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The nurse is caring for the client with hepatic encephalopathy who is receiving lactulose. Which finding should the nurse expect after the administration of this medication?
- A. An increase in body temperature
- B. Neurological changes, such as confusion
- C. A change in urine specific gravity
- D. A decrease in oral fluid intake
Correct Answer: B
Rationale: A. The client’s temperature will not be affected. B. Elevated serum ammonia levels may cause neurological changes, such as confusion. C. The client’s urine specific gravity will not be affected. D. Oral fluid intake should be encouraged if tolerated by the client.
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The charge nurse is making assignments. Staffing includes a registered nurse with five (5) years of medical-surgical experience, a newly graduated registered nurse, and two (2) unlicensed assistive personnel (UAPs). Which client should be assigned to the most experienced nurse?
- A. The 39-year-old client diagnosed with lower esophageal dysfunction who is complaining of pyrosis.
- B. The 54-year-old client diagnosed with Barrett's esophagus who is scheduled to have an endoscopy this morning.
- C. The 46-year-old client diagnosed with gastroesophageal reflux disease who has wheezes in all five (5) lobes.
- D. The 68-year-old client who is three (3) days postoperative for hiatal hernia and needs to be ambulated four (4) times today.
Correct Answer: C
Rationale: The client with GERD and wheezing in all five lobes indicates potential respiratory complications, possibly asthma or aspiration, requiring complex assessment and management best suited for the experienced nurse. The other clients have less acute or complex needs.
The experienced nurse is teaching the new nurse about surgery to repair a hiatal hernia. The experienced nurse is most likely to state that the surgery is becoming more common to prevent which emergency complication?
- A. Severe dysphagia
- B. Esophageal edema
- C. Hernia strangulation
- D. Aspiration
Correct Answer: C
Rationale: A. Although dysphagia is a complication of hiatal hernia, it is not an emergency condition. B. Esophageal edema is not a complication of hiatal hernia. C. A hiatal hernia can become strangulated (Circulation of blood to the hernia is cut off by constriction). Strangulation can occur with any type of hernia. D. Although aspiration is a complication of hiatal hernia, it is not an emergency condition.
The 70-year-old client is admitted to the medical unit diagnosed with acute diverticulitis. Which interventions should the nurse implement? Select all that apply.
- A. Tell the client not to eat or drink.
- B. Start an intravenous line.
- C. Assess the client for abdominal tenderness.
- D. Have the dietitian consult for a low-residue diet.
- E. Place the client on bedrest with bathroom privileges.
Correct Answer: A,B,C,E
Rationale: NPO status, IV line, abdominal assessment, and bedrest manage acute diverticulitis by resting the bowel and monitoring complications. Low-residue diets are for stable phases.
The nurse is caring for the immediate postoperative client who had a laparoscopic cholecystectomy. Which task could the nurse delegate to the unlicensed assistive personnel (UAP)?
- A. Check the abdominal dressings for bleeding.
- B. Increase the IV fluid if the blood pressure is low.
- C. Ambulate the client to the bathroom.
- D. Auscultate the breath sounds in all lobes.
Correct Answer: C
Rationale: Ambulating the client is within the UAP’s scope, promoting recovery. Checking dressings, adjusting IV fluids, and auscultating breath sounds require RN assessment skills.
A client has had a liver biopsy. After the procedure, the nurse should position him on his right side with a pillow under his rib cage. What is the primary reason for this position?
- A. To immobilize the diaphragm
- B. To facilitate full chest expansion
- C. To minimize the danger of aspiration
- D. To reduce the likelihood of bleeding
Correct Answer: D
Rationale: Right-side positioning with a pillow applies pressure to the biopsy site, reducing the risk of bleeding.