Nokea
The nurse is caring for a client with advanced liver cirrhosis receiving prescribed medications. Which medications would the nurse clarify with the primary healthcare provider (PHCP)? Select all that apply.
- A. Isoniazid
- B. Valproic Acid
- C. Amiodarone
- D. Lithium
- E. Thiamine
Correct Answer: A,B,C
Rationale: Isoniazid, valproic acid, and amiodarone are hepatotoxic and can exacerbate liver damage in cirrhosis, requiring clarification with the PHCP. Lithium is not primarily hepatotoxic, and thiamine is often beneficial in cirrhosis to prevent Wernicke’s encephalopathy.
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The nurse cares for a client four days postoperative following an open splenectomy. The client's vital signs are T 101.1°F (38.4°C), P 92, RR 17, BP 152/86, and pulse oximetry reading 95% on oxygen at 2 L/min via nasal cannula. The surgical wound is assessed to have erythema and purulent drainage. The nurse should take which actions? Select all that apply.
- A. Request an order for an antibiotic
- B. Notify the physician
- C. Ambulate the client to the bedside chair
- D. Obtain an order for blood cultures
- E. Increase the nasal cannula oxygen to 4 L/minute
Correct Answer: A,B,D
Rationale: Fever, erythema, and purulent drainage suggest infection, requiring notifying the physician (B), requesting antibiotics (A), and obtaining blood cultures (D). Ambulation (C) and increasing oxygen (E) are not indicated.
The nurse is teaching a client about their newly established colostomy. Which of the following statements by the client would require follow-up?
- A. I will call my primary healthcare provider (PHCP) immediately if my stoma becomes bluish.
- B. I should slowly introduce high-fiber foods in my diet.
- C. I must always wear a pouch over my stoma.
- D. I should clean the skin around my stoma with rubbing alcohol.
Correct Answer: D
Rationale: Using rubbing alcohol (D) can irritate the skin around the stoma. Options A, B, and C are appropriate for colostomy care.
Which of the following clients does the nurse suspect would benefit most from placement of a nasogastric tube?
- A. A 9-year-old client with a femur fracture.
- B. An 82-year-old client with congestive heart failure.
- C. A 65-year-old client on dialysis.
- D. A 52-year-old client with leukemia who is receiving chemotherapy.
Correct Answer: D
Rationale: A client receiving chemotherapy (D) may experience severe nausea and vomiting, necessitating an NG tube for decompression or feeding. The other conditions are less likely to require NG tube placement.
The nurse is caring for a client with appendicitis. Which of the following statements are correct regarding this condition? Select all that apply.
- A. McBurney's point tenderness is a sign of appendicitis
- B. Appendicitis is more common among males
- C. A low carbohydrate diet is a risk factor for appendicitis
- D. Diagnosis of appendicitis is confirmed by endoscopic retrograde cholangiopancreatography
- E. The client may have an elevated white blood cell count (WBC)
Correct Answer: A,E
Rationale: McBurney's point tenderness (A) and elevated WBC (E) are hallmark signs of appendicitis. It is not more common in males (B), low-carb diets (C) are not a risk factor, and ERCP (D) is not used for diagnosis.
The nurse is caring for a client who is having a liver biopsy. Which positioning should the nurse place the client in immediately following the procedure?
- A. Supine
- B. Right lateral
- C. Sitting position with legs dangling off the edge of the bed
- D. Left lateral
Correct Answer: B
Rationale: Right lateral positioning (B) applies pressure to the biopsy site, minimizing bleeding risk post-liver biopsy.