Nokea
The nurse is assessing a client with cirrhosis who has developed hepatic encephalopathy. The nurse should notify the physician of a decrease in which lab serum that is a potential precipitating factor for hepatic encephalopathy?
- A. Aldosterone.
- B. Creatinine.
- C. Potassium.
- D. Protein.
Correct Answer: C
Rationale: Hypokalemia (C) can precipitate hepatic encephalopathy by increasing ammonia production. Aldosterone (A), creatinine (B), and protein (D) are less directly related.
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A client has a ureteral catheter in place after renal surgery. A priority nursing action for care of the ureteral catheter would be to:
- A. Irrigate the catheter with 30 mL of normal saline every 8 hours.
- B. Ensure that the catheter is draining freely.
- C. Clamp the catheter every 2 hours for 30 minutes.
- D. Ensure that the catheter drains at least 30 mL/hour.
Correct Answer: B
Rationale: Ensuring free drainage prevents obstruction or pressure buildup, which could harm the surgical site or kidney function.
A client who is scheduled for an open cholecystectomy has a 20-pack-year history of smoking. For which postoperative complication is the client most at risk?
- A. Deep vein thrombosis.
- B. Atelectasis and pneumonia.
- C. Delayed wound healing.
- D. Prolonged immobility.
Correct Answer: B
Rationale: Smoking impairs lung function and ciliary clearance, increasing the risk of atelectasis and pneumonia post-surgery due to reduced lung expansion and mucus clearance.
Which of the following explains the influence of aging on the development of peripheral vascular disease?
- A. Decreased resistance
- B. Increased resistance
- C. Decreased viscosity
- D. Increased viscosity
Correct Answer: B
Rationale: Aging increases vascular resistance due to arterial stiffening and reduced elasticity from collagen buildup and atherosclerosis. This elevates blood pressure and impairs peripheral blood flow, contributing to PVD. Resistance does not decrease, and viscosity changes are less significant in aging-related PVD.
The nurse is teaching a client with a new colostomy about dietary modifications. Which of the following foods should the client avoid to prevent excessive gas?
- A. Broccoli.
- B. Chicken.
- C. Rice.
- D. Yogurt.
Correct Answer: A
Rationale: Broccoli, a cruciferous vegetable, can cause excessive gas in clients with a colostomy, which may lead to pouch ballooning. Chicken, rice, and yogurt are less likely to produce significant gas. CN: Physiological adaptation; CL: Synthesize
Which of the following diets would be most appropriate for the client with ulcerative colitis?
- A. High-calorie, low-protein.
- B. High-protein, low-residue.
- C. Low-fat, high-fiber.
- D. Low-sodium, high-carbohydrate.
Correct Answer: B
Rationale: A high-protein, low-residue diet is appropriate for ulcerative colitis as it provides nutrients for healing while minimizing bowel irritation. High-fiber diets may worsen symptoms during flares, and the other options are less tailored to the condition's needs. CN: Physiological adaptation; CL: Apply