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The RN is caring for the client following a liver biopsy with the assistance of the student nurse. The RN evaluates that the student understands the postprocedure care when making which observation of the student nurse?
- A. Takes the client’s vital signs every hour
- B. Walks the client 1 hour postprocedure
- C. Positions the client onto the right side
- D. Has the client cough and deep-breathe hourly
Correct Answer: C
Rationale: A. After a liver biopsy VS should be assessed every 15 minutes times two, every 30 minutes times four, and then every hour times four to monitor for shock, peritonitis, and pneumothorax. B. The client should be kept flat in bed for 12 to 14 hours following the procedure to prevent the risk of bleeding. C. Positioning the client on the right side after a liver biopsy splints the puncture site to prevent and decrease bleeding. D. The client should be cautioned to avoid coughing, which could precipitate bleeding.
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The nurse is performing an admission assessment on a client diagnosed with GERD. Which signs and symptoms would indicate GERD?
- A. Pyrosis, water brash, and flatulence.
- B. Weight loss, dysarthria, and diarrhea.
- C. Decreased abdominal fat, proteinuria, and constipation.
- D. Midepigastric pain, positive H. pylori test, and melena.
Correct Answer: A
Rationale: Pyrosis (heartburn), water brash (regurgitation of sour fluid), and flatulence are classic symptoms of GERD due to acid reflux and gas buildup. The other options include symptoms more associated with other conditions like peptic ulcer disease or systemic disorders.
The client has severe liver disease. Which of the following observations is most indicative of serious problems?
- A. The client has generalized urticaria.
- B. The client is 'confused' and can no longer write his name legibly.
- C. The client is jaundiced.
- D. The client has ecchymotic areas on his arms.
Correct Answer: B
Rationale: Confusion and impaired handwriting suggest hepatic encephalopathy, a serious complication of liver disease due to ammonia buildup.
The nurse is discussing the therapeutic diet for the client diagnosed with diverticulosis. Which meal indicates the client understands the discharge teaching?
- A. Fried fish, mashed potatoes, and iced tea.
- B. Ham sandwich, applesauce, and whole milk.
- C. Chicken salad on whole-wheat bread and water.
- D. Lettuce, tomato, and cucumber salad and coffee.
Correct Answer: C
Rationale: A high-fiber diet, like whole-wheat bread, prevents constipation and flare-ups in diverticulosis. Fried foods, low-fiber applesauce, and salads with seeds (e.g., tomatoes) are less appropriate.
Which medication should the nurse expect the HCP to order to treat the client diagnosed with botulism secondary to eating contaminated canned goods?
- A. An antidiarrheal medication.
- B. An aminoglycoside antibiotic.
- C. An antitoxin medication.
- D. An ACE inhibitor medication.
Correct Answer: C
Rationale: Botulism is treated with antitoxin to neutralize the toxin and prevent further paralysis. Antidiarrheals, antibiotics, and ACE inhibitors are inappropriate for botulism.
The client is admitted to a hospital for medical management of acute diverticulitis. The nurse should anticipate that this client’s treatment plan will include which component?
- A. NPO (nothing per mouth) status
- B. Frequent ambulation
- C. Prescribed antibiotics
- D. Antiemetic medication
- E. Deep breathing every 2 hours
Correct Answer: A, C
Rationale: The nurse should plan for the client to be NPO. Medical management for diverticulitis includes resting the bowel. NPO status will help to achieve this. B. Ambulation is not encouraged; resting the body promotes bowel rest. C. Broad-spectrum antibiotics effective against known enteric pathogens are used in treating every stage of diverticulitis. D. Nausea is not a concern with diverticulitis. E. The client did not have surgery; there is no need for deep breathing every 2 hours.