Nokea
Which patient poses the least infection risk to an immunosuppressed patient who had a liver transplant?
- A. The patient with chronic pancreatitis
- B. The patient currently infected with a respiratory virus
- C. The patient with a healing leg wound
- D. The patient with a urinary tract infection
Correct Answer: C
Rationale: The patient with a healing leg wound poses the least infection risk to an immunosuppressed patient who had a liver transplant. Chronic pancreatitis can lead to complications such as infections that can pose a risk to immunosuppressed individuals. Patients infected with respiratory viruses or urinary tract infections are actively infectious, which can put immunosuppressed patients at a higher risk of acquiring infections. Therefore, the patient with a healing leg wound is the least likely to pose an immediate infection risk.
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Which finding indicates to the nurse that a patient's transjugular intrahepatic portosystemic shunt (TIPS) placed 3 months ago has been effective?
- A. Increased serum albumin level
- B. Decreased indirect bilirubin level
- C. Improved alertness and orientation
- D. Fewer episodes of bleeding varices
Correct Answer: D
Rationale: The correct answer is 'Fewer episodes of bleeding varices.' A transjugular intrahepatic portosystemic shunt (TIPS) is used to reduce pressure in the portal venous system, thus decreasing the risk of bleeding from esophageal varices. This outcome would indicate the effectiveness of the TIPS procedure. The other choices are incorrect because: Increased serum albumin level and decreased indirect bilirubin level are not direct indicators of TIPS effectiveness. Improved alertness and orientation could be influenced by various factors and may not directly correlate with the effectiveness of the TIPS procedure. Additionally, TIPS can actually increase the risk of hepatic encephalopathy, which contradicts the choice of improved alertness and orientation.
A clinic nurse interviews a parent who is suspected of abusing her child. Which of the following characteristics is the nurse least likely to find in an abusing parent?
- A. Low self-esteem
- B. Unemployment
- C. Self-blame for the injury to the child
- D. Single status
Correct Answer: C
Rationale: The profile of a parent at risk of abusive behavior includes a tendency to blame the child or others for the injury sustained. Abusers typically blame others, especially their partners, for the mistakes in their lives. This is related to hypersensitivity, but they are not necessarily alike. This occurs because most abusive people don't hold themselves as being accountable for the actions they commit. Instead, they'll try to shift the blame to the person that they have abused and somehow say they "deserved it"? or that they were forced into a corner.
Which of the following interventions should the nurse use when working with a Jackson-Pratt drain?
- A. Strip the tubing to remove clots by milking the tubing back toward the client
- B. Empty the drain when the amount of fluid reaches 25 cc
- C. Strip the tubing to remove clots by milking the tubing away from the client
- D. Maintain the level of the drain above the client's incision
Correct Answer: C
Rationale: A Jackson-Pratt drain is a type of active wound drain that may be placed following a surgical procedure. This drain actively draws excess blood and fluid out of the wound. If clots develop within the tubing, the nurse should strip the tubing by milking it in a direction away from the client. This action helps to ensure the drain remains patent and effective. Option A is incorrect because the tubing should be milked away from the client, not towards. Option B is incorrect as the drain should be emptied based on the healthcare provider's orders, not at a fixed volume. Option D is incorrect because the level of the drain should be below the level of the incision to allow drainage by gravity.
A client is being instructed in the use of an incentive spirometer. Which of the following statements from the nurse indicates correct teaching about using this device?
- A. Lie back in a reclining position while using the spirometer.
- B. Take slow deep breaths to reach your goal.
- C. Set a goal of using the spirometer at least 3 times per day.
- D. Practice coughing after taking 10 breaths.
Correct Answer: D
Rationale: An incentive spirometer is a device used to improve lung function and reduce the risk of atelectasis. The correct way to use the spirometer is by sitting up and taking slow, deep breaths to achieve the set goal, not by lying back in a reclining position or taking rapid, quick breaths. Setting a goal of using the spirometer multiple times a day is beneficial, but it is not the best indicator of correct teaching. After using the spirometer, the client should practice coughing to help clear any loosened secretions that may have occurred during the breathing exercises.
A serum potassium level of 3.2 mEq/L (3.2 mmol/L) is reported for a patient with cirrhosis who has scheduled doses of spironolactone (Aldactone) and furosemide (Lasix) due. Which action should the nurse take?
- A. Administer both drugs.
- B. Administer the spironolactone.
- C. Withhold the spironolactone and administer the furosemide.
- D. Withhold both drugs until discussed with the healthcare provider.
Correct Answer: B
Rationale: A serum potassium level of 3.2 mEq/L is low (hypokalemia), which can be concerning in a patient with cirrhosis who is already at risk for electrolyte imbalances. Spironolactone is a potassium-sparing diuretic that can help increase the patient's potassium level and correct the hypokalemia. Therefore, the appropriate action for the nurse to take in this scenario is to administer the spironolactone. Withholding the spironolactone could further lower the potassium level. Furosemide, on the other hand, is a loop diuretic that can lead to potassium loss and worsen hypokalemia; hence, it should be withheld until the nurse discusses the situation with the healthcare provider. While the healthcare provider should be informed about the low potassium value, immediate administration of spironolactone is necessary to address the hypokalemia in this patient population.