Nokea
The nurse is caring for the client diagnosed with cirrhosis. After completing discharge education, the nurse recognizes the need for further teaching when the client makes which statement?
- A. “My cirrhosis was caused from too much alcohol; I plan to stop drinking.”
- B. “I need to rest more; I plan on only going to work on a part-time basis.”
- C. “Propranolol has been ordered to decrease my blood pressure.”
- D. “Furosemide will help to reduce the amount of abdominal fluid.”
Correct Answer: C
Rationale: A. Alcohol intake is a major cause of cirrhosis and must be eliminated from the client’s diet. B. Rest may enable the liver to restore itself and should be encouraged. C. Although propranolol (Inderal) does decrease BP, it is not ordered for this purpose in treating cirrhosis. Prophylactic treatment with a nonselective beta blocker like propranolol has been shown to reduce the risk of bleeding from esophageal varices and to reduce bleeding-related deaths. D. Furosemide (Lasix) is used in combination with potassium-sparing diuretics to decrease ascites.
You may also like to solve these questions
The nurse is caring for the newly admitted client with acute necrotizing pancreatitis. Which interventions, if prescribed, should the nurse implement?
- A. NS 1000 mL IV over 1 hour, then IV fluids at 250 mL/hour
- B. Initiate nasojejunal enteral feedings with a low-fat formula
- C. Imipenem-cilastatin 500 mg IV every 6 hours
- D. Up to chair for meals and ambulate four times daily
- E. Position left side-lying with head of bed elevated 30 degrees
- F. Insert a urinary catheter; monitor urine output every 2 hours
Correct Answer: A, B, C, F
Rationale: Giving an IV bolus followed by fluids at 250 mL/hour should be implemented. A large amount of fluids is lost due to third spacing into the retroperitoneum and intraabdominal area. Fluids are needed to prevent hypovolemia and maintain hemodynamic stability. B. Nasojejunal enteral feedings with a low-fat formula should be initiated to decrease the secretion of secretin, meet calorie needs, and maintain a positive nitrogen balance. C. Antibiotics, usually medications of the imipenem class such as imipenem-cilastatin (Primaxin), are used when pancreatitis is complicated by infected pancreatic necrosis. They have greater potency and a broader antimicrobial spectrum than other beta-lactam antibiotics. D. The client should be maintained on bedrest to decrease the metabolic rate and therefore reduce pancreatic secretions. E. Discomfort frequently improves with the client in the supine position rather than side-lying. F. A urinary catheter should be inserted to closely monitor urine output for circulating fluid volume status and to monitor for complications.
The client with a new colostomy is being discharged. Which statement made by the client indicates the need for further teaching?
- A. If I notice any skin breakdown, I will call the HCP.
- B. I should drink only liquids until the colostomy starts to work.
- C. I should not take a tub bath until the HCP okays it.
- D. I should not drive or lift more than five (5) pounds.
Correct Answer: B
Rationale: A liquid-only diet is unnecessary; a regular diet can be resumed as tolerated unless otherwise specified, as colostomies begin functioning soon after surgery. The other statements reflect correct colostomy care.
The nurse is preparing to administer the initial dose of an aminoglycoside antibiotic to the client diagnosed with acute diverticulitis. Which intervention should the nurse implement?
- A. Obtain a serum trough level.
- B. Ask about drug allergies.
- C. Monitor the peak level.
- D. Assess the vital signs.
Correct Answer: B
Rationale: Checking for drug allergies before administering an aminoglycoside prevents allergic reactions, a critical safety step. Trough and peak levels are monitored later, and vital signs are routine but not specific to the initial dose.
The male client had abdominal surgery and the nurse suspects the client has peritonitis. Which assessment data support the diagnosis of peritonitis?
- A. Absent bowel sounds and potassium level of 3.9 mEq/L.
- B. Abdominal cramping and hemoglobin of 14 g/dL.
- C. Profuse diarrhea and stool specimen shows Campylobacter.
- D. Hard, rigid abdomen and white blood cell count 22,000/mm3.
Correct Answer: D
Rationale: A hard, rigid abdomen and elevated WBC count (22,000/mm3) indicate peritonitis due to peritoneal inflammation and infection. Absent bowel sounds are nonspecific, cramping with normal hemoglobin is less indicative, and diarrhea with Campylobacter suggests gastroenteritis.
The client is diagnosed with an acute exacerbation of inflammatory bowel disease (IBD). Which food selection would be the best choice for a meal?
- A. Roast beef on wheat bread and a milk shake.
- B. Hamburger, french fries, and a cola.
- C. Pepper steak, brown rice, and iced tea.
- D. Roasted turkey, instant mashed potatoes, and water.
Correct Answer: D
Rationale: Roasted turkey, instant mashed potatoes, and water are low-residue, easy-to-digest foods suitable for acute IBD exacerbation. Other options are high-fiber or irritating.