NS 520: UNIT IV

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Question 1 of 1

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614410

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In reviewing the medical record shown in the accompanying figure for a patient admitted with acute pancreatitis, the nurse sees that the patient has a positive Cullen’s sign. Indicate the area where the nurse will assess for this change.

Select the correct answer(s).

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Explanation

The area around the umbilicus should be indicated. Cullen’s sign consists of ecchymosis around the umbilicus. Cullen’s sign occurs because of seepage of bloody exudates from the inflamed pancreas and indicates severe acute pancreatitis.

614411

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After an unimmunized individual is exposed to hepatitis B through a needle-stick injury, which actions will the nurse plan to take (select all that apply)?

Select the correct answer(s).

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Explanation

The recommendations for hepatitis B exposure include both vaccination and immune globulin administration. In addition, baseline testing for hepatitis B antibodies will be needed. Interferon and oral antivirals are not used for hepatitis B prophylaxis.

614454

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A patient has been admitted with acute liver failure. Which assessment data are most important for the nurse to communicate to the health care provider?

Select the correct answer(s).

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Explanation

The patient’s findings of asterixis and lethargy are consistent with grade 2 hepatic encephalopathy. Patients with acute liver failure can deteriorate rapidly from grade 1 or 2 to grade 3 or 4 hepatic encephalopathy and need early transfer to a transplant center. The other findings are typical of patients with hepatic failure and would be reported but would not indicate a need for an immediate change in the therapeutic plan.

614455

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A patient born in 1955 had hepatitis A infection 1 year ago. According to Centers for Disease Control and Prevention (CDC) guidelines, which action should the nurse include in care when the patient is seen for a routine annual physical examination?

Select the correct answer(s).

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Explanation

Current CDC guidelines indicate that all patients who were born between 1945 and 1965 should be screened for hepatitis C because many individuals who are positive have not been diagnosed. Although routine hepatitis B immunization is recommended for infants, children, and adolescents, vaccination for hepatitis B is recommended only for adults at risk for blood-borne infections. Because the patient has already had hepatitis A, immunization and anti-HAV IgM levels will not be needed.

614456

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Which action will the nurse include in the plan of care for a patient who has been diagnosed with chronic hepatitis B?

Select the correct answer(s).

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Explanation

Patients with chronic hepatitis are at higher risk for development of liver cancer and should be screened for liver cancer every 6 to 12 months. Patients with chronic hepatitis are advised to completely avoid alcohol. There is no hepatitis C vaccine. Because anti-HBs is present whenever there has been a past hepatitis B infection or vaccination, there is no need to regularly monitor for this antibody.

614457

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For a patient with cirrhosis, which nursing action can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP)?

Select the correct answer(s).

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Explanation

Providing oral hygiene is within the scope of UAP. Assessments and assisting patients to choose therapeutic diets are nursing actions that require higher level nursing education and scope of practice and would be delegated to licensed practical/vocational nurses (LPNs/LVNs) or RNs.

614458

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A patient had an incisional cholecystectomy 6 hours ago. The nurse will place the highest priority on assisting the patient to

Select the correct answer(s).

(0/0)

Explanation

Postoperative nursing care after a cholecystectomy focuses on prevention of respiratory complications because the surgical incision is high in the abdomen and impairs coughing and deep breathing. The other nursing actions are also important to implement but are not as high a priority as ensuring adequate ventilation.

614459

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Which assessment information will be most important for the nurse to report to the health care provider about a patient with acute cholecystitis?

Select the correct answer(s).

(0/0)

Explanation

Tan or gray stools indicate biliary obstruction, which requires rapid intervention to resolve. The other data are not unusual for a patient with this diagnosis, although the nurse would also report the other assessment information to the health care provider.

614460

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The nurse is caring for a patient with pancreatic cancer. Which nursing action is the highest priority?

Select the correct answer(s).

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Explanation

Effective pain management will be necessary in order for the patient to improve nutrition, be receptive to teaching, or manage anxiety or depression.

614461

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The nurse is planning care for a patient with acute severe pancreatitis. The highest priority patient outcome is

Select the correct answer(s).

(0/0)

Explanation

Respiratory failure can occur as a complication of acute pancreatitis and maintenance of adequate respiratory function is the priority goal. The other outcomes would also be appropriate for the patient.

614462

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Which action should the nurse in the emergency department take first for a new patient who is vomiting blood?

Select the correct answer(s).

