Nokea
The nurse is admitting a patient to the emergency department with pancreatitis who has been vomiting blood. Which of the following actions should the nurse take first?
- A. Insert a large-gauge IV catheter.
- B. Draw blood for coagulation studies.
- C. Check BP, heart rate, and respirations.
- D. Place the patient in the supine position.
Correct Answer: C
Rationale: The nurse's first action should be to determine the patient's hemodynamic status by assessing vital signs. Drawing blood for coagulation studies and inserting an IV catheter also are appropriate. However, the vital signs may indicate the need for more urgent actions. Since aspiration is a concern for this patient, the nurse will need to assess the patient's vital signs and neurological status before placing the patient in the supine position.
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The nurse is assessing a patient who had a liver transplant a week previously and obtains the following data. Which of the following findings is most important to communicate to the health care provider?
- A. Dry lips and oral mucosa
- B. Crackles at both lung bases
- C. Temperature 38.2°C (100.8°F)
- D. Pain at the incision site
Correct Answer: B
Rationale: Crackles at both lung bases may indicate pulmonary edema or infection, which are serious complications post-liver transplant requiring immediate attention. Dry lips, fever, and incisional pain are also concerning but less urgent unless accompanied by other critical symptoms.
The nurse is admitting a patient with acute bleeding from esophageal varices who asks the nurse the purpose for the ordered pantoprazole. Which of the following responses by the nurse is best?
- A. The medication will reduce the risk for aspiration.
- B. The medication will decrease nausea and anorexia.
- C. The medication will inhibit the development of gastric ulcers.
- D. The medication will prevent irritation to the esophageal varices.
Correct Answer: D
Rationale: Pantoprazole is a proton pump inhibitor. Supportive measures during an acute variceal bleed include administration of fresh-frozen plasma and packed red blood cells, vitamin K, and proton pump inhibitors. Although pantoprazole does decrease the risk for peptic ulcers, reduce nausea, and help prevent aspiration pneumonia, these are not the primary purpose for its use in this patient.
The nurse is caring for a patient with persistent hepatitis C infection who has these
- A. Teach symptoms of variceal bleeding
- B. Review the patient's current medication list.
- C. Draw blood for hepatitis serology testing.
Correct Answer: C
Rationale: Reviewing the patient's current medication list is critical to identify drugs that may exacerbate liver damage or interact with hepatitis C treatments. Teaching about variceal bleeding is not relevant unless the patient has advanced liver disease with portal hypertension. Hepatitis serology is unnecessary since the diagnosis of persistent hepatitis C is already established.
The nurse is preparing a teaching plan for a young adult patient who is diagnosed with early alcoholic cirrhosis. Which of the following topics is most important to include in patient teaching?
- A. Need to abstain from alcohol
- B. Use of vitamin B supplements
- C. Maintenance of a nutritious diet
- D. Treatment with lactulose
Correct Answer: A
Rationale: The disease progression can be stopped or reversed by alcohol abstinence. The other interventions may be used when cirrhosis becomes more severe to decrease symptoms or complications, but the priority for this patient is to stop the progression of the disease.
The nurse is caring for a patient following an incisional cholecystectomy for cholelithiasis. Which of the following actions is priority for the nurse to implement?
- A. Patient education about low-fat food choices.
- B. Perform leg exercises hourly while awake.
- C. Ambulate the evening of the operative day.
- D. Turn, cough, and deep breathe every 2 hours.
Correct Answer: D
Rationale: Postoperative nursing care for incisional cholecystectomy is the same as general postoperative nursing care. Postoperative nursing care after a cholecystectomy focuses on prevention of respiratory complications because the surgical incision is high in the abdomen and impairs coughing and deep breathing. The other nursing actions also are important to implement but are not as high a priority as ensuring adequate ventilation.