Nokea
Which of the following nursing actions should be included in the plan of care for a patient with cirrhosis who has ascites and 4+ edema of the feet and legs?
- A. Weekly weight of patient.
- B. Reposition the patient every 4 hours.
- C. Restrict sodium intake.
- D. Perform passive range-of-motion QID.
Correct Answer: C
Rationale: To maintain skin integrity, restrict sodium intake as ordered to prevent additional fluid retention. The patient should be weighed daily, not weekly. Repositioning the patient every 4 hours will not be adequate to maintain skin integrity, patients should be repositioned at least every two hours. Passive range of motion will not take pressure off areas like the sacrum that are vulnerable to breakdown.
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The nurse is caring for a patient following an incisional cholecystectomy for cholelithiasis. Which of the following actions is priority for the nurse to implement?
- A. Patient education about low-fat food choices.
- B. Perform leg exercises hourly while awake.
- C. Ambulate the evening of the operative day.
- D. Turn, cough, and deep breathe every 2 hours.
Correct Answer: D
Rationale: Postoperative nursing care for incisional cholecystectomy is the same as general postoperative nursing care. Postoperative nursing care after a cholecystectomy focuses on prevention of respiratory complications because the surgical incision is high in the abdomen and impairs coughing and deep breathing. The other nursing actions also are important to implement but are not as high a priority as ensuring adequate ventilation.
The nurse is caring for a patient who is admitted with an abrupt onset of jaundice, nausea, and abnormal liver function studies. Serological testing is negative for viral causes of hepatitis. Which of the following questions by the nurse is best?
- A. Is there any history of IV drug use?
- B. Are you taking corticosteroids for any reason?
- C. Do you use any over-the-counter (OTC) drugs?
- D. Have you recently travelled to a foreign country?
Correct Answer: C
Rationale: The patient's symptoms, lack of antibodies for hepatitis, and the abrupt onset of symptoms suggest toxic hepatitis, which can be caused by commonly used OTC drugs such as acetaminophen. Travel to a foreign country and a history of IV drug use are risk factors for viral hepatitis. Corticosteroid use does not cause the symptoms listed.
Which of the following findings in a blood specimen indicates that the administration of hepatitis B vaccine to a patient has been effective?
- A. HBsAg
- B. Anti-HBs
- C. Anti-HBc IgG
- D. Anti-HBc IgM
Correct Answer: B
Rationale: The presence of surface antibody to HBV (anti-HBs) is a marker of a positive response to the vaccine. The other laboratory values indicate current infection with HBV.
The nurse is caring for a patient with cirrhosis who has scheduled doses of spironolactone and furosemide and has a serum potassium level of 3.2 mmol/L. Which of the following actions should the nurse take?
- A. Give both drugs as scheduled
- B. Administer the spironolactone
- C. Administer the furosemide and withhold the spironolactone
- D. Withhold both drugs until talking with the health care provider.
Correct Answer: B
Rationale: Spironolactone is a potassium-sparing diuretic and will help to increase the patient's potassium level. The nurse does not need to talk with the doctor before giving the spironolactone, although the health care provider should be notified about the low potassium value. The furosemide will further decrease the patient's potassium level and should be held until the nurse talks with the health care provider.
A patient contracts hepatitis from contaminated food. During the acute (icteric) phase of the patient's illness, which of the following serological findings should the nurse expect?
- A. Antibody to hepatitis D virus (anti-HDV)
- B. Hepatitis B surface antigen (HBsAg)
- C. Anti-hepatitis A virus immunoglobulin G (anti-HAV IgG)
- D. Anti-hepatitis A virus immunoglobulin M (anti-HAV IgM)
Correct Answer: D
Rationale: Hepatitis A is transmitted through the oral-fecal route, and antibody to HAV IgM appears during the acute phase of hepatitis A. The patient would not have antigen for hepatitis B or antibody for hepatitis D. Anti-HAV IgG would indicate past infection and lifelong immunity.