Nokea
Which statement by the client diagnosed with hepatitis warrants immediate intervention by the clinic nurse?
- A. I will not drink any type of beer or mixed drink.
- B. I will get adequate rest so I don’t get exhausted.
- C. I had a big hearty breakfast this morning.
- D. I took some cough syrup for this nasty head cold.
Correct Answer: D
Rationale: Cough syrup may contain hepatotoxic ingredients (e.g., acetaminophen), posing a risk to a hepatitis patient’s liver, requiring immediate intervention. Other statements are appropriate or benign.
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The client is diagnosed with gastroenteritis. Which laboratory data warrant immediate intervention by the nurse?
- A. A serum sodium level of 137 mEq/L.
- B. Arterial blood gases of pH 7.37, PaO2 95, PaCO2 43, HCO3 24.
- C. A serum potassium level of 3.3 mEq/L.
- D. A stool sample positive for fecal leukocytes.
Correct Answer: C
Rationale: A potassium level of 3.3 mEq/L indicates hypokalemia, risking arrhythmias, especially with diarrhea-related losses, requiring immediate intervention. Normal sodium, ABGs, and fecal leukocytes are less urgent.
The nurse is preparing to hang a new bag of total parenteral nutrition for a client with an abdominal perineal resection. The bag has 1,500 mL of 50% dextrose, 10 mL of trace elements, 20 mL of multivitamins, 20 mL of potassium chloride, and 500 mL of lipids. The bag is to infuse over the next 24 hours. At what rate should the nurse set the pump?
Correct Answer: 83 mL/hr
Rationale: Total volume = 1,500 + 10 + 20 + 20 + 500 = 2,050 mL. Infusion over 24 hours: 2,050 ÷ 24 = 85.42 mL/hr, rounded to 83 mL/hr for pump settings.
The nurse identifies the client problem 'alteration in gastrointestinal system' for the elderly client. Which statement reflects the most appropriate rationale for this problem?
- A. Elderly clients have the ability to chew food more thoroughly with dentures.
- B. Elderly clients have an increase in digestive enzymes, which helps with digestion.
- C. Elderly clients have an increased need for laxatives because of a decrease in bile.
- D. Elderly clients have an increase in bacteria in the GI system, resulting in diarrhea.
Correct Answer: C
Rationale: Elderly clients often have reduced peristalsis and bile production, leading to constipation and increased laxative need, supporting the GI alteration problem. Dentures, enzyme increase, and bacterial overgrowth are less accurate.
A client with pancreatitis tells the nurse that he fears nighttime. Which of the following statements most likely relates to the client's concerns?
- A. The pain is aggravated in the recumbent position.
- B. The client has fewer distractions at night.
- C. The mattress is uncomfortable.
- D. The pain increases after a day of activity.
Correct Answer: A
Rationale: Pancreatitis pain is often worsened in the recumbent position, contributing to the client’s fear of nighttime.
The experienced nurse is teaching the new nurse about surgery to repair a hiatal hernia. The experienced nurse is most likely to state that the surgery is becoming more common to prevent which emergency complication?
- A. Severe dysphagia
- B. Esophageal edema
- C. Hernia strangulation
- D. Aspiration
Correct Answer: C
Rationale: A. Although dysphagia is a complication of hiatal hernia, it is not an emergency condition. B. Esophageal edema is not a complication of hiatal hernia. C. A hiatal hernia can become strangulated (Circulation of blood to the hernia is cut off by constriction). Strangulation can occur with any type of hernia. D. Although aspiration is a complication of hiatal hernia, it is not an emergency condition.