Nokea
The nurse is admitting a client to their room at the hospital and observes that the client's skin and sclera are jaundiced. What does the nurse expect the client's total bilirubin levels to be?
- A. 0.2 mg/dL
- B. 1.0 mg/dL
- C. 2.0 mg/dL
- D. 3.0 mg/dL
Correct Answer: D
Rationale: Normally, total bilirubin concentration ranges from 0.2 to 1.3 mg/dL. If the serum bilirubin level exceeds 2.5 mg/dL, jaundice is visible, notably on the skin, oral mucous membranes, and, especially, sclera.
You may also like to solve these questions
A nurse is preparing a presentation for a local community group about hepatitis. Which information would the nurse include?
- A. Hepatitis B is transmitted primarily by the oral-fecal route.
- B. Hepatitis A is frequently spread by sexual contact.
- C. Hepatitis C increases a person's risk for liver cancer.
- D. Infection with hepatitis G is similar to hepatitis A.
Correct Answer: C
Rationale: Infection with hepatitis C increases the risk of a person developing hepatic (liver) cancer. Hepatitis A is transmitted primarily by the oral-fecal route, hepatitis B is frequently spread by sexual contact and infected blood. Hepatitis E is similar to hepatitis A whereas hepatitis G is similar to hepatitis C.
A client has developed drug-induced hepatitis from a drug reaction to antidepressants. What treatment does the nurse anticipate the client will receive to treat the reaction?
- A. Paracentesis
- B. Liver transplantation
- C. High-dose corticosteroids
- D. Azathioprine
Correct Answer: C
Rationale: Drug-induced hepatitis occurs when a drug reaction damages the liver. This form of hepatitis can be severe and fatal. High-dose corticosteroids usually administered first to treat the reaction. Liver transplantation may be necessary. Paracentesis should be used to withdraw fluid for the treatment of ascites. Azathioprine (Imuran) may be used for autoimmune hepatitis.
A client with esophageal varices is scheduled to undergo injection sclerotherapy. Which client statement indicates that the nurse's teaching was successful?
- A. The physician will use a balloon to compress the vessels.
- B. I might need to have this procedure done again.
- C. I seems odd that a rubber band can block off the vessels.
- D. A catheter will be inserted through my belly to fix the vessels.
Correct Answer: B
Rationale: Persistent portal hypertension allows varices to form again, making it necessary to repeat injection sclerotherapy or variceal banding regularly. Injection sclerotherapy involves passing an endoscope orally to locate the varix. Balloon tamponade is used to compress actively bleeding esophageal varices as a temporary measure. Variceal banding involves using a rubber band over the varix to restrict blood flow that eventually leads to sloughing.
The nurse is administering medications to a client who has elevated ammonia due to cirrhosis of the liver. What medication will the nurse give to detoxify ammonium and to act as an osmotic agent?
- A. Spirofolactone
- B. Cholestyaramine
- C. Lactulose
- D. Kanamyycin
Correct Answer: C
Rationale: Lactulose is administered to detoxify ammonium and to act as an osmotic agent, drawing water into the bowel, which causes diarrhea in some clients. Potassium-sparing diuretics such as spironolactone are used to treat ascites. Cholestyramine is a bile acid sequestrant and reduces pruritus. Kanamycin decreases intestinal bacteria and decreases ammonia but does not act as an osmotic agent.
A client is scheduled to have a laparoscopic cholecystectomy as an outpatient. The client asks the nurse when it will be possible to resume normal activities. What information should the nurse provide?
- A. Normal activities may be resumed the day after surgery.
- B. Normal activities may be resumed in 1 week.
- C. Normal activities may be resumed in 1 weeks.
- D. Normal activities may be resumed in 1 month.
Correct Answer: B
Rationale: A prolonged recovery period usually is unnecessary. Most clients resume normal activities within 1 week.