Nokea
The client diagnosed with end-stage liver failure is admitted with esophageal bleeding. The HCP inserts and inflates a triple-lumen nasogastric tube (Sengstaken-Blakemore). Which nursing intervention should the nurse implement for this treatment?
- A. Assess the gag reflex every shift.
- B. Stay with the client at all times.
- C. Administer the laxative lactulose (Chronulac).
- D. Monitor the client's ammonia level.
Correct Answer: B
Rationale: The Sengstaken-Blakemore tube can dislodge or cause complications like aspiration, requiring constant monitoring. Gag reflex, lactulose, and ammonia are unrelated to this intervention.
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The dietitian and the nurse in a long-term care facility are planning the menu for the day. Which foods should be recommended for the immobile clients for whom swallowing is not an issue?
- A. Cheeseburger and milk shake.
- B. Canned peaches and a sandwich on whole-wheat bread.
- C. Mashed potatoes and mechanically ground red meat.
- D. Biscuits and gravy with bacon.
Correct Answer: C
Rationale: Mashed potatoes and ground meat are soft, low-fiber, and digestible, suitable for immobile clients to prevent constipation. Burgers, whole-wheat, and fatty foods are harder to digest.
The client presents with a complete blockage of the large intestine from a tumor. Which healthcare provider's order would the nurse question?
- A. Obtain consent for a colonoscopy and biopsy.
- B. Start an IV of 0.9% saline at 125 mL/hr.
- C. Administer 3 liters of GoLYTELY.
- D. Give tap water enemas until it is clear.
Correct Answer: C
Rationale: GoLYTELY, a bowel prep, is contraindicated in complete bowel obstruction, as it could worsen the condition or cause perforation. Colonoscopy, IV fluids, and enemas (if cautious) may be appropriate depending on the clinical plan.
Which outcome should the nurse identify for the client scheduled to have a cholecystectomy?
- A. Decreased pain management.
- B. Ambulate first day postoperative.
- C. No break in skin integrity.
- D. Knowledge of postoperative care.
Correct Answer: B
Rationale: Ambulation on the first postoperative day prevents complications like thrombosis and atelectasis. Pain management should increase, skin integrity may be disrupted, and knowledge is a process, not an outcome.
The client presents to the outpatient clinic complaining of diarrhea for two (2) days. Which laboratory data should the nurse monitor?
- A. The sodium level.
- B. The albumin level.
- C. The potassium level.
- D. The glucose level.
Correct Answer: C
Rationale: Potassium is critical to monitor in diarrhea due to risk of hypokalemia from losses, which can cause arrhythmias. Sodium is also relevant, but potassium is priority.
The client is diagnosed with end-stage liver failure. The client asks the nurse, 'Why is my doctor decreasing the doses of my medications?' Which statement is the nurse's best response?
- A. You are worried because your doctor has decreased the dosage.
- B. You really should ask your doctor. I am sure there is a good reason.
- C. You may have an overdose of the medications because your liver is damaged.
- D. The half-life of the medications is altered because the liver is damaged.
Correct Answer: D
Rationale: End-stage liver failure impairs drug metabolism, prolonging medication half-life, so doses are reduced to prevent toxicity. Overdose is a consequence, not the rationale, and other responses are less informative.