Nokea
The client with cirrhosis is scheduled for a transjugular intrahepatic portosystemic shunt (TIPS) placement. The nurse realizes the client does not understand the procedure when the client makes which statement?
- A. “I hope the abdominal incision heals fast after this procedure so I can return home.”
- B. “My risk of bleeding from my esophagus again should be decreased after this procedure.”
- C. “The shunt they are placing could become occluded in the future; I hope it doesn’t happen.”
- D. “This procedure should keep me from getting so much fluid buildup in my abdomen.”
Correct Answer: A
Rationale: A. This statement indicates the client does not understand the procedure. There is no need for an abdominal incision. The TIPS is placed through the jugular vein and threaded down to the hepatic vein. B. The TIPS procedure will decrease pressure in the portal vein and thus decrease the risk of bleeding from esophageal varices. C. There is a risk that the stent that is placed will become occluded. D. The shunt will decrease ascites formation.
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The nurse is administering morning medications at 0730. Which medication should have priority?
- A. A proton pump inhibitor.
- B. A nonnarcotic analgesic.
- C. A histamine receptor antagonist.
- D. A mucosal barrier agent.
Correct Answer: A
Rationale: Proton pump inhibitors (PPIs) are the mainstay treatment for GERD, reducing acid production and preventing esophageal damage. They should be prioritized over analgesics, histamine receptor antagonists, or mucosal barrier agents, which are less critical for immediate symptom control and healing.
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.
The female nurse sticks herself with a contaminated needle. Which action should the nurse implement first?
- A. Notify the infection control nurse.
- B. Cleanse the area with soap and water.
- C. Request postexposure prophylaxis.
- D. Check the hepatitis status of the client.
Correct Answer: B
Rationale: Cleansing the area with soap and water immediately reduces infection risk, including hepatitis. Notification, prophylaxis, and checking status follow after initial decontamination.
The nurse caring for a client diagnosed with GERD writes the client problem of 'behavior modification.' Which intervention should be included for this problem?
- A. Teach the client to sleep with a foam wedge under the head.
- B. Encourage the client to decrease the amount of smoking.
- C. Instruct the client to take over-the-counter medication for relief of pain.
- D. Discuss the need to attend Alcoholics Anonymous to quit drinking.
Correct Answer: A
Rationale: Sleeping with a foam wedge elevates the head, reducing reflux by preventing stomach acid from flowing into the esophagus during sleep, a key behavioral modification for GERD. Smoking cessation is beneficial but less specific to immediate symptom relief, and the other options are not directly related to behavior modification for GERD.
Which data should the nurse report to the healthcare provider when assessing the oral cavity of an elderly client?
- A. The client's tongue is rough and beefy red.
- B. The client's tonsils are +1 on a grading scale.
- C. The client's mucosa is pink and moist.
- D. The client's uvula rises with the mouth open.
Correct Answer: A
Rationale: A rough, beefy red tongue may indicate vitamin B12 deficiency or glossitis, warranting HCP notification. Normal tonsil size, pink/moist mucosa, and uvula movement are expected findings.