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Explanation

The nurse’s first action should be to determine the patient’s hemodynamic status by assessing vital signs. Drawing blood for coagulation studies and inserting an IV catheter are also appropriate. However, the vital signs may indicate the need for more urgent actions. Because aspiration is a concern for this patient, the nurse will need to assess the patient’s vital signs and neurologic status before placing the patient in a supine position.

614463

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Which goal has the highest priority in the plan of care for a 26-yr-old patient who is homeless who was admitted with viral hepatitis who has severe anorexia and fatigue?

Select the correct answer(s).

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Explanation

The highest priority outcome is to maintain nutrition because adequate nutrition is needed for hepatocyte regeneration. Finding a home for the patient and identifying the source of the infection would be appropriate activities, but they do not have as high a priority as ensuring adequate nutrition. Although the patient’s activity level will be gradually increased, rest is indicated during the acute phase of hepatitis.

614464

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During change-of-shift report, the nurse learns about the following four patients. Which patient requires assessment first?

Select the correct answer(s).

(0/0)

Explanation

This patient’s history and fever suggest possible spontaneous bacterial peritonitis, which would require rapid assessment and interventions such as antibiotic therapy. The clinical manifestations for the other patients are consistent with their diagnoses and do not indicate complications are occurring.

614465

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A patient with chronic hepatitis C infection has several medications prescribed. Which medication requires further discussion with the health care provider before administration?

Select the correct answer(s).

(0/0)

Explanation

Pegylated a-interferon is administered subcutaneously, not orally. The medications are all appropriate for a patient with chronic hepatitis C infection.

614466

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Which action will be included in the care for a patient who has recently been diagnosed with asymptomatic nonalcoholic fatty liver disease (NAFLD)?

Select the correct answer(s).

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Explanation

Some medications can increase the risk for NAFLD, and they should be eliminated. NAFLD is not associated with hepatitis, weight loss is usually indicated, and variceal bleeding would not be a concern in a patient with asymptomatic NAFLD.

NS 520: UNIT IV

Question 1 of 1

Time Left

In reviewing the medical record shown in the accompanying figure for a patient admitted with acute pancreatitis, the nurse sees that the patient has a positive Cullen’s sign. Indicate the area where the nurse will assess for this change.

Select the correct answer(s).

(0/0)

Explanation

After an unimmunized individual is exposed to hepatitis B through a needle-stick injury, which actions will the nurse plan to take (select all that apply)?

Select the correct answer(s).

(0/0)

Explanation

A patient has been admitted with acute liver failure. Which assessment data are most important for the nurse to communicate to the health care provider?

Select the correct answer(s).

(0/0)

Explanation

A patient born in 1955 had hepatitis A infection 1 year ago. According to Centers for Disease Control and Prevention (CDC) guidelines, which action should the nurse include in care when the patient is seen for a routine annual physical examination?

Select the correct answer(s).

(0/0)

Explanation

Which action will the nurse include in the plan of care for a patient who has been diagnosed with chronic hepatitis B?

Select the correct answer(s).

(0/0)

Explanation

For a patient with cirrhosis, which nursing action can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP)?

Select the correct answer(s).

(0/0)

Explanation

A patient had an incisional cholecystectomy 6 hours ago. The nurse will place the highest priority on assisting the patient to

Select the correct answer(s).

(0/0)

Explanation

Which assessment information will be most important for the nurse to report to the health care provider about a patient with acute cholecystitis?

Select the correct answer(s).

(0/0)

Explanation

The nurse is caring for a patient with pancreatic cancer. Which nursing action is the highest priority?

Select the correct answer(s).

(0/0)

Explanation

The nurse is planning care for a patient with acute severe pancreatitis. The highest priority patient outcome is

Select the correct answer(s).

(0/0)

Explanation

Which action should the nurse in the emergency department take first for a new patient who is vomiting blood?

Select the correct answer(s).

(0/0)

Explanation

Which goal has the highest priority in the plan of care for a 26-yr-old patient who is homeless who was admitted with viral hepatitis who has severe anorexia and fatigue?

Select the correct answer(s).

(0/0)

Explanation

During change-of-shift report, the nurse learns about the following four patients. Which patient requires assessment first?

Select the correct answer(s).

(0/0)

Explanation

A patient with chronic hepatitis C infection has several medications prescribed. Which medication requires further discussion with the health care provider before administration?

Select the correct answer(s).

(0/0)

Explanation

Which action will be included in the care for a patient who has recently been diagnosed with asymptomatic nonalcoholic fatty liver disease (NAFLD)?

Select the correct answer(s).

(0/0)

Explanation

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