Nokea
The nurse is caring for a client with cirrhosis of the liver who is receiving lactulose. Which of the following findings indicate a therapeutic response?
- A. Increased liver enzymes
- B. Increased level of consciousness
- C. Decreased urinary calcium
- D. Increased gastric pH
Correct Answer: B
Rationale: Lactulose reduces ammonia levels in cirrhosis by promoting its excretion, improving hepatic encephalopathy and thus increasing level of consciousness. Increased liver enzymes, decreased urinary calcium, and increased gastric pH are not therapeutic outcomes.
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The nurse is developing a plan of care for a client who had bariatric surgery. Which of the following should the nurse include?
- A. Applying pneumatic compression devices
- B. Inserting an indwelling urinary catheter
- C. Placing the client on strict bed rest
- D. Measuring the abdominal girth
Correct Answer: A
Rationale: Pneumatic compression devices (A) prevent thromboembolism, a key risk post-bariatric surgery due to immobility and obesity. Catheters (B), bed rest (C), and girth measurement (D) are not routinely required.
The nurse is assessing a client with ulcerative colitis. Which of the following would be an expected finding?
- A. Projectile vomiting
- B. Frequent bloody stools
- C. Absent bowel sounds
- D. Periumbilical bruising
Correct Answer: B
Rationale: Frequent bloody stools (B) are a hallmark of ulcerative colitis due to mucosal inflammation. Projectile vomiting (A), absent bowel sounds (C), and periumbilical bruising (D) are not typically associated with UC.
The following scenario applies to the next 1 items
The nurse is caring for a client in the outpatient clinic
Item 1 of 1
Nurses’ Note
35-year-female arrives at the clinic for reported loss of appetite and nausea. The client reports that she is not eating as much because she experiences palpitations, sweating, and dizziness about thirty minutes after she eats. She reports that she has not been adherent to the prescribed diet and her symptoms worsen when she eats something sweet and drinks cola.
Medical History
• Morbid obesity (BMI 42)
• Roux-en-Y procedure eight weeks ago
Complete the following sentence by choosing from the list of options. To prevent.........., the nurse should instruct the client ............. and ...........
- A. Pernicious anemia
- B. Dumping syndrome
- C. Lie down after meals
- D. Exercise after meals
- E. Avoid drinking with meals
- F. Eat food high in carbohydrates
- G. Eat food high in vitamin B12
Correct Answer: B,E
Rationale: Dumping syndrome (B) occurs post-Roux-en-Y due to rapid gastric emptying. Avoiding drinking with meals (E) slows digestion, reducing symptoms. Lying down after meals (C) can worsen symptoms and is not advised.
The nurse is caring for a client who has ascites and hepatic encephalopathy. Which of the following prescriptions should the nurse clarify with the primary healthcare provider (PHCP)?
- A. Alprazolam
- B. Rifaximin
- C. Lactulose
- D. Spironolactone
Correct Answer: A
Rationale: Alprazolam (A), a benzodiazepine, can worsen hepatic encephalopathy by increasing sedation and ammonia levels. Rifaximin (B), lactulose (C), and spironolactone (D) are appropriate for managing hepatic encephalopathy and ascites.
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.