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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.
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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.
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.
The nurse is providing discharge instructions to a patient following a laparoscopic cholecystectomy. Which of the following patient statements indicate that the teaching has been effective?
- A. I can remove the bandages on my incisions tomorrow and take a shower.
- B. I can expect some yellow-green drainage from the incision for a few days.
- C. I should plan to limit my activities and not return to work for 4-6 weeks.
- D. I will always need to maintain a low-fat diet since I no longer have a gallbladder.
Correct Answer: A
Rationale: After a laparoscopic cholecystectomy, the patient will have Band-Aids in place over the incisions. Patients are discharged the same (or next) day and have few restrictions on activities of daily living. Drainage from the incisions would be abnormal, and the patient should be instructed to call the health care provider if this occurs. A low-fat diet may be recommended for a few weeks after surgery but will not be a lifelong requirement.
The nurse is planning care for a patient with acute severe pancreatitis. Which of the following patient outcomes is priority?
- A. Expressing satisfaction with pain control
- B. Developing no ongoing pancreatic problems
- C. Maintaining normal respiratory function
- D. Having adequate fluid and electrolyte balance
Correct Answer: C
Rationale: Respiratory failure can occur as a complication of acute pancreatitis, and maintenance of adequate respiratory function is the priority goal. The other outcomes also would be appropriate for the patient.
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.