a client with cirrhosis of the liver is experiencing pruritus which intervention should the nurse implement to help relieve the clients symptoms
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Nursing Elites

ATI LPN

ATI PN Adult Medical Surgical 2019

1. A client with cirrhosis of the liver is experiencing pruritus. Which intervention should the nurse implement to help relieve the client's symptoms?

Correct answer: B

Rationale: Pruritus is a common symptom in clients with cirrhosis due to bile salts accumulating in the skin. Applying lotion to the skin helps soothe the itching and can prevent skin breakdown. Acetaminophen can worsen liver damage in clients with cirrhosis as it is metabolized in the liver. Encouraging a high-protein diet is not directly related to relieving pruritus. Providing a warm bath may further dry the skin, exacerbating the itching. Therefore, the most appropriate intervention to help relieve pruritus in a client with cirrhosis is to apply lotion to the skin.

2. A client with peptic ulcer disease is prescribed omeprazole (Prilosec). Which instruction should the nurse include in the client's teaching plan?

Correct answer: C

Rationale: The correct instruction for a client prescribed omeprazole (Prilosec) is to take the medication on an empty stomach. This is important for optimal absorption and effectiveness of the medication in treating peptic ulcer disease. Choice A ('Take the medication with food') is incorrect because omeprazole should be taken on an empty stomach. Choice B ('Take the medication at bedtime') is incorrect as it does not align with the optimal timing for omeprazole administration. Choice D ('Take the medication as needed for pain relief') is incorrect because omeprazole is not typically used for immediate pain relief but rather for long-term management of peptic ulcer disease.

3. A 38-year-old male client collapsed at his outside construction job in Texas in July. His admitting vital signs to ICU are, BP 82/70, heart rate 140 beats/minute, urine output 10 ml/hr, skin cool to the touch. Pulmonary artery (PA) pressures are, PAWP 1, PAP 8/2, RAP -1, SVR 1600. What nursing action has the highest priority?

Correct answer: B

Rationale: The correct answer is to increase the client's IV fluid rate to 200 ml/hr. The client's vital signs indicate signs of shock and hypovolemia, making fluid resuscitation the priority to address these conditions. Improving intravascular volume is crucial to stabilize the client's blood pressure, heart rate, and urine output, ultimately improving organ perfusion and addressing the underlying issue of hypovolemia.

4. Which assessment finding indicates a client's readiness to leave the nursing unit for a bronchoscopy?

Correct answer: C

Rationale: Administering on-call sedation is crucial before a bronchoscopy to ensure the client is comfortable and adequately prepared for the procedure. Sedation helps reduce anxiety, discomfort, and ensures the client remains still during the bronchoscopy, enabling the healthcare provider to perform the procedure effectively.

5. A 62-year-old male client with a history of coronary artery disease complains that his heart is 'racing' and he often feels dizzy. His blood pressure is 110/60, and he uses portable oxygen at 2 liters per nasal cannula. Based on the rhythm shown, which prescription should the nurse administer?

Correct answer: C

Rationale: Administering IV adenosine is the appropriate intervention for a client with symptomatic tachycardia to restore normal sinus rhythm. Adenosine is a medication used to treat supraventricular tachycardia (SVT) by interrupting the reentry pathways through the AV node and restoring normal sinus rhythm. It is a rapid-acting medication given as a rapid IV push followed by a saline flush. The dose is typically administered in a healthcare setting where cardiac monitoring is available due to its potential to cause transient asystole.

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