Nurse Rachel teaches a client who has been recently diagnosed with hepatitis A about untoward signs and symptoms related to Hepatitis that may develop. The one that should be reported immediately to the physician is:
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Solution
Clay-colored stools
Option D: Clay-colored stools are indicative of hepatic obstruction
A client who has undergone a cholecystectomy asks the nurse whether there are any dietary restrictions that must be followed. Nurse Hilary would recognize that the dietary teaching was well understood when the client tells a family member that:
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Solution
“Most people can tolerate regular diet after this type of surgery”
Option D: It may take 4 to 6 months to eat anything, but most people can eat anything they want.
After gastroscopy, an adaptation that indicates major complication would be:
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Solution
Abdominal distention
Option B: Abdominal distension may be associated with pain, may indicate perforation, a complication that could lead to peritonitis.
A client has Gastroesophageal Reflux Disease (GERD). The nurse should teach the client that after every meals, the client should…
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Solution
Rest in sitting position
Option A: Gravity speeds up digestion and prevents reflux of stomach contents into the esophagus.
Dr. Marquez tells a client that an increased intake of foods that are rich in Vitamin E and beta-carotene are important for healthier skin. The nurse teaches the client that excellent food sources of both of these substances are:
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Solution
Spinach and mangoes
Option D: Beta-carotene and Vitamin E are antioxidants which help to inhibit oxidation. Vitamin E is found in the following foods: wheat germ, corn, nuts, seeds, olives, spinach, asparagus and other green leafy vegetables. Food sources of beta-carotene include dark green vegetables, carrots, mangoes and tomatoes.
Paul is admitted to the hospital due to metabolic acidosis caused by Diabetic ketoacidosis (DKA). The nurse prepares which of the following medications as an initial treatment for this problem?
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Solution
Regular insulin
Option A: Metabolic acidosis is anaerobic metabolism caused by lack of ability of the body to use circulating glucose. Administration of insulin corrects this problem.
Nurse Lucy is planning to give preoperative teaching to a client who will be undergoing rhinoplasty. Which of the following should be included?
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Solution
Aspirin-containing medications should not be taken 14 days before surgery
Option D: Aspirin-containing medications should not be taken 14 days before surgery to decrease the risk of bleeding.
A client has 15% blood loss. Which of the following nursing assessment findings indicates hypovolemic shock?
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Solution
Systolic blood pressure less than 90mm Hg
Option A: Typical signs and symptoms of hypovolemic shock includes systolic blood pressure of less than 90 mm Hg.
A newly admitted client is diagnosed with Hodgkin’s disease undergoes an excisional cervical lymph node biopsy under local anesthesia. What does the nurse assess first after the procedure?
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Solution
Airway
Option C: Assessing for an open airway is the priority. The procedure involves the neck, the anesthesia may have affected the swallowing reflex or the inflammation may have closed in on the airway leading to ineffective air exchange.
A male client with a history of cirrhosis and alcoholism is admitted with severe dyspnea resulted to ascites. The nurse should be aware that the ascites is most likely the result of increased…
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Solution
Pressure in the portal vein
Option A: Enlarged cirrhotic liver impinges the portal system causing increased hydrostatic pressure resulting to ascites.