Nokea
The nurse identifies the client problem 'excess fluid volume' for the client in liver failure. Which short-term goal would be most appropriate for this problem?
- A. The client will not gain more than two (2) kg a day.
- B. The client will have no increase in abdominal girth.
- C. The client's vital signs will remain within normal limits.
- D. The client will receive a low-sodium diet.
Correct Answer: B
Rationale: No increase in abdominal girth indicates stable ascites, directly addressing excess fluid volume. Weight gain limits, vital signs, and diet are related but less specific.
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The client complains to the nurse of unhappiness with the health-care provider. Which intervention should the nurse implement next?
- A. Call the HCP and suggest he or she talk with the client.
- B. Determine what about the HCP is bothering the client.
- C. Notify the nursing supervisor to arrange a new HCP to take over.
- D. Explain the client cannot request another HCP until after discharge.
Correct Answer: B
Rationale: Determining the specific issue allows the nurse to address the concern effectively, whether through communication, advocacy, or escalation. Contacting the HCP or supervisor prematurely or dismissing the client’s request is less appropriate.
The client diagnosed with end-stage liver failure is admitted with esophageal bleeding. The HCP inserts and inflates a triple-lumen nasogastric tube (Sengstaken-Blakemore). Which nursing intervention should the nurse implement for this treatment?
- A. Assess the gag reflex every shift.
- B. Stay with the client at all times.
- C. Administer the laxative lactulose (Chronulac).
- D. Monitor the client's ammonia level.
Correct Answer: B
Rationale: The Sengstaken-Blakemore tube can dislodge or cause complications like aspiration, requiring constant monitoring. Gag reflex, lactulose, and ammonia are unrelated to this intervention.
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.
The nurse is preparing to care for the client immediately after a Whipple procedure. The nurse should plan to include which action?
- A. Monitor the blood glucose levels
- B. Administer enteral feedings
- C. Irrigate the NG tube with 30 mL of saline
- D. Assist with bowel elimination within 8 hours of surgery
Correct Answer: A
Rationale: A. The Whipple procedure induces insulin-dependent diabetes because the proximal pancreas is resected. Thus, the blood glucose levels should be monitored closely starting immediately after surgery. B. Parenteral (not enteral) feedings are the method of choice for providing nutrition immediately after surgery. C. The NG tube is strategically placed during surgery and should not be irrigated without a surgeon’s order. With an order, gentle irrigation with 10 to 20 mL of NS is appropriate. D. Since this surgery reshapes the GI tract, the client will not have peristalsis and bowel movements for several days.
The client is being prepared for discharge after a laparoscopic cholecystectomy. Which intervention should the nurse implement?
- A. Discuss the need to change the abdominal dressing daily.
- B. Tell the client to check the T-tube output every eight (8) hours.
- C. Include the significant other in the discharge teaching.
- D. Instruct the client to stay off clear liquids for two (2) days.
Correct Answer: C
Rationale: Including the significant other ensures support and reinforces discharge teaching for recovery. Daily dressing changes are unnecessary, T-tubes are not used in laparoscopic procedures, and clear liquids are encouraged.