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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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The nurse is caring for a client with hyperthyroidism. Which intervention should the nurse implement to manage the client's condition?
- A. Provide a high-calorie diet.
- B. Encourage frequent rest periods.
- C. Restrict fluid intake.
- D. Administer a stool softener.
Correct Answer: B
Rationale: The correct answer is B: Encourage frequent rest periods. For a client with hyperthyroidism, rest is crucial to conserve energy and support the body's recovery. Hyperthyroidism is characterized by increased metabolic rate, leading to fatigue and weakness. Rest periods help reduce metabolic demands and prevent exhaustion. A high-calorie diet (choice A) may be necessary to support increased metabolism but is not the priority. Restricting fluid intake (choice C) can lead to dehydration, which should be avoided in hyperthyroidism. Administering a stool softener (choice D) is unrelated to managing hyperthyroidism.
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.
A client with chronic renal failure is scheduled to receive epoetin alfa (Epogen). Which laboratory result should the nurse review before administering the medication?
- A. Blood urea nitrogen (BUN)
- B. Creatinine clearance
- C. Hemoglobin level
- D. Serum potassium
Correct Answer: C
Rationale: The correct answer is C: Hemoglobin level. In chronic renal failure, the kidneys may not produce enough erythropoietin, leading to anemia. Epoetin alfa stimulates red blood cell production. Therefore, reviewing the hemoglobin level is crucial to determine the need for the medication.
Incorrect choices:
A: Blood urea nitrogen (BUN) and B: Creatinine clearance are indicators of kidney function but not directly related to monitoring the effectiveness of epoetin alfa.
D: Serum potassium is important in renal failure but not specifically needed to review before administering epoetin alfa.
A client with left-sided heart failure is experiencing dyspnea and orthopnea. Which position should the nurse place the client in to relieve these symptoms?
- A. High Fowler's position.
- B. Supine position.
- C. Trendelenburg position.
- D. Sims' position.
Correct Answer: A
Rationale: The correct answer is A: High Fowler's position. Placing the client in a High Fowler's position helps reduce dyspnea and orthopnea by facilitating lung expansion and improving ventilation. In this position, the client's head and chest are elevated at a 90-degree angle, allowing for maximal chest expansion and improved oxygenation. This position also helps reduce the workload on the heart by decreasing venous return, which can help alleviate symptoms of left-sided heart failure.
Summary:
- A: High Fowler's position is correct as it facilitates lung expansion and improves ventilation.
- B: Supine position would not be ideal as it can exacerbate symptoms by increasing pressure on the lungs and heart.
- C: Trendelenburg position would worsen symptoms by increasing venous return and fluid overload.
- D: Sims' position is used for procedures or to facilitate drainage, not for relieving dyspnea and orthopnea.
A client who is receiving heparin therapy has an activated partial thromboplastin time (aPTT) of 90 seconds. What action should the nurse take?
- A. Increase the heparin infusion rate.
- B. Notify the healthcare provider.
- C. Apply pressure to the injection site.
- D. Administer protamine sulfate.
Correct Answer: B
Rationale: The correct answer is B: Notify the healthcare provider. A prolonged aPTT of 90 seconds indicates the client is at risk for bleeding due to excessive anticoagulation from heparin therapy. The nurse should notify the healthcare provider immediately to adjust the dosage or consider discontinuing heparin to prevent bleeding complications. Increasing the heparin infusion rate (A) would worsen the risk of bleeding. Applying pressure to the injection site (C) is not appropriate in this situation. Administering protamine sulfate (D) is the antidote for heparin overdose, but it is not the first action to take in this scenario.