Nursing Elites

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

• A. Administer acetaminophen (Tylenol).
• B. Apply lotion to the skin.
• C. Encourage a high-protein diet.
• D. Provide a warm bath.

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 56-year-old woman presents to discuss the results of her recent upper endoscopy. She was having some mild abdominal pain, so she underwent the procedure, which revealed an ulcer in the antrum of the stomach. Biopsy of the lesion revealed the presence of H. pylori. All of the following statements regarding her condition are correct except

• A. H. pylori has been associated with gastric MALT (mucosa-associated lymphoid tissue)
• B. Reinfection is rare despite adequate treatment
• C. Triple drug therapy has been shown to be more effective than dual drug therapy
• D. If her H. pylori IgG antibody titer was elevated prior to therapy, it can be used to monitor treatment efficacy

Correct answer: B

Rationale: H. pylori is associated with a majority of peptic ulcer disease cases and has links to gastric MALT and adenocarcinoma. Triple drug therapy is more effective than dual therapy. Reinfection after adequate treatment is rare. While urea breath testing is a better diagnostic tool, quantitative serology can monitor treatment efficacy. A 30% decrease in IgG titer should occur post-therapy, indicating effectiveness.

3. A client's telemetry monitor indicates the sudden onset of ventricular fibrillation. Which assessment finding should the nurse anticipate?

• A. Bounding erratic pulse.
• B. Regularly irregular pulse.
• C. Thready irregular pulse.
• D. No palpable pulse.

Correct answer: D

Rationale: Ventricular fibrillation is a life-threatening arrhythmia characterized by chaotic, asynchronous contractions of the ventricles, resulting in ineffective cardiac output. This leads to the absence of a palpable pulse. Nurses should be prepared to initiate immediate interventions such as defibrillation to restore normal cardiac rhythm in a client experiencing ventricular fibrillation.

4. A client who is receiving heparin therapy has an activated partial thromboplastin time (aPTT) of 90 seconds. What action should the nurse take?

• A. Increase the heparin infusion rate.
• B. Notify the healthcare provider.
• C. Apply pressure to the injection site.
• D. Administer protamine sulfate.

Correct answer: B

Rationale: An activated partial thromboplastin time (aPTT) of 90 seconds is elevated, indicating a risk of bleeding. The appropriate action for the nurse is to notify the healthcare provider. Increasing the heparin infusion rate can further elevate the aPTT, leading to an increased risk of bleeding. Applying pressure to the injection site is not relevant in this situation. Administering protamine sulfate is used to reverse the effects of heparin in cases of overdose or bleeding, but it is not the initial action for an elevated aPTT.

5. A patient who is receiving chemotherapy for breast cancer develops thrombocytopenia. What should the nurse include in the care plan?

• A. Encourage light exercise.
• B. Avoid intramuscular injections.
• C. Do not administer aspirin.
• D. Use a soft toothbrush for oral care.

Correct answer: B

Rationale: Thrombocytopenia is a condition characterized by a low platelet count, which can lead to an increased risk of bleeding. To minimize this risk, patients with thrombocytopenia should avoid activities that can cause injury or bleeding, such as intramuscular injections. Encouraging light exercise can be beneficial, as it promotes circulation without increasing the risk of trauma. However, avoiding intramuscular injections is crucial to prevent bleeding episodes. Aspirin should be avoided as it can further impair platelet function, exacerbating the condition. Using a soft toothbrush for oral care is recommended to prevent gum bleeding in patients with thrombocytopenia.

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