Nokea
The client has end-stage liver failure secondary to alcoholic cirrhosis. Which complication indicates the client is at risk for developing hepatic encephalopathy?
- A. Gastrointestinal bleeding.
- B. Hypoalbuminemia.
- C. Splenomegaly.
- D. Hyperaldosteronism.
Correct Answer: A
Rationale: GI bleeding increases ammonia levels (from blood protein breakdown), a key trigger for hepatic encephalopathy. Other complications are less directly linked to this risk.
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Which type of precaution should the nurse implement to protect from being exposed to any of the hepatitis viruses?
- A. Airborne Precautions.
- B. Standard Precautions.
- C. Droplet Precautions.
- D. Exposure Precautions.
Correct Answer: B
Rationale: Standard Precautions protect against hepatitis viruses (A, B, C, D) by assuming all body fluids are infectious, covering fecal-oral and bloodborne transmission. Other precautions are inappropriate.
The client with acute diverticulitis has a nasogastric tube draining green liquid bile. Which intervention should the nurse implement?
- A. Document the findings as normal.
- B. Assess the client's bowel sounds.
- C. Determine the client's last bowel movement.
- D. Insert the NG tube at least two (2) more inches.
Correct Answer: A
Rationale: Green bile drainage from an NG tube is normal, indicating proper placement and function, so documenting this is appropriate. Further insertion or other assessments are unnecessary unless other symptoms arise.
The nurse is caring for the client who is 6 hours post—open cholecystectomy. The client's T—tube drainage bag is empty, and the nurse notes slight jaundice of the sclera. Which action by the nurse is most important?
- A. Reposition the client to promote T-tube drainage
- B. Telephone the surgeon to report these findings
- C. Ask a nursing assistant to obtain a blood pressure
- D. Record the findings and continue to monitor the client
Correct Answer: B
Rationale: A. Repositioning the client might promote bile flow into the T—tube if the client were lying on the tube. However, the jaundice indicates that the problem is internal. B. The T-tube is placed in the common bile duct to ensure patency of the duct. Lack of bile draining into the T—tube and jaundiced sclera are signs of an obstruction to the bile flow. This is most important to report to the surgeon. C. The client’s BP would not be affected by this situation. D. Recording the findings and continuing to monitor the client are inappropriate because the client is experiencing signs of a complication.
The client is diagnosed with an acute exacerbation of ulcerative colitis. Which intervention should the nurse implement?
- A. Provide a low-residue diet.
- B. Rest the client's bowel.
- C. Assess vital signs daily.
- D. Administer antacids orally.
Correct Answer: B
Rationale: During an acute exacerbation of ulcerative colitis, resting the bowel (often via NPO status or clear liquids) reduces inflammation and irritation. A low-residue diet is used in stable phases, daily vital signs are routine, and antacids are irrelevant.
The nurse is caring for the surgical client during the first 24 hours after an abdominal-perineal resection. Which action should be priority?
- A. Provide a diet that is low in residue
- B. Check the colostomy bag for stool amount
- C. Assess the perineal dressing for drainage
- D. Encourage the client to see the colostomy site
Correct Answer: C
Rationale: The perineal incision must be examined frequently to assess for drainage and the need for dressing changes.