Nokea
The nurse is providing discharge instructions for a client with cirrhosis. Which of the following statements best indicates that the client has understood the teaching?
- A. I should eat a high-protein, high-carbohydrate diet to provide energy.'
- B. It is safer for me to take acetaminophen (Tylenol) for pain instead of aspirin.'
- C. I should avoid constipation to decrease chances of bleeding.'
- D. If I get enough rest and follow my diet, it is possible for my cirrhosis to be cured.'
Correct Answer: C
Rationale: Avoiding constipation (C) prevents ammonia buildup and bleeding risks. High-protein diets (A) may worsen encephalopathy, acetaminophen (B) is hepatotoxic, and cirrhosis is irreversible (D).
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The nurse should expect single-donor platelets to be ordered for which of the following clients?
- A. A client who is receiving multiple platelet transfusions.
- B. A client who is deficient in coagulation factors.
- C. A client whose platelet count is greater than 50,000/mm³.
- D. A client who is refractory to random-donor platelets.
Correct Answer: D
Rationale: Single-donor platelets are used for clients refractory to random-donor platelets to reduce the risk of alloimmunization and improve transfusion efficacy.
Which of the following areas is a priority to evaluate when completing discharge planning for a client who has had a lobectomy for treatment of lung cancer?
- A. The support available to assist the client at home.
- B. The distance the client lives from the hospital.
- C. The client's ability to do home blood pressure monitoring.
- D. The client's knowledge of the causes of lung cancer.
Correct Answer: A
Rationale: Home support is critical post-lobectomy to assist with recovery, medication adherence, and monitoring complications. Distance from the hospital, blood pressure monitoring, and knowledge of cancer causes are less immediate priorities.
A client states that she is afraid of receiving vitamin B12 injections because of potential toxic effects, which is the nurse's best response to relieve these fears?
- A. Vitamin B12 will cause ringing in the ears before a toxic level is reached.'
- B. Vitamin B12 may cause a very mild rash initially.'
- C. Vitamin B12 may cause mild nausea but nothing toxic.'
- D. Vitamin B12 is generally free of toxicity because it is water-soluble.'
Correct Answer: D
Rationale: Vitamin B12 is a water-soluble vitamin, and excess amounts are excreted in urine, making toxicity rare. This response reassures the client by addressing her fear of toxic effects accurately. The other responses are incorrect, as B12 does not typically cause ringing in the ears, rash, or nausea as signs of toxicity.
The nurse is assessing a client with dark skin for presence of a Stage I pressure ulcer. The nurse should:
- A. Use a fluorescent light source to assess the skin.
- B. L rescued the skin only when the Braden score is above 12.
- C. Look for skin color that is darker than the surrounding tissue.
- D. Avoid touching the skin during inspection.
Correct Answer: C
Rationale: In dark skin, Stage I pressure ulcers appear as darker areas compared to surrounding tissue, due to persistent redness or discoloration.
The nurse is assessing an older Caucasian male who has a history of peripheral vascular disease. The nurse observes that the man's left great toe is black. The discoloration is probably a result of:
- A. Atrophy
- B. Contraction
- C. Gangrene
- D. Rubor
Correct Answer: C
Rationale: A black great toe in a client with PVD likely indicates gangrene, resulting from tissue necrosis due to severe ischemia from arterial occlusion. Atrophy causes muscle wasting, contraction is not a relevant term, and rubor refers to reddish discoloration, not black.