Dr. Marquez orders serum electrolytes. To determine the effect of persistent vomiting, Nurse Trish should be most concerned with monitoring the:
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Solution
Chloride and sodium levels
Option A: Sodium, which is concerned with the regulation of extracellular fluid volume, it is lost with vomiting. Chloride, which balances cations in the extracellular compartments, is also lost with vomiting, because sodium and chloride are parallel electrolytes, hyponatremia will accompany.
Nurse Trish is aware that the laboratory test result that most likely would indicate acute pancreatitis is an elevated:
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Solution
Serum amylase level
Option B: Amylase concentration is high in the pancreas and is elevated in the serum when the pancreas becomes acutely inflamed and also it distinguishes pancreatitis from other acute abdominal problems.
Tony was diagnosed with hepatitis A. The information from the health history that is most likely linked to hepatitis A is:
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Solution
Working as local plumber
Option B: Hepatitis A is primarily spread via fecal-oral route. Sewage polluted water may harbor the virus.
Immediately after liver biopsy, the client is placed on the right side, the nurse is aware that this position should be maintained because it will:
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Solution
Help stop bleeding if any occurs
Option A: Pressure applied in the puncture site indicates that a biliary vessel was puncture which is a common complication after liver biopsy.
Louis develops peritonitis and sepsis after surgical repair of ruptured diverticulum. The nurse in charge should expect an assessment of the client to reveal:
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Solution
Abdominal rigidity
Option B: With increased intraabdominal pressure, the abdominal wall will become tender and rigid.
When teaching a client about the signs of colorectal cancer, Nurse Trish stresses that the most common complaint of persons with colorectal cancer is:
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Solution
Change in bowel habits
Option D: Constipation, diarrhea, and/or constipation alternating with diarrhea are the most common symptoms of colorectal cancer.
44. Tony returns from surgery with permanent colostomy. During the first 24 hours, the colostomy does not drain. The nurse should be aware that:
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Solution
Absence of gastrointestinal motility
Option C: This is primarily caused by the trauma of intestinal manipulation and the depressive effects anesthetics and analgesics.
Mark has multiple abrasions and a laceration to the trunk and all four extremities says, “I can’t eat all this food”. The food that the nurse should suggest to be eaten first should be:
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Solution
Meatloaf and strawberries
Option B: Meat provides proteins and the fruit proteins vitamin C that both promote wound healing.
Nurse Trish is aware that temporary heterograft (pig skin) is used to treat burns because this graft will:
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Solution
Relieve pain and promote rapid epithelialization
Option A: The graft covers the nerve endings, which reduces pain and provides framework for granulation
Louie, with burns over 35% of the body, complains of chilling. In promoting the client’s comfort, the nurse should:
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Solution
Limit the occurrence of drafts
Option C: A Client with burns is very sensitive to temperature changes because heat is lost in the burn areas.