Nokea
Which assessment question is priority for the nurse to ask the client diagnosed with end-stage liver failure secondary to alcoholic cirrhosis?
- A. How many years have you been drinking alcohol?
- B. Have you completed an advance directive?
- C. When did you have your last alcoholic drink?
- D. What foods did you eat at your last meal?
Correct Answer: C
Rationale: Recent alcohol consumption can exacerbate liver failure and affect treatment decisions, making it the priority question. Duration of drinking, advance directives, and diet are secondary.
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The client tells the nurse about being diagnosed with a 2-cm cancerous tumor in the liver. The client wants to know about the treatment. Which statement should be the basis for the nurse’s response?
- A. The use of chemotherapy is the first-line treatment for liver cancer.
- B. Liver transplantation is not an option for clients with liver cancer.
- C. Radiofrequency ablation can be successful in treating tumors of this size.
- D. A tumor of this size can only be removed through an open surgical approach.
Correct Answer: C
Rationale: A. Chemotherapy is only used for clients who are not likely to benefit from other therapies. B. Liver transplantation is used when the tumor is large or localized. C. Radiofrequency ablation is a treatment technique that uses high-frequency alternating electrical current to heat tissue cells and destroy them. It can be successfully used to treat tumors less than 5 cm in size because these tumors tend to be slow growing and encapsulated. D. Surgical resection of the tumor is used when the tumor is large or localized.
The client who has had an abdominal perineal resection is being discharged. Which discharge information should the nurse teach?
- A. The stoma should be a white, blue, or purple color.
- B. Limit ambulation to prevent the pouch from coming off.
- C. Take pain medication when the pain level is at an '8.'
- D. Empty the pouch when it is one-third to one-half full.
Correct Answer: D
Rationale: Emptying the pouch when one-third to one-half full prevents leaks and skin irritation. A healthy stoma is pink/moist, ambulation is encouraged, and pain medication should be taken before pain becomes severe.
A client had a barium enema. Following the barium enema, the nurse should anticipate an order for which of the following?
- A. An antacid
- B. A laxative
- C. A muscle relaxant
- D. A sedative
Correct Answer: B
Rationale: Barium is constipating, and a laxative is typically ordered to prevent bowel obstruction post-barium enema.
The client receiving antibiotic therapy complains of white, cheesy plaques in the mouth. Which intervention should the nurse implement?
- A. Notify the health-care provider to obtain an antifungal medication.
- B. Explain the patches will go away naturally in about two (2) weeks.
- C. Instruct to rinse the mouth with diluted hydrogen peroxide and water daily.
- D. Allow the client to verbalize feelings about having the plaques.
Correct Answer: A
Rationale: White, cheesy plaques suggest oral candidiasis, a common side effect of antibiotics. Notifying the HCP for an antifungal medication is the most appropriate intervention. The patches won’t resolve naturally, hydrogen peroxide is not standard, and verbalizing feelings is secondary.
The client diagnosed with gastroenteritis is being discharged from the emergency department. Which intervention should the nurse include in the discharge teaching?
- A. If diarrhea persists for more than 96 hours, contact the health-care provider.
- B. Instruct the client to wash hands thoroughly before handling any type of food.
- C. Explain the importance of decreasing steroids gradually as instructed.
- D. Discuss how to collect all stool samples for the next 24 hours.
Correct Answer: B
Rationale: Handwashing prevents the spread of gastroenteritis, a key discharge teaching point. Persistent diarrhea is concerning but less specific, steroids are irrelevant, and stool collection is not routine.