Nokea
The home health nurse is performing a follow-up visit for the client diagnosed with chronic hepatitis B. The client is being treated with interferon alpha-2b. Which client comment requires further assessment by the nurse?
- A. “My clothes are tight; I gained 2 pounds this month.”
- B. “Whenever I just bump into anything, I get a bruise.”
- C. “I’ve been staying home and avoiding large crowds.”
- D. “I get tired easily, so I just take my time with things.”
Correct Answer: B
Rationale: A. Anorexia is commonly seen with hepatitis B. A weight gain of 2 lb in one month would typically not be a cause for concern. B. Bruising can indicate thrombocytopenia, which is an adverse effect of treatment. Thrombocytopenia can also occur from liver dysfunction. C. Avoiding large crowds is appropriate; the client will be at increased risk for infection while taking interferon alpha-2b. D. Fatigue is commonly associated with chronic hepatitis B.
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The client being admitted from the emergency department is diagnosed with a fecal impaction. Which nursing intervention should be implemented?
- A. Administer an antidiarrheal medication every day and prn.
- B. Perform bowel training every two (2) hours.
- C. Administer an oil retention enema.
- D. Prepare for an upper gastrointestinal (UGI) series x-ray.
Correct Answer: C
Rationale: An oil retention enema softens and facilitates removal of impacted stool. Antidiarrheals are contraindicated, bowel training is long-term, and UGI is irrelevant.
The nurse is assessing the client who is 24 hours post—GI hemorrhage. The findings include BUN of 40 mg/dL and serum creatinine of 0.8 mg/dL. Which action should be taken by the nurse?
- A. Immediately call the health care provider to report these results.
- B. Monitor urine output, as this may be a sign of kidney failure.
- C. Document the findings and continue to monitor the client.
- D. Encourage the client to limit his or her dietary protein intake.
Correct Answer: C
Rationale: A. No treatment is required; it is unnecessary to call the HCP. B. If acute kidney failure is present, both the BUN and creatinine would be elevated. C. The findings should be documented. The BUN can be elevated after a significant GI hemorrhage from the breakdown of blood proteins. The protein breakdown releases nitrogen that is then converted to urea. D. Limiting protein intake in the presence of healthy kidneys is unnecessary.
The nurse assesses the client previously diagnosed as having an inguinal hernia. The nurse considers that the client’s hernia may be strangulated when which assessment findings are noted?
- A. Abdominal distention
- B. Dyspnea with exertion
- C. Severe abdominal pain
- D. No stool for the past week
- E. Hyperactive bowel sounds
Correct Answer: A, C, D
Rationale: Abdominal distention occurs because the bowel is obstructed when the hernia is strangulated. B. Dyspnea with exertion is not associated with strangulation of an inguinal hernia. C. Lack of blood supply from strangulation causes severe abdominal pain. D. A bowel obstruction prevents the passage of stool. E. Bowel sounds with strangulation and bowel obstruction would be hypoactive or absent, not hyperactive.
The nurse is caring for the postoperative client who underwent an open Roux-en-Y gastric bypass. The charge nurse should intervene if which observation is made?
- A. The nursing care plan for postoperative day one indicates restricting fluids to 30—60 mL per hour of clear liquids.
- B. The nurse is instructing the licensed practical nurse (LPN) to remove the client’s urinary catheter 24 hours after surgery.
- C. The client is wearing a bilevel positive airway pressure (BiPAP) mask when sleeping during the day.
- D. A bottle of saline and 60-mL catheter-tip syringe are on the bedside table for nasogastric (NG) tube irrigation.
Correct Answer: D
Rationale: A. For the first 24-48 hours postoperatively, the client sips small amounts of clear liquids to avoid nausea, vomiting, and distention and stress on the suture line. B. If used, urinary catheters should be removed within 24 hours after surgery to prevent UTIs and to encourage mobility. The nurse may delegate this task to an LPN. C. The BiPAP mask is used to keep the airway open and should be worn whenever the client is sleeping. D. A bottle of saline and a large-sized syringe may indicate that the client’s NG tube has been or will be irrigated. Manipulating or irrigating an NG tube with too much solution can lead to disruption of the anastomosis in gastric surgeries. If an NG tube is present the surgeon should be consulted before irrigating the tube.
The school nurse is discussing methods to prevent an outbreak of hepatitis A with a group of high school teachers. Which action is the most important to teach the high school teachers?
- A. Do not allow students to eat or drink after each other.
- B. Drink bottled water as much as possible.
- C. Encourage protected sexual activity.
- D. Sing the happy birthday song while washing hands.
Correct Answer: D
Rationale: Handwashing (e.g., for the duration of singing 'Happy Birthday') is the most effective way to prevent fecal-oral transmission of hepatitis A in a school setting. Sharing food/drink is a risk but less critical than hygiene.