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A nurse is caring for a client after having a splenectomy following a motor vehicle crash. Which of the following client care measures has the highest priority?
Promoting lung aeration
A nurse is caring for a client who is placed on a low-bacteria diet in combination with an oral selective bowel decontamination solution prior to a liver transplant. The nurse understands that the client should avoid consuming which of the following?
fresh grapes
A client is receiving a tube feeding via a continuous enteral pump at 75 ml/hr. When the nurse assesses the client at 0800, which of the following nursing observations requires intervention?
The head of the bed is elevated 20 degree
A nurse assesses a client's bowel sounds 3 days following a gastroplasty for obesity and notes that they have returned. A 1 oz serving of which of the following is appropriate as an initial feeding?
Water
A nurse is teaching a client with diverticulitis about preventing acute attacks. The nurse should advise the client to consume foods that are...
high in fiber.
A nurse is assessing a client who is in the early stages of hepatitis A. Which of the following manifestations should the client report?
Anorexia
A nurse is caring for a client who is diagnosed with fulminant hepatic failure. Which of the following procedures should the nurse expect the client to be prepared for?
Liver transplant
A nurse is caring for a client who is scheduled to undergo a liver biopsy for a suspected malignancy. Which of the following should the nurse monitor prior to the procedure?
PT
A nurse is caring for a client who has returned to the unit following a laparoscopic cholecystectomy and reports severe pain in the left shoulder. The nurse should recognize that the client's pain
is
due to carbon dioxide instilled into the abdomen during surgery
A nurse is preparing a community education program about Hep B. Which of the following statements should be included in the nurses discussion?
Hep B immunization is given to infants and children.
A community health nurse is planning an educational program to prevent the transmission of Hep A in a community where the virus is becoming endemic. When preparing the materials, the nurse realizes the population group likely to become infected with the hep A virus is which of the following?
Children and young adults
A nurse is caring for a hospitalized client with acute pancreatitis. After treatment begins, the nurse anticipates that which serum lab value will return to normal within 72h?
Amylase
A nurse is caring for a client with severe GERD who is to undergo a esophagoscopy. While teaching the client about the procedure, the nurse should state.
"Esophagoscopy is useful in determining how well the lower part of your esophagus works."
A nurse is completing an admission history and assessment on a client admitted with an exacerbation of chronic pancreatitis. The nurse recognizes that which of the following findings is likely to be the cause of chronic pancreatitis?
Alcohol usage
A nurse is caring for an unconscious client recovering from a closed-head injury following placement of PEG tube. Which of the following actions has the highest priority?
Place the client in high-Fowler's position during PEG tube feedings.
A nurse is caring for a client with a history of Laennecs cirrhosis who is admitted to the hospitl with manifestations of hepatic encephalopathy. The client denies consuming alcohol. The nurse anticipates that which of the following diagnostic enzymes tests will be ordered to investigate the possibility of alcohol abuse?
GGT
A nurse is caring for a client who is scheduled to have an EGD. The nurse should recognize that this procedure is used to do which of the following?
Sclerose esophageal varices
A nurse is caring for a client with bleeding esophageal varices who was treated with a double balloon tamponade. Several hours after the gastric and esophageal balloons were inflated, the nurse notes that the client has become increasingly agitated, and respiration are 36/min and shallow. Which of the following is an appropriate nursing action?
use scissors to cut the tubing in front of the nose guard or sponge
A nurse is caring for a client admitted with a bowel obstruction who develops severe abdominal pain. Which of the following assessment findings should indicate to the nurse that a possible bowel perforation has occurred?
Rigid abdomen
A client returns to the nursing unit 1 hr following physical therapy. The nurse notes that the infusion pump for the client's total parenteral nutrition is turned off. After restarting the infusion pump, the nurse should monitor the client for which of the following?
Shakiness and diaphoresis