The nurse has given the client diagnosed with hepatitis instructions about post discharge management during convalescence. The nurse determines a need for further teaching if the client makes which statement?
1."I should avoid alcohol and aspirin."
2."I should eat a high-carbohydrate, low-fat ...
The nurse has given the client diagnosed with hepatitis instructions about post discharge management
during convalescence. The nurse determines a need for further teaching if the client makes which
statement?
1."I should avoid alcohol and aspirin."
2."I should eat a high-carbohydrate, low-fat diet."
3."I should resume a full activity level within 1 week."
4."I should take the prescribed amounts of vitamin K." Answer: The client with hepatitis is easily
fatigued and may require several weeks to resume a full activity level. It is important for the client to get
adequate rest so that the liver may heal. The client should take in a high-carbohydrate and low-fat diet.
The client should avoid hepatotoxic substances, such as aspirin and alcohol. If prescribed for prolonged
clotting times the client should take vitamin K
The nurse is checking a client's record for probable signs of pregnancy. Which are the probable signs of
pregnancy that the nurse should note? Select all that apply. Answer: The probable signs of
pregnancy include uterine enlargement; Hegar's sign (the compressibility and softening of the lower
uterine segment that occurs at about week 6); Goodell's sign (the softening of the cervix that occurs at
the beginning of the second month of pregnancy); Chadwick's sign (the violet coloration of the mucous
membranes of the cervix, vagina, and vulva that occurs at about week 4); ballottement (the rebounding
of the fetus against the examiner's fingers on palpation); Braxton Hicks contractions; and a positive
pregnancy test that measures for human chorionic gonadotropin. Positive signs of pregnancy include a
fetal heart rate that is detected by an electronic device (Doppler transducer) at 10 to 12 weeks'
gestation and by a nonelectronic device (fetoscope) at 20 weeks' gestation; active fetal movements that
are palpable by the examiner; and an outline of the fetus via radiography or ultrasound.
The nurse is monitoring the behavior of the client and understands that the client with anorexia nervosa
manages anxiety by which action? Answer: Clients with anorexia nervosa have the desire to please
others. Their need to be correct or perfect interferes with rational decision-making processes. These
clients are moralistic. Rules and rituals help the clients manage their anxiety.
,A client is receiving heparin sodium by continuous intravenous (IV) infusion. The licensed practical nurse
(LPN) is concerned that the client received a bolus of medication when the tubing was removed from
the IV pump during a gown change. The LPN immediately notifies the registered nurse or health care
provider and then checks to see whether which medication is available in the medication supply area in
case it is prescribed? Answer: If the tubing is removed from an IV pump and the tubing is not
clamped, the client will receive a bolus of the solution and the medication contained in the solution. The
client who receives a bolus dose of heparin is at risk for bleeding. A partial thromboplastin time (PTT)
will be drawn and evaluated. If the results of the PTT are too high, a dose of protamine sulfate, the
antidote for heparin, may be prescribed. Aminocaproic acid is an antifibrinolytic (inhibits clot
breakdown). Enoxaparin is an anticoagulant. Vitamin K is the antidote for warfarin sodium.
The nursing instructor has taught a lecture on the reproductive cycle of the female and asks a nursing
student to identify the functions of the vagina. The student correctly responds by identifying which
functions? Select all that apply. Answer: The pelvis is a bony structure that supports and protects
the lower abdominal and internal reproductive organs. The vagina is the female organ of coitus, allows
discharge of the menstrual flow, and assists in the passage of the fetus from the uterus to outside the
mother's body during childbirth. The fallopian tubes are lined with folded epithelium containing cilia
that beat rhythmically toward the uterine cavity to propel the ovum through the tube. The functions of
the ovaries include sex hormone production and maturation of an ovum during each reproductive cycle.
A client scheduled for a pulmonary angiography is fearful about the procedure and asks the nurse if the
procedure involves significant pain and radiation exposure. The nurse gives a response to the client that
provides reassurance, based on which understanding? Answer: Pulmonary angiography involves
minimal exposure to radiation. The procedure is painless, although the client may feel discomfort with
insertion of the needle for the catheter that is used for dye injection. No and moderate pain and no
exposure to radiation are incorrect.
The nurse prepares to administer digoxin to a 3-year-old with a diagnosis of heart failure and notes that
the apical heart rate is 120 beats per minute. Which nursing action is appropriate? Answer: The
normal apical heart rate for a 3-year-old is 80 to 125 beats per minute. Because the apical heart rate is
within normal range, options 1, 3, and 4 are inappropriate.
The nurse is caring for a new postoperative client and is monitoring the client for signs of shock. The
nurse monitors for which signs of this postoperative complication? Answer: Postoperative
hypotension or shock can have numerous causes such as inadequate ventilation, side effects of
, anesthetic agents or preoperative medications, and fluid or blood loss. The symptoms of shock include
hypotension; tachycardia; cold, moist, pale, or cyanotic skin; and increased restlessness and
apprehension.
A client receiving therapy with carbidopa/levodopa is upset and tells the nurse that his urine has turned
a darker color since he began to take the medication. The client wants to discontinue its use. In
formulating a response to the client's concerns, how does the nurse interpret this development?
Answer: With carbidopa/levodopa therapy, a darkening of the urine or sweat may occur. The client
should be reassured that this is a harmless effect of the medication, and its use should be continued.
Options 1, 2, and 4 are incorrect interpretations.
A client newly diagnosed with chronic kidney disease will be receiving peritoneal dialysis. During the
infusion of the dialysate, the client complains of abdominal pain. Which action by the nurse is
appropriate? Answer: Pain during the inflow of dialysate is common during the first few exchanges
because of peritoneal irritation; however, it disappears after a week or two. The infusion amount should
not be decreased, and the infusion should not be slowed or stopped.
The nurse is initiating cardiopulmonary resuscitation on an adult client. The nurse should place the
hands in which position to begin chest compressions? Answer: Chest compressions are done by
placing the hands on the lower half of the sternum. The locations in options 2, 3, and 4 would not
provide effective chest compressions.
The nurse is caring for a client who had a total knee replacement and was put on a continuous passive
motion (CPM) machine in the postanesthesia care unit (PACU). What are some of the actions the nurse
needs to monitor to operate this machine? Select all that apply. Answer: While not as commonly
used today, the CPM machine keeps the prosthetic knee in motion and may prevent the formation of
scar tissue which could decrease knee mobility and increase postoperative pain. It should be used as
much as the client can tolerate. The nurse needs to make sure that the machine is well padded and
assess the client's response to the machine. Also, the machine needs to be turned off while the client is
having a meal in bed. It is very important that the nurse ensures that the joint being moved is positioned
properly on the machine. The cycle and range-of-motion settings must be checked every 8 hours and not
once a day. When the machine is not in use, it should not be stored on the floor. If the client is confused,
place the controls to the machine out of his or her reach.
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller Schoolflix. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $15.49. You're not tied to anything after your purchase.
