Nokea
Which topic is most important to include in patient teaching for a 41-year-old patient diagnosed with early alcoholic cirrhosis?
- A. Maintaining good nutrition
- B. Avoiding alcohol ingestion
- C. Taking lactulose (Cephulac)
- D. Using vitamin B supplements
Correct Answer: B
Rationale: The most important topic to include in patient teaching for a 41-year-old patient diagnosed with early alcoholic cirrhosis is avoiding alcohol ingestion. Alcohol abstinence is crucial in stopping or reversing the progression of the disease. While maintaining good nutrition, taking lactulose (Cephulac), and using vitamin B supplements are important interventions in managing cirrhosis, abstaining from alcohol is the priority for this patient to prevent further damage to the liver and halt disease progression.
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The nurse is caring for a 10-year-old on admission to the burn unit. One assessment
parameter that will indicate that the child has adequate fluid replacement is:
- A. Urinary output of 30 ml per hour
- B. No complaints of thirst
- C. Increased hematocrit
- D. Good skin turgor around burn
Correct Answer: A
Rationale: For a child of this age, this is adequate output, yet does not suggest overload. Disruption
of sodium-ATPase activity presumably causes an intracellular sodium shift which
contributes to hypovolemia and cellular edema. Heat injury also initiates the release of
inflammatory and vasoactive mediators. These mediators are responsible for local
vasoconstriction, systemic vasodilation, and increased transcapillary permeability. Increase
in transcapillary permeability results in a rapid transfer of water, inorganic solutes, and
plasma proteins between the intravascular and interstitial spaces.
Which action will be included in the care for a patient who has recently been diagnosed with asymptomatic nonalcoholic fatty liver disease (NAFLD)?
- A. Teach about symptoms of variceal bleeding
- B. Draw blood for hepatitis serology testing
- C. Discuss the need to increase caloric intake
- D. Review the patient's current medication list
Correct Answer: D
Rationale: The correct action for a patient diagnosed with asymptomatic nonalcoholic fatty liver disease (NAFLD) would be to review the patient's current medication list. This is important because certain medications can increase the risk for NAFLD, and they should be identified and possibly eliminated. Teaching about symptoms of variceal bleeding is not necessary as variceal bleeding is not a concern in a patient with asymptomatic NAFLD. Drawing blood for hepatitis serology testing is not indicated as NAFLD is not associated with hepatitis. Discussing the need to increase caloric intake is also not appropriate since weight loss is usually recommended in the management of NAFLD.
The healthcare professional in the Emergency Room is treating a patient suspected to have a Peptic Ulcer. On assessing lab results, the healthcare professional finds that the patient's blood pressure is 95/60, pulse is 110 beats per minute, and the patient reports epigastric pain. What is the PRIORITY intervention?
- A. Start a large-bore IV in the patient's arm
- B. Ask the patient for a stool sample
- C. Prepare to insert an NG Tube
- D. Administer intramuscular morphine sulfate as ordered
Correct Answer: A
Rationale: The priority intervention in this scenario is to start a large-bore IV in the patient's arm. The patient's low blood pressure (95/60) and elevated pulse rate (110 beats per minute) indicate a potential hemorrhage, requiring immediate fluid resuscitation. Starting a large-bore IV will allow for rapid administration of fluids to stabilize the patient's condition. Asking for a stool sample, preparing to insert an NG tube, or administering morphine sulfate should not take precedence over addressing the hemodynamic instability and potential hemorrhage observed in the patient. These actions may be considered later in the patient's care, but the primary focus should be on addressing the critical issue of fluid replacement and stabilization.
While caring for the client during the first hour after delivery, the nurse determines that the uterus is boggy and there is vaginal bleeding. What should be the nurse's first action?
- A. Check vital signs.
- B. Massage the fundus.
- C. Offer a bedpan.
- D. Check for perineal lacerations.
Correct Answer: B
Rationale: The nurse's first action should be to massage the fundus until it is firm as uterine atony is the primary cause of bleeding in the first hour after delivery. Massaging the fundus helps to stimulate uterine contractions, which can help control the bleeding. Checking vital signs would be important but addressing the primary cause of bleeding takes precedence. Offering a bedpan is not a priority in this situation as the focus should be on managing the postpartum bleeding. Checking for perineal lacerations is also important but not the initial action needed to address the boggy uterus and vaginal bleeding.
A 38-year-old patient with cirrhosis has ascites and 4+ edema of the feet and legs. Which nursing action will be included in the plan of care?
- A. Restrict daily dietary protein intake.
- B. Reposition the patient every 4 hours.
- C. Place the patient on a pressure-relieving mattress.
- D. Perform passive range of motion daily.
Correct Answer: C
Rationale: Placing the patient on a pressure-relieving mattress is crucial to decrease the risk of skin breakdown, especially with significant edema and ascites. Adequate dietary protein intake is essential in patients with ascites to improve oncotic pressure and prevent malnutrition. Repositioning the patient every 4 hours alone may not be sufficient to prevent skin breakdown, especially in areas prone to pressure ulcers. Performing passive range of motion exercises is important for maintaining joint mobility but does not directly address the risk of skin breakdown associated with prolonged pressure on vulnerable areas.