Nokea
The nurse is performing teaching for a client scheduled for gastric bypass surgery. Which client statement requires follow-up by the nurse?
- A. Once I am home, I can advance my diet as tolerated.
- B. I will have to take a multivitamin after this surgery.
- C. I will be encouraged to perform leg exercises while I am in bed.
- D. My weight may increase if I do not change my eating habits.
Correct Answer: A
Rationale: Advancing the diet as tolerated (A) is incorrect; gastric bypass patients follow a strict, staged diet progression to prevent complications. Other statements (B, C, D) are accurate.
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The nurse is assessing a client with suspected acute cholecystitis. Which of the following findings would support a diagnosis of acute cholecystitis?
- A. Decreased serum bilirubin
- B. Increased high density lipoprotein cholesterol (HDL-C)
- C. Decreased serum aminotransferases
- D. Increased white blood cell count (WBC)
Correct Answer: D
Rationale: An increased WBC count (D) indicates inflammation or infection, supporting a diagnosis of acute cholecystitis. Bilirubin (A) and aminotransferases (C) may rise, and HDL-C (B) is unrelated.
The nurse is caring for a client who has ascites and hepatic encephalopathy. Which of the following prescriptions should the nurse anticipate from the primary healthcare provider (PHCP)? Select all that apply.
- A. Furosemide
- B. Neomycin
- C. Naproxen
- D. Lactulose
- E. Diazepam
Correct Answer: A,B,D
Rationale: Furosemide (A) manages ascites, neomycin (B) reduces gut ammonia production, and lactulose (D) treats hepatic encephalopathy. Naproxen (C) and diazepam (E) can worsen liver dysfunction or encephalopathy.
The nurse is performing an assessment on a client being admitted for acute pancreatitis. Which assessment finding would support a diagnosis of acute pancreatitis?
- A. Homan's sign
- B. Cullen's sign
- C. Hyperactive bowel sounds
- D. Kernig's sign
Correct Answer: B
Rationale: Cullen's sign (B), periumbilical bruising, is associated with acute pancreatitis due to retroperitoneal hemorrhage. Homan's (A) and Kernig's (D) signs are unrelated, and bowel sounds (C) are typically hypoactive.
The nurse is caring for a client who has ascites and hepatic encephalopathy. Which of the following prescriptions should the nurse clarify with the primary healthcare provider (PHCP)?
- A. Alprazolam
- B. Rifaximin
- C. Lactulose
- D. Spironolactone
Correct Answer: A
Rationale: Alprazolam (A), a benzodiazepine, can worsen hepatic encephalopathy by increasing sedation and ammonia levels. Rifaximin (B), lactulose (C), and spironolactone (D) are appropriate for managing hepatic encephalopathy and ascites.
The nurse assesses a client receiving total parenteral nutrition (TPN) and fat emulsions. The nurse observes that the fat emulsion infusion is one hour behind schedule. The nurse should take which action?
- A. Adjust the infusion rate to make up the difference over the next hour, then revert the infusion rate back to the prescribed rate.
- B. Increase the infusion rate to ensure that the infusion finishes at the correct time.
- C. Ensure the fat emulsion infusion rate is infusing at the prescribed rate and maintain the rate at the prescribed rate.
- D. Stop the infusion and inform the primary health care provider (PHCP).
Correct Answer: C
Rationale: Fat emulsions must be infused at a steady, prescribed rate to prevent complications like fat overload syndrome. Adjusting or increasing the rate can be dangerous, and stopping the infusion is unnecessary unless there’s a specific issue.