A nurse is reinforcing teaching with a client who has end-stage liver disease and a recent diagnosis of thrombocytopenia. Which of the following statements provides the best recommendation to prevent complications of bleeding?

Wear sleeveless or short-sleeved shirts and shorts to better visualize any skin issues.

Use a floss pick instead of the floss string to floss in between the teeth.

Apply an ice pack over a bleeding wound.

Only use a soft-bristle toothbrush.

Answer and Explanation

The Correct Answer is D

A. Wear sleeveless or short-sleeved shirts and shorts to better visualize any skin issues: While wearing loose or visible clothing may allow skin issues to be seen, it does not directly prevent bleeding complications, and there are more effective measures to focus on.

B. Use a floss pick instead of the floss string to floss in between the teeth: Flossing in any form, especially using a floss pick, can still increase the risk of gum bleeding in thrombocytopenic clients. It is safer to avoid flossing altogether or consult a dentist.

C. Apply an ice pack over a bleeding wound: While applying an ice pack may reduce bleeding once it occurs, it does not prevent bleeding. The focus should be on avoiding activities that increase the risk of bleeding.

D. Only use a soft-bristle toothbrush: Using a soft-bristle toothbrush helps reduce the risk of bleeding from the gums, which is a common issue for clients with thrombocytopenia due to the reduced platelet count.

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Correct Answer is D

Explanation

A. Flush the T-tube with sterile water every 6 hours to maintain patency: T-tubes are generally not flushed unless prescribed by a healthcare provider because flushing can introduce bacteria and cause complications. Patency is typically maintained by gravity drainage alone.

B. Clamp the T-tube for 12 hours each day to reduce bile flow: Clamping the T-tube is not routinely recommended for such long periods unless directed by the healthcare provider. Clamping is usually done gradually, often for 1-2 hours, to assess the patient’s ability to tolerate bile drainage naturally before tube removal.

C. Secure the T-tube to the patient's gown to prevent accidental dislodgement: While securing the T-tube prevents accidental dislodgement, the tube should be taped to the skin rather than the gown, as attaching it to clothing can increase the risk of unintentional dislodgement with movement.

D. Maintain the drainage bag below the level of the abdomen to promote gravity drainage. This is the correct answer because positioning the drainage bag below the abdomen allows for gravity to assist in the flow of bile from the bile duct, preventing backup and promoting proper drainage.

A. Frothy urine B. Hypertension C. Fish-type urine odor D. Mental confusion E. Lower abdominal pain F. Weak urine stream

Correct Answer is ["B","C","D","E"]

Explanation

A. Frothy urine: Frothy urine is typically associated with proteinuria, seen in nephrotic syndrome, not pyelonephritis.

B. Hypertension: Hypertension can occur due to kidney inflammation and impaired function in pyelonephritis.

C. Fish-type urine odor: A foul or fishy-smelling urine odor is often associated with a urinary tract infection, including pyelonephritis.

D. Mental confusion: Mental confusion can occur in elderly patients with pyelonephritis due to systemic infection or sepsis.

E. Lower abdominal pain: Lower abdominal pain can occur with pyelonephritis due to infection in the urinary tract.

F. Weak urine stream: A weak urine stream is more characteristic of lower urinary tract issues, such as benign prostatic hyperplasia (BPH), rather than pyelonephritis.

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A nurse is reinforcing teaching with a client who has end-stage liver disease and a recent diagnosis of thrombocytopenia. Which of the following statements provides the best recommendation to prevent complications of bleeding?

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Naxlex Comprehensive Predictor Exams

A patient is recovering from a common bile duct exploration and has a T-tube drain in place. As the nurse, which action is most appropriate to ensure proper function and patient safety?

Correct Answer is D

Explanation

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Correct Answer is ["B","C","D","E"]

Explanation

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