A nurse is caring for a patient admitted with acute cholecystitis. On assessment the nurse notes a positive Murphy’s sign, RUQ tenderness, temperature of 38.2°C, and nausea after eating. Which nursing interventions does the nurse include in the plan of care? (Select all that apply)  

A patient with cirrhosis and hepatic encephalopathy is receiving dietary teaching. Which lunch tray selection indicates the patient has understood the teaching?  

A patient with severe acute pancreatitis has the following vital sign trends over the past 4 hours:   0800 1000 1200 BP 118/76 104/68 92/60 HR 88 102 118 RR 18 22 26 Temp 37.8 C 38.5 C 39.3 C   Which interpretation by the nurse reflects the highest clinical priority?

A 62-year-old patient with decompensated cirrhosis and severe ascites undergoes a large-volume paracentesis with removal of 6 liters of fluid. Six hours later, the nurse notes: BP: 86/54 mmHg HR: 118 bpm Urine output: 15 mL/hr Serum creatinine: increased from 1.0 to 1.9 mg/dL Sodium: 126 mEq/L Abdomen: softer, less distended No evidence of bleeding Which interpretation by the nurse is most accurate?  

A nurse in the emergency department is assessing a child with suspected acute appendicitis. Based on the progression of the disorder, which findings should the nurse anticipate and prioritize as consistent with appendicitis? (Select all that apply.)

A patient diagnosed with cirrhosis is being treated with lactulose. Current serum ammonia level is elevated. Which clinical manifestation would indicate a complication of this elevation?  

The family member of a patient admitted with acute cholecystitis and an elevated bilirubin asks the nurse, “She doesn’t have a liver problem — why does she keep scratching herself?” Which response by the nurse best explains the relationship?  

A patient with cirrhosis and portal hypertension has been taking metoprolol for hypertension. His provider discontinues the metoprolol and prescribes propranolol. The patient asks the nurse, “I don’t understand — I was already on a beta blocker. Why do I need a different one?” Which response by the nurse best explains the reason for the medication change?  

A nurse is preparing to administer the Hepatitis B vaccine when the patient makes several statements. Which statement requires the nurse to hold the vaccine and notify the provider?

Q34. The nurse is educating a patient with cancer about combination chemotherapy. Which is an accurate statement?