Nokea
The nurse is developing a plan of care for the client with cirrhosis. Which intervention should be included in the client’s plan of care?
- A. Monitor the client’s blood sugar level.
- B. Place the client on NPO status.
- C. Administer antibiotics every 6 hours.
- D. Encourage ambulation every 4 hours.
Correct Answer: A
Rationale: A. The nurse should prepare to monitor the client’s blood sugar level. The client with cirrhosis may develop insulin resistance. Impaired glucose tolerance is common with cirrhosis, and about 20% to 40% of clients also have diabetes. Hypoglycemia may occur during fasting because of decreased hepatic glycogen reserves and decreased gluconeogenesis. B. The client with cirrhosis would not be NPO but should receive a high-protein diet unless hepatic encephalopathy is present. C. Antibiotics are not part of the treatment plan of cirrhosis because it is not caused by microorganisms. D. The client with cirrhosis requires rest; thus, ambulation should not be encouraged every 4 hours.
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Which statement indicates to the emergency department nurse the client diagnosed with acute gastroenteritis understands the discharge teaching?
- A. I will probably have some leg cramps while I have gastroenteritis.
- B. I should decrease my fluid intake until the diarrhea subsides.
- C. I should reintroduce solid foods very slowly back into my diet.
- D. I should only drink bottled water until the abdominal cramping stops.
Correct Answer: C
Rationale: Slowly reintroducing solid foods prevents GI irritation, indicating understanding of gastroenteritis recovery. Leg cramps are possible but not emphasized, and decreasing fluids or bottled water is incorrect.
The client tells the nurse about being diagnosed with a 2-cm cancerous tumor in the liver. The client wants to know about the treatment. Which statement should be the basis for the nurse’s response?
- A. The use of chemotherapy is the first-line treatment for liver cancer.
- B. Liver transplantation is not an option for clients with liver cancer.
- C. Radiofrequency ablation can be successful in treating tumors of this size.
- D. A tumor of this size can only be removed through an open surgical approach.
Correct Answer: C
Rationale: A. Chemotherapy is only used for clients who are not likely to benefit from other therapies. B. Liver transplantation is used when the tumor is large or localized. C. Radiofrequency ablation is a treatment technique that uses high-frequency alternating electrical current to heat tissue cells and destroy them. It can be successfully used to treat tumors less than 5 cm in size because these tumors tend to be slow growing and encapsulated. D. Surgical resection of the tumor is used when the tumor is large or localized.
The nurse is caring for a client diagnosed with GERD. Which nursing interventions should be implemented?
- A. Place the client prone in bed and administer nonsteroidal anti-inflammatory medications.
- B. Have the client remain upright at all times and walk for 30 minutes three (3) times a week.
- C. Instruct the client to maintain a right lateral side-lying position and take antacids before meals.
- D. Elevate the head of the bed (HOB) 30 degrees and discuss lifestyle modifications with the client.
Correct Answer: D
Rationale: Elevating the head of the bed prevents reflux during sleep, and lifestyle modifications (e.g., avoiding trigger foods, not lying down after meals) are key to managing GERD. Prone positioning worsens reflux, remaining upright at all times is impractical, and right lateral positioning is less effective than head elevation.
The client is placed on percutaneous endoscopic gastrostomy (PEG) tube feedings. Which occurrence warrants immediate intervention by the nurse?
- A. The client tolerates the feedings being infused at 50 mL/hr.
- B. The client pulls.Concurrent with the PEG tube out.
- C. The client complains of being thirsty.
- D. The client has green, watery stool.
Correct Answer: B
Rationale: A dislodged PEG tube risks peritonitis or feeding leakage, requiring immediate intervention. Tolerated feedings, thirst, and green stool are less urgent.
The client is one (1) day postoperative major abdominal surgery. Which client problem is priority?
- A. Impaired skin integrity.
- B. Fluid and electrolyte imbalance.
- C. Altered bowel elimination.
- D. Altered body image.
Correct Answer: B
Rationale: Fluid and electrolyte imbalance is the priority due to risks of dehydration or imbalances from surgery, impacting hemodynamic stability. Skin integrity, bowel elimination, and body image are secondary in the immediate postoperative period.