A nurse is teaching a client who has hepatitis A about preventing the transmission of the virus. Which of the following strategies should the nurse include in the teaching?

Wear barrier protection during vaginal intercourse.

Avoid sharing needles with others.

Avoid eating at fast food restaurants.

Practice effective hand hygiene.

Answer and Explanation

The Correct Answer is D

Choice A rationale
Wearing barrier protection during vaginal intercourse is a general precaution to prevent the transmission of sexually transmitted infections (STIs), including hepatitis B and C. However, hepatitis A is primarily transmitted through the fecal-oral route, not sexual contact.

Choice B rationale
Avoiding needle sharing is critical for preventing the spread of bloodborne pathogens, including hepatitis B and C. While it is always good practice, hepatitis A is not typically transmitted through blood.

Choice C rationale
The suggestion to avoid eating at fast food restaurants does not directly relate to the prevention of hepatitis A. The virus is usually spread through contaminated food or water, so ensuring food safety is important, but singling out fast food restaurants is not necessary.

Choice D rationale
Practicing effective hand hygiene is the most effective way to prevent the transmission of hepatitis A. The virus can be spread through close contact or ingestion of contaminated food or water, so washing hands can significantly reduce the risk.

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Correct Answer is A

Explanation

Choice A rationale
In the case of hyperkalemia, which can cause fatal cardiac arrhythmias, the most immediate nursing action is to place the patient on a cardiac monitor. This allows for continuous monitoring of the heart's rhythm and immediate detection of any life-threatening changes, which is crucial for timely intervention.

Choice B rationale
Inserting a urinary retention catheter may be necessary for managing oliguria, but it is not the most urgent action when compared to the potential cardiac risks associated with hyperkalemia.

Choice C rationale
Administering spironolactone, a potassium-sparing diuretic, could be part of the treatment for hyperkalemia, but it is not the first action to take. Spironolactone works more slowly and does not address the immediate risk of cardiac arrhythmias.

Choice D rationale
Epoetin alfa (Epogen) is used to treat anemia, particularly in chronic kidney disease, to increase red blood cell production. However, it does not have an immediate effect and is not the priority in the presence of hyperkalemia and potential cardiac complications.

A. Percuss between the iliac crest and ribs at the midaxillary line. B. Push fingers upward into the two lowest intercostal spaces. C. Palpate along both sides of the lumbar vertebral column. D. Strike a flat hand covering the costovertebral angle (CVA).

Correct Answer is D

Explanation

Choice A rationale
Percussion between the iliac crest and ribs at the midaxillary line is not the standard method for assessing flank tenderness associated with pyelonephritis. This technique may not elicit the characteristic pain of kidney inflammation.

Choice B rationale
Pushing fingers upward into the two lowest intercostal spaces is not a specific test for flank tenderness and may not accurately assess for pyelonephritis. This action is more related to assessing the integrity of the rib cage and intercostal muscles.

Choice C rationale
Palpating along both sides of the lumbar vertebral column is not the correct method for assessing flank tenderness due to pyelonephritis. This approach is more suited for assessing the musculoskeletal structure rather than the kidneