Nokea
The nurse is caring for a patient with acute pancreatitis. Which of the following findings is of most concern?
- A. Absent bowel sounds
- B. Abdominal tenderness
- C. Left upper quadrant pain
- D. Palpable abdominal mass
Correct Answer: D
Rationale: A palpable abdominal mass in acute pancreatitis may indicate a pancreatic pseudocyst or abscess, which are serious complications requiring urgent intervention. Absent bowel sounds, abdominal tenderness, and left upper quadrant pain are common findings in acute pancreatitis but are less concerning unless accompanied by other critical symptoms.
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Which of the following patients should alert the nurse that screening for hepatitis C should be done?
- A. The patient eats frequent meals in fast-food restaurants.
- B. The patient recently travelled to an undeveloped country.
- C. The patient had a blood transfusion after surgery in 1999.
- D. The patient reports a one-time use of IV drugs 20 years ago.
Correct Answer: D
Rationale: Any patient with a history of IV drug use should be tested for hepatitis C. Blood transfusions given after 1992, when an antibody test for hepatitis C became available, do not pose a risk for hepatitis C. Hepatitis C is not spread by the oral-fecal route and therefore is not caused by contaminated food or by travelling in underdeveloped countries.
A patient contracts hepatitis from contaminated food. During the acute (icteric) phase of the patient's illness, which of the following serological findings should the nurse expect?
- A. Antibody to hepatitis D virus (anti-HDV)
- B. Hepatitis B surface antigen (HBsAg)
- C. Anti-hepatitis A virus immunoglobulin G (anti-HAV IgG)
- D. Anti-hepatitis A virus immunoglobulin M (anti-HAV IgM)
Correct Answer: D
Rationale: Hepatitis A is transmitted through the oral-fecal route, and antibody to HAV IgM appears during the acute phase of hepatitis A. The patient would not have antigen for hepatitis B or antibody for hepatitis D. Anti-HAV IgG would indicate past infection and lifelong immunity.
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.
The nurse is caring for a patient following an incisional cholecystectomy for cholelithiasis. Which of the following actions is priority for the nurse to implement?
- A. Patient education about low-fat food choices.
- B. Perform leg exercises hourly while awake.
- C. Ambulate the evening of the operative day.
- D. Turn, cough, and deep breathe every 2 hours.
Correct Answer: D
Rationale: Postoperative nursing care for incisional cholecystectomy is the same as general postoperative nursing care. Postoperative nursing care after a cholecystectomy focuses on prevention of respiratory complications because the surgical incision is high in the abdomen and impairs coughing and deep breathing. The other nursing actions also are important to implement but are not as high a priority as ensuring adequate ventilation.
The nurse is caring for a patient with persistent hepatitis C who is prescribed combination therapy of ?±-interferon and ribavirin. Which of the following findings should the nurse monitor for the presence of hepatitis C in the patient?
- A. Leukopenia
- B. Hypokalemia
- C. Polycythemia
- D. Hypoglycemia
Correct Answer: A
Rationale: Therapy with ribavirin and ?±-interferon may cause leukopenia. The other problems are not associated with this drug therapy.