Nokea
The nurse assisting in the treatment of a patient with ruptured esophageal varices who has received vasopressin IV will carefully assess for which complication?
- A. muscular twitching/spasm.
- B. hematuria.
- C. macular rash on trunk and arms.
- D. evidence of cardiac ischemia.
Correct Answer: D
Rationale: Vasopressin is a strong vasoconstrictor given to try to stop the hemorrhage of the varices. Unfortunately it also constricts all vessels and may cause cardiac ischemia.
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Which is the most common procedure for the removal of the gallbladder?
- A. Laparoscopic cholecystectomy
- B. Cholangiography
- C. Open cholecystectomy
- D. Choledochostomy
Correct Answer: A
Rationale: The most recently developed operative procedure, which is now the most common treatment for cholecystitis and cholelithiasis, is done by way of endoscopy. It is called laparoscopic cholecystectomy and uses laser cautery to remove the gallbladder.
A patient returning from a 2-week camping trip a few days ago, reports having nausea, anorexia, and dark urine. Which additional information would assist in diagnosing hepatitis A?
- A. Exposure to blood
- B. Recent ingestion of raw fish
- C. History of intravenous drug use
- D. Multiple sex partners
Correct Answer: B
Rationale: Hepatitis A spreads by direct contact through the oral-fecal route, usually by food and water contaminated with feces.
The patient with cirrhosis has a rising ammonia level and is becoming disoriented. The patient's hands flap when the patient stretches out the arm. How will the nurse interpret this?
- A. As an attempt to get the nurse's attention
- B. As asterixis
- C. As an indication of respiratory obstruction from varices
- D. As spasticity
Correct Answer: B
Rationale: Asterixis is the 'flapping tremor' seen as the patient deteriorates into ammonia intoxication or hepatic encephalopathy.
A patient with pancreatitis is on nothing by mouth status (NPO). The patient asks the nurse 'Why am I unable to have anything by mouth?'. Which is the best response?
- A. Diagnostic tests depend on you not eating anything.'
- B. The pancreas is stimulated whenever you eat or drink and causes pain.'
- C. Eating causes the need for a bowel movement, which excretes your medication too rapidly.'
- D. Resting your gastrointestinal tract will cure your pancreatitis.'
Correct Answer: B
Rationale: Food and fluids are withheld to avoid stimulating pancreatic activity, and IV fluids are administered.
When caring for an extremely jaundiced patient with cirrhosis, which does the nurse expect to see included in the plan of care?
- A. Encouraging consumption of a high-fat diet
- B. Skin care to relieve pruritus
- C. Offering foods rich in fat-soluble vitamins
- D. Meticulous foot care
Correct Answer: B
Rationale: Jaundice causes pruritus and can lead to skin lesions and pressure injury.