eaten.
- D. Explain that proteins should be 75% of the recommended diet.
Correct Answer: C
Rationale: Determining carbohydrate amounts (e.g., carb counting) is key for glycemic control in type 2 diabetes per ADA guidelines. Weighing food, carb-only for hypoglycemia, and high protein are incorrect.
Which assessment data indicate to the nurse the client recovering from an open cholecystectomy may require pain medication?
- A. The client's pulse is 65 beats per minute.
- B. The client has shallow respirations.
- C. The client's bowel sounds are 20 per minute.
- D. The client uses a pillow to splint when coughing.
Correct Answer: B
Rationale: Shallow respirations suggest pain, as patients avoid deep breathing to minimize discomfort. Normal pulse, bowel sounds, and splinting are less direct indicators of pain.
The nurse is performing an initial postoperative assessment on the client following upper GI surgery. The client has an NG tube to low intermittent suction. To best assess the client for the presence of bowel sounds, which intervention should the nurse implement?
- A. Start auscultating to the left of the umbilicus.
- B. Turn off the NG suction before auscultation.
- C. Use the bell of the stethoscope for auscultation.
- D. Empty the drainage canister before auscultation.
Correct Answer: B
Rationale: A. When the client has hypoactive bowel sounds, which would be expected in a postsurgical client, the nurse should begin listening over the ileocecal valve in the right lower abdominal quadrant rather than to the left of the umbilicus. The ileocecal valve normally is a very active area. B. When listening for bowel sounds on the client who has an NG tube to suction, the nurse should turn off the suction during auscultation to prevent mistaking the suction sound for bowel sounds. C. The diaphragm of the stethoscope should be utilized for bowel sounds. The bell of the stethoscope should be utilized for abdominal vascular sounds, such as bruits. D. There is no reason to empty the canister before auscultation.
The nurse is caring for the client diagnosed with ascites secondary to hepatic cirrhosis. Which information should the nurse report to the health-care provider?
- A. A decrease in the client's daily weight of one (1) pound.
- B. An increase in urine output after administration of a diuretic.
- C. An increase in abdominal girth of two (2) inches.
- D. A decrease in the serum direct bilirubin to 0.6 mg/dL.
Correct Answer: C
Rationale: An increase in abdominal girth (2 inches) suggests worsening ascites, requiring HCP notification. Weight loss, increased urine output, and normal bilirubin are expected or less urgent.