Nokea
The nurse is monitoring which laboratory results that are most closely associated with cirrhosis?
- A. Decreased ammonia levels
- B. Decreased glucose levels
- C. Prolonged prothrombin times
- D. Increased cholesterol levels
- E. Decreased total protein levels
Correct Answer: B,C,E
Rationale: When caring for a patient with cirrhosis, the nurse will most likely note decreased glucose levels, prolonged prothrombin times and decreased total protein levels. The ammonia levels are increased with cirrhosis, and cholesterol levels decrease.
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Which is an essential nursing measure to prevent injury to the patient who is to receive a paracentesis?
- A. Have patient sign a permit.
- B. Pad side rails.
- C. Check for allergy to contrast media or to shellfish.
- D. Have patient void immediately before procedure.
Correct Answer: D
Rationale: To prevent the puncturing of the bladder, the patient must void immediately before the procedure. A permit is required but it is not a safety precaution for the patient. There is no contrast media used in a paracentesis.
When caring for an extremely jaundiced patient with cirrhosis, which does the nurse expect to see included in the plan of care?
- A. Encouraging consumption of a high-fat diet
- B. Skin care to relieve pruritus
- C. Offering foods rich in fat-soluble vitamins
- D. Meticulous foot care
Correct Answer: B
Rationale: Jaundice causes pruritus and can lead to skin lesions and pressure injury.
The nurse is aware that the hepatitis A immunization provides immunity in:
- A. 5 days.
- B. 10 days.
- C. 15 days.
- D. 30 days.
Correct Answer: D
Rationale: Primary immunization with hepatitis A vaccine provides immunity within 30 days.
A patient with a T tube for an open cholecystectomy has resumed oral intake. The T tube is clamped 2 hours before meals and unclamped 2 hours after meals to aid in the digestion of fat. During the time the tube is clamped the patient complains of abdominal pain and nausea. Which intervention is most appropriate?
- A. Notify the health care provider.
- B. Unclamp the tube immediately.
- C. Increase the IV fluids.
- D. Change the T-tube dressing.
Correct Answer: B
Rationale: While the tube is clamped, the patient may show signs of abdominal pain, nausea, vomiting, etc. Unclamp the tube immediately to allow for drainage and relief of both nausea and pain.
The patient with cirrhosis has an albumin of 2.8 g/dL. The nurse is aware that normal is 3.5 to 5 g/dL. Based on these findings, which would the nurse expect the patient to exhibit?
- A. Jaundice
- B. Edema
- C. Copious urine output
- D. Pallor
Correct Answer: B
Rationale: Low serum albumin levels result also from excessive loss of albumin into urine or into third-space volumes, causing ascites or edema.