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The nurse is planning care for a client with cirrhosis of the liver. Which intervention should the nurse include to reduce the risk of bleeding?
- A. Monitor for signs of infection.
- B. Limit the client's dietary protein intake.
- C. Administer vitamin K as prescribed.
- D. Encourage the client to increase fluid intake.
Correct Answer: C
Rationale: Correct Answer: C - Administer vitamin K as prescribed.
Rationale:
1. Cirrhosis impairs liver function, leading to decreased synthesis of clotting factors, increasing the risk of bleeding.
2. Vitamin K is essential for synthesizing clotting factors; administering it helps improve clotting ability.
3. Monitoring for infection (A) is important but does not directly address the clotting issue.
4. Limiting protein intake (B) is not necessary for bleeding prevention in cirrhosis.
5. Encouraging fluid intake (D) is important for overall health but does not specifically reduce the risk of bleeding.
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A client with chronic pain is prescribed a fentanyl (Duragesic) patch. Which instruction should the nurse provide to the client?
- A. Apply the patch to a clean, dry, and hairless area of the skin.
- B. Use a heating pad over the patch to enhance absorption.
- C. Change the patch daily to maintain effectiveness.
- D. Place the patch on the same site with each application.
Correct Answer: A
Rationale: The correct answer is A. Applying the fentanyl patch to a clean, dry, and hairless area of the skin ensures proper absorption and effectiveness. Moisture, oils, and hair can interfere with absorption. Option B is incorrect as heating pads can increase drug absorption and lead to overdose. Option C is incorrect because fentanyl patches are usually changed every 72 hours, not daily. Option D is incorrect because rotating application sites helps prevent skin irritation and tolerance development.
What action should the nurse take to prevent tracheal tissue damage in a client with a tracheostomy?
- A. Secure the tracheostomy ties firmly.
- B. Change the tracheostomy tube daily.
- C. Use the minimal leak technique when inflating the cuff.
- D. Clean the stoma with hydrogen peroxide.
Correct Answer: C
Rationale: The correct action to prevent tracheal tissue damage in a client with a tracheostomy is to use the minimal leak technique when inflating the cuff (Choice C). This technique helps maintain proper cuff pressure, preventing excessive pressure on the tracheal tissue. Securing the tracheostomy ties firmly (Choice A) may cause pressure ulcers on the neck. Changing the tracheostomy tube daily (Choice B) is unnecessary and may introduce infection. Cleaning the stoma with hydrogen peroxide (Choice D) can be too harsh and damaging to the delicate tracheal tissue.
The healthcare provider is assessing a client with Cushing's syndrome. Which clinical manifestation should the healthcare provider expect to find?
- A. Hyperpigmentation of the skin.
- B. Hypotension.
- C. Moon face and buffalo hump.
- D. Weight loss.
Correct Answer: C
Rationale: The correct answer is C: Moon face and buffalo hump. In Cushing's syndrome, excessive cortisol production leads to characteristic symptoms like moon face (round, puffy face) and buffalo hump (fat accumulation at the back of the neck). This is due to redistribution of fat in the body. Hyperpigmentation (choice A) is seen in Addison's disease, not Cushing's. Hypotension (choice B) is unlikely due to the cortisol-induced sodium retention. Weight loss (choice D) is less common in Cushing's due to the metabolic changes causing weight gain.
A client with type 2 diabetes mellitus presents to the clinic with a foot ulcer. Which instruction should the nurse provide to the client to promote healing of the ulcer?
- A. Apply a heating pad to the ulcer twice daily.
- B. Wear tight-fitting shoes to protect the ulcer.
- C. Keep the ulcer clean and dry.
- D. Limit walking to reduce pressure on the ulcer.
Correct Answer: C
Rationale: The correct answer is C: Keep the ulcer clean and dry. This instruction is essential for promoting healing of the foot ulcer in a client with type 2 diabetes mellitus. Keeping the ulcer clean helps prevent infection, while keeping it dry promotes a better environment for healing.
A: Applying a heating pad can increase the risk of burns and should be avoided.
B: Wearing tight-fitting shoes can cause further damage and hinder healing.
D: Limiting walking may reduce pressure on the ulcer, but mobility is important for circulation and overall health. Keeping the ulcer clean and dry is the most critical instruction.
A client with a history of diabetes mellitus presents with confusion, sweating, and palpitations. What should the nurse do first?
- A. Check the client's blood glucose level.
- B. Administer 10 units of insulin.
- C. Give the client a high-protein snack.
- D. Measure the client's blood pressure.
Correct Answer: A
Rationale: The correct answer is A: Check the client's blood glucose level. The client's symptoms are indicative of hypoglycemia, which is a common complication in diabetes mellitus. Checking the blood glucose level will confirm the diagnosis and guide appropriate interventions. Administering insulin (B) could worsen the hypoglycemia. Giving a high-protein snack (C) may help raise blood sugar levels but should be done after confirming the diagnosis. Measuring blood pressure (D) is not the priority in this situation.