Nokea
When caring for an extremely jaundiced patient with cirrhosis, which does the nurse expect to see included in the plan of care?
- A. Encouraging consumption of a high-fat diet
- B. Skin care to relieve pruritus
- C. Offering foods rich in fat-soluble vitamins
- D. Meticulous foot care
Correct Answer: B
Rationale: Jaundice causes pruritus and can lead to skin lesions and pressure injury.
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Which is the most common procedure for the removal of the gallbladder?
- A. Laparoscopic cholecystectomy
- B. Cholangiography
- C. Open cholecystectomy
- D. Choledochostomy
Correct Answer: A
Rationale: The most recently developed operative procedure, which is now the most common treatment for cholecystitis and cholelithiasis, is done by way of endoscopy. It is called laparoscopic cholecystectomy and uses laser cautery to remove the gallbladder.
Which nursing intervention should be completed immediately after the health care provider has performed a needle liver biopsy?
- A. Assisting to ambulate for the bathroom
- B. Keeping the patient on the right side for a minimum of 2 hours
- C. Taking vital signs every 4 hours
- D. Keeping the patient on the left side for a minimum of 4 hours
Correct Answer: B
Rationale: Keep the patient lying on the right side with a rolled towel against the puncture site for minimum of 2 hours to splint the puncture site. It compresses the liver capsule against the chest wall to decrease the risk of hemorrhage or bile leak. Vital signs are taken every 15 minutes for 30 minutes, then every 30 minutes for 2 hours.
The nurse assisting in the treatment of a patient with ruptured esophageal varices who has received vasopressin IV will carefully assess for which complication?
- A. muscular twitching/spasm.
- B. hematuria.
- C. macular rash on trunk and arms.
- D. evidence of cardiac ischemia.
Correct Answer: D
Rationale: Vasopressin is a strong vasoconstrictor given to try to stop the hemorrhage of the varices. Unfortunately it also constricts all vessels and may cause cardiac ischemia.
Which is the most appropriate method used by high-risk health workers to prevent hepatitis B?
- A. Hepatitis B vaccine
- B. Diligent hand washing
- C. Wearing protective gear
- D. Hb immune globulin injections
Correct Answer: A
Rationale: The best preventive measure against the contraction of hepatitis B is HBV vaccine.
What should the nurse monitor in caring for the patient undergoing a paracentesis?
- A. The urinary output
- B. Hypervolemia
- C. Fluid removal over at least 30 minutes
- D. Seizure
Correct Answer: C
Rationale: The fluid removed during a paracentesis is removed over a period of 30 to 90 minutes to prevent sudden changes in blood pressure leading to syncope. The bed should be in a high Fowler's position. Food and fluid restriction is usually not necessary.