Nokea
The client is admitted to the emergency department complaining of acute epigastric pain and reports vomiting a large amount of bright-red blood at home. Which interventions should the nurse implement? List in order of priority.
- A. Assess the client's vital signs.
- B. Insert a nasogastric tube.
- C. Begin iced saline lavage.
- D. Start an IV with an 18-gauge needle.
- E. Type and crossmatch for a blood transfusion.
Correct Answer: A, D,B,C,E
Rationale: 1. Assessing vital signs evaluates hemodynamic stability (priority for bleeding). 2. Starting an IV ensures access for fluids/blood. 3. Inserting an NG tube removes blood and assesses bleeding. 4. Iced saline lavage controls bleeding. 5. Type and crossmatch prepares for transfusion.
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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.
The client diagnosed with chronic pancreatitis is concerned about pain control. The nurse explains that the initial plan for chronic pancreatic pain control involves the administration of which of the following?
- A. Opioid analgesics, such as morphine sulfate
- B. Nonsteroidal anti-inflammatory drugs (NSAIDs)
- C. Pancreatic enzymes with H2 blocker medications
- D. Injection of medication directly into the nerves
Correct Answer: C
Rationale: A. Opioid analgesics may be prescribed if pancreatic enzymes do not relieve pain. B. NSAIDs, such as ibuprofen, may be used to treat chronic pancreatic pain, but they are not the initial treatment and are usually not sufficient to control the pain. C. The initial pain control measures include exogenous pancreatic enzymes because pancreatic stimulation by food is thought to cause pain. Pancreatic enzymes are coupled with H2 blockers, which block the action of histamine on parietal cells in the stomach. H2 blockers are used because gastric acid destroys the lipase needed to break down fats. D. A nerve block relieves pain in about 50 percent of people who undergo the procedure, but this is not the initial measure for pain control.
The nurse writes the problem 'imbalanced nutrition: less than body requirements' for the client diagnosed with hepatitis. Which intervention should the nurse include in the plan of care?
- A. Provide a high-calorie intake diet.
- B. Discuss total parenteral nutrition (TPN).
- C. Instruct the client to decrease salt intake.
- D. Encourage the client to increase water intake.
Correct Answer: A
Rationale: A high-calorie diet addresses malnutrition and weight loss common in hepatitis, supporting recovery. TPN is invasive, salt restriction is unrelated, and water intake is less critical.
The nurse assesses a large amount of red drainage on the dressing of a client who is six (6) hours postoperative open cholecystectomy. Which intervention should the nurse implement?
- A. Measure the abdominal girth.
- B. Palpate the lower abdomen for a mass.
- C. Turn client onto side to assess for further drainage.
- D. Remove the dressing to determine the source.
Correct Answer: D
Rationale: Removing the dressing to assess the source of red drainage (e.g., bleeding or dehiscence) is critical for timely intervention. Other actions are secondary to identifying the cause.
The RN is caring for the client following a liver biopsy with the assistance of the student nurse. The RN evaluates that the student understands the postprocedure care when making which observation of the student nurse?
- A. Takes the client’s vital signs every hour
- B. Walks the client 1 hour postprocedure
- C. Positions the client onto the right side
- D. Has the client cough and deep-breathe hourly
Correct Answer: C
Rationale: A. After a liver biopsy VS should be assessed every 15 minutes times two, every 30 minutes times four, and then every hour times four to monitor for shock, peritonitis, and pneumothorax. B. The client should be kept flat in bed for 12 to 14 hours following the procedure to prevent the risk of bleeding. C. Positioning the client on the right side after a liver biopsy splints the puncture site to prevent and decrease bleeding. D. The client should be cautioned to avoid coughing, which could precipitate bleeding.