Nokea
The client diagnosed with end-stage liver failure is admitted with hepatic encephalopathy. Which dietary restriction should be implemented by the nurse to address this complication?
- A. Restrict sodium intake to 2 g/day.
- B. Limit oral fluids to 1,500 mL/day.
- C. Decrease the daily fat intake.
- D. Reduce protein intake to 60 to 80 g/day.
Correct Answer: D
Rationale: Reducing protein intake limits ammonia production, which exacerbates hepatic encephalopathy. Sodium, fluid, and fat restrictions are less directly related to this complication.
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The nurse is preparing the client for a fiberoptic colonoscopy for colon polyps. Which task can be delegated to the unlicensed assistive personnel (UAP)?
- A. Administer the polyethylene glycol electrolyte lavage solution.
- B. Explain to the client why this morning's breakfast is withheld.
- C. Start an intravenous site with 0.9% normal saline fluid.
- D. Administer a cleansing enema until the return is clear.
Correct Answer: D
Rationale: Administering a cleansing enema is within the UAP’s scope with training. Administering solutions, explaining procedures, and starting IVs require RN skills.
The nurse is caring for the client who had a vertical banded gastroplasty. The nurse teaches that nausea can occur after this surgery from which situation?
- A. The stomach pouch becomes overfilled.
- B. The lower half of the stomach becomes spastic.
- C. The duodenum incision becomes inflamed.
- D. The dumping syndrome from a high-protein meal.
Correct Answer: A
Rationale: A. A small pouch (15—20 mL capacity) is constructed in the upper part of the stomach during vertical banded gastroplasty. Overfilling of this pouch stimulates afferent nerve fibers, which relay information to the chemoreceptor trigger zone in the brain, causing nausea. B. The function of the lower half of the stomach is not affected with a vertical banded gastroplasty. C. The duodenum is not incised during a vertical banded gastroplasty. D. Dumping syndrome is more likely to occur from a meal high in simple carbohydrates, not protein.
Which gastrointestinal assessment data should the nurse expect to find when assessing the client in end-stage liver failure?
- A. Hypoalbuminemia and muscle wasting.
- B. Oligomenorrhea and decreased body hair.
- C. Clay-colored stools and hemorrhoids.
- D. Dyspnea and caput medusae.
Correct Answer: A
Rationale: Hypoalbuminemia and muscle wasting are common in end-stage liver failure due to impaired protein synthesis and malnutrition. Other options include less specific or unrelated findings.
A client with pancreatitis tells the nurse that he fears nighttime. Which of the following statements most likely relates to the client's concerns?
- A. The pain is aggravated in the recumbent position.
- B. The client has fewer distractions at night.
- C. The mattress is uncomfortable.
- D. The pain increases after a day of activity.
Correct Answer: A
Rationale: Pancreatitis pain is often worsened in the recumbent position, contributing to the client’s fear of nighttime.
The nurse is teaching the client diagnosed with diverticulosis. Which instruction should the nurse include in the teaching session?
- A. Discuss the importance of drinking 1,000 mL of water daily.
- B. Instruct the client to exercise at least three (3) times a week.
- C. Teach the client about eating a low-residue diet.
- D. Explain the need to have daily bowel movements.
Correct Answer: B
Rationale: Regular exercise promotes bowel motility, reducing the risk of diverticulitis in diverticulosis. A high-fiber diet (not low-residue) is recommended, 1,000 mL of water is insufficient, and daily bowel movements are not mandatory.