Nokea
The following nursing diagnosis is written for a comatose client with cirrhosis of the liver and secondary splenomegaly--High risk for injury: Increased susceptibility to bleeding related to:
- A. Increased absorption of vitamin K
- B. Thrombocytopenia due to hypersplenism
- C. Diminished function of the Kupffer cells
- D. Increased synthesis of the clotting factors
Correct Answer: B
Rationale: There is a decreased absorption of vitamin K with cirrhosis of the liver. This decrease impairs blood coagulation and the formation of prothrombin. Thrombocytopenia, an increased destruction of platelets, occurs secondary to hypersplenism. A diminished function of the Kupffer cells occurs with cirrhosis of the liver, causing the client to become more susceptible to infections. A decrease in the synthesis of fibrinogen and clotting factors VII, IX, and X occurs with cirrhosis of the liver and increases the susceptibility to bleeding.
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A client with pregnancy-induced hypertension is scheduled for a C-section. Before surgery, the nurse should keep the client:
- A. On her right side
- B. Supine with a small pillow
- C. On her left side
- D. In knee chest position
Correct Answer: C
Rationale: The left lateral position improves uteroplacental blood flow in pregnancy-induced hypertension, reducing fetal distress risk. Right-sided, supine, or knee-chest positions are less optimal.
A client had a right below-the-knee amputation 4 days ago. He is complaining of pain in his right lower leg. The nurse should:
- A. Remind the client that he no longer has that part of his leg and assure him he will be OK
- B. Call the physician to request a psychological consultation for the client
- C. Turn on the television to distract the client's attention from his amputated leg
- D. Give the client his order of Demerol 50 mg IM prn
Correct Answer: D
Rationale: Phantom pain is a normal, very real experience for an amputee and should be treated with pain medication.
The client with a history of epilepsy is prescribed valproic acid (Depakote). Which laboratory test should the nurse monitor?
- A. Liver function tests
- B. Renal function tests
- C. Complete blood count
- D. Electrolytes
Correct Answer: A
Rationale: Valproic acid can cause hepatotoxicity, so liver function tests (e.g., AST, ALT) are monitored regularly. Renal function, blood counts, and electrolytes are less commonly affected.
The charge nurse is making assignments for the day. After accepting the assignment to care for a client with leukemia, the nurse tells the charge nurse that her child has chickenpox. Which initial action should the charge nurse take?
- A. Change the nurse's assignment to another client.
- B. Explain to the nurse that there is no risk to the client.
- C. Ask the nurse if the chickenpox have crusted.
- D. Ask the nurse if she has ever had the chickenpox.
Correct Answer: D
Rationale: The charge nurse should first ask if the nurse has had chickenpox or been vaccinated, as immunity prevents transmission to the immunocompromised leukemia client. If non-immune, the assignment should be changed. Asking about crusting or explaining no risk is incorrect, as varicella is contagious until lesions crust.
While the RN is assessing a mother's perineum on her 2nd postpartum day after having a vaginal delivery, the RN notes a large ecchymotic area located to the left of the mother's perineum. Which one of the following interventions should the RN initiate at this time?
- A. Have the client expose the area to air.
- B. Apply ice to the perineum.
- C. Encourage the client to take warm sitz baths.
- D. Inform the physician.
Correct Answer: C
Rationale: Warm sitz baths increase circulation, promote healing, and reduce edema in a traumatized perineum, making it appropriate for an ecchymotic area.