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The nurse is admitting a patient who is homeless and has viral hepatitis with symptoms of severe anorexia and fatigue. Which of the following patient goals should have the highest priority when the nurse is developing the plan of care?
- A. Increase activity level.
- B. Maintain adequate nutrition.
- C. Establish a stable home environment.
- D. Identify the source of exposure to hepatitis.
Correct Answer: B
Rationale: The highest priority outcome is to maintain nutrition because adequate nutrition is needed for hepatocyte regeneration. Finding a home for the patient and identifying the source of the infection would be appropriate activities, but they do not have as high a priority as ensuring adequate nutrition. Although the patient's activity level will be gradually increased, rest is indicated during the acute phase of hepatitis.
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Which of the following nursing actions should be included in the plan of care for a patient who is being treated for bleeding esophageal varices with balloon tamponade using a device such as a Blakemore tube?
- A. Monitor the patient for shortness of breath.
- B. Encourage the patient to cough every 4 hours.
- C. Deflate the gastric balloon every 12 hours.
- D. Verify the position of the balloon every 6 hours.
Correct Answer: A
Rationale: A common complication of balloon tamponade is occlusion of the airway by the balloon, so it is important to monitor the patient's respiratory status. In addition, if the gastric balloon ruptures, the esophageal balloon may slip upward and occlude the airway. Coughing increases the pressure on the varices and increases the risk for bleeding. Balloon position is verified after insertion and does not require further verification. The esophageal balloon is deflated every 8-12 hours to avoid necrosis, but if the gastric balloon is deflated, the esophageal balloon may occlude the airway.
Which of the following assessment findings in a patient with acute pancreatitis should the nurse report urgently to the health care provider?
- A. Nausea and vomiting
- B. Hypotonic bowel sounds
- C. Abdominal tenderness and guarding
- D. Muscle twitching and finger numbness
Correct Answer: D
Rationale: Muscle twitching and finger numbness indicate hypocalcemia, which may lead to tetany unless calcium gluconate is administered. Numbness or tingling around the lips and in the fingers is an early indicator of hypocalcemia. Although the other findings also should be reported to the health care provider, they do not indicate complications that require rapid action.
The nurse is caring for a patient with cirrhosis and esophageal varices who has a new prescription for propranolol. Which of the following assessment findings is the best indicator that the medication has been effective?
- A. The apical pulse rate is 68 beats/minute.
- B. Stools test negative for occult blood.
- C. The patient denies complaints of chest pain.
- D. Blood pressure is less than 140/90 mm Hg.
Correct Answer: B
Rationale: Since the purpose of β-blocker therapy for patients with esophageal varices is to decrease the risk for bleeding from esophageal varices, the best indicator of the effectiveness for propranolol is the lack of blood in the stools. Although propranolol is used to treat hypertension, angina, and tachycardia, the purpose for use in this patient is to decrease the risk for bleeding from esophageal varices.
The nurse is admitting a patient with acute cholecystitis. Which of the following findings is most important for the nurse to report to the health care provider?
- A. The patient's urine is bright yellow.
- B. The patient's stools are clay coloured.
- C. The patient complains of persistent heartburn.
- D. The patient has an increase in pain after eating.
Correct Answer: B
Rationale: The clay-coloured stools indicate biliary obstruction, which requires rapid intervention to resolve. The other data are not unusual for a patient with this diagnosis, although the nurse also would report the other assessment information to the health care provider.
Which of the following findings in a blood specimen indicates that the administration of hepatitis B vaccine to a patient has been effective?
- A. HBsAg
- B. Anti-HBs
- C. Anti-HBc IgG
- D. Anti-HBc IgM
Correct Answer: B
Rationale: The presence of surface antibody to HBV (anti-HBs) is a marker of a positive response to the vaccine. The other laboratory values indicate current infection with HBV.