The nurse is planning care for a client with cirrhosis of the liver. Which intervention should the nurse include to reduce the risk of bleeding?

Correct Answer: C

Rationale: Correct Answer: C - Administer vitamin K as prescribed. Rationale: 1. Cirrhosis impairs liver function, leading to decreased synthesis of clotting factors, increasing the risk of bleeding. 2. Vitamin K is essential for synthesizing clotting factors; administering it helps improve clotting ability. 3. Monitoring for infection (A) is important but does not directly address the clotting issue. 4. Limiting protein intake (B) is not necessary for bleeding prevention in cirrhosis. 5. Encouraging fluid intake (D) is important for overall health but does not specifically reduce the risk of bleeding.

Correct Answer: B

Rationale: The correct answer is B: Notify the healthcare provider. A prolonged aPTT of 90 seconds indicates the client is at risk for bleeding due to excessive anticoagulation from heparin therapy. The nurse should notify the healthcare provider immediately to adjust the dosage or consider discontinuing heparin to prevent bleeding complications. Increasing the heparin infusion rate (A) would worsen the risk of bleeding. Applying pressure to the injection site (C) is not appropriate in this situation. Administering protamine sulfate (D) is the antidote for heparin overdose, but it is not the first action to take in this scenario.

Correct Answer: B

Rationale: Step 1: Initiating short, frequent contacts with the client will promote trust by establishing a consistent and supportive presence. Step 2: This approach allows the nurse to build rapport and demonstrate genuine concern for the client's well-being. Step 3: Regular interactions can help the client feel understood and supported, leading to a more trusting relationship. Step 4: By maintaining frequent contact, the nurse can monitor the client's well-being and provide reassurance as needed. Step 5: This proactive approach fosters trust and a therapeutic alliance, enhancing the client's overall care experience.

Correct Answer: C

Rationale: The correct answer is C: Hemoglobin level. In chronic renal failure, the kidneys may not produce enough erythropoietin, leading to anemia. Epoetin alfa stimulates red blood cell production. Therefore, reviewing the hemoglobin level is crucial to determine the need for the medication. Incorrect choices: A: Blood urea nitrogen (BUN) and B: Creatinine clearance are indicators of kidney function but not directly related to monitoring the effectiveness of epoetin alfa. D: Serum potassium is important in renal failure but not specifically needed to review before administering epoetin alfa.

Correct Answer: A

Rationale: The correct answer is A: Increased anteroposterior chest diameter. In COPD, the chronic airway obstruction leads to air trapping, causing the chest to become hyperinflated. This results in an increase in the anteroposterior chest diameter, often referred to as "barrel chest." Explanation for why other choices are incorrect: B: Decreased respiratory rate is not typically seen in COPD; patients often exhibit an increased respiratory rate due to difficulty breathing. C: Dull percussion sounds over the lungs are associated with conditions like pneumonia or pleural effusion, not COPD. D: Hyperresonance on chest percussion is typically found in conditions like emphysema, a type of COPD, but it is not specific to COPD as a whole.

Correct Answer: C

Rationale: Correct Answer: C - Keep the head of the bed elevated at 30 degrees. Rationale: 1. Elevating the head of the bed at 30 degrees helps prevent aspiration by promoting proper drainage of gastric contents. 2. This position reduces the risk of reflux and pulmonary complications in clients with NG tubes. 3. It also helps maintain the proper position of the tube in the stomach, decreasing the likelihood of displacement. Summary of Other Choices: A. Flushing the NG tube with water before and after feedings is important for tube patency but does not directly prevent complications associated with the NG tube. B. Checking gastric residual volume every 6 hours is important to monitor feeding tolerance but does not directly prevent complications related to the NG tube. D. Replacing the NG tube every 24 hours is not necessary unless there are specific indications such as tube blockage or dislodgment. Regular replacement can increase the risk of complications and is not a standard practice.

Correct Answer: A

Rationale: The correct answer is A: Encourage daily walking. Bradykinesia in Parkinson's disease refers to slowness of movement. Walking helps improve coordination, balance, and overall mobility in clients with Parkinson's. It promotes muscle strength and flexibility, counteracting the effects of bradykinesia. Walking also stimulates dopamine release, which is reduced in Parkinson's. Choice B is incorrect as thickened liquids are for dysphagia, not bradykinesia. Choice C is incorrect as meal frequency does not directly address bradykinesia. Choice D is incorrect as adaptive utensils help with fine motor skills, not slowness of movement.

Correct Answer: C

Rationale: The correct answer is C: Keep the ulcer clean and dry. This instruction is essential for promoting healing of the foot ulcer in a client with type 2 diabetes mellitus. Keeping the ulcer clean helps prevent infection, while keeping it dry promotes a better environment for healing. A: Applying a heating pad can increase the risk of burns and should be avoided. B: Wearing tight-fitting shoes can cause further damage and hinder healing. D: Limiting walking may reduce pressure on the ulcer, but mobility is important for circulation and overall health. Keeping the ulcer clean and dry is the most critical instruction.

Correct Answer: D

Rationale: The correct answer is D, Both A and C. Brudzinski's sign and Kernig's sign are both indicative of meningeal irritation. Brudzinski's sign is when flexion of the neck causes involuntary flexion of the hip and knee. Kernig's sign is when there is resistance or pain with knee extension after hip flexion. These signs suggest inflammation of the meninges, commonly seen in meningitis. Babinski reflex (choice B) is not specific to meningitis and is related to upper motor neuron dysfunction. Therefore, the correct answer is D as it includes the two most relevant signs for meningeal irritation, while the other choices are not directly associated with this condition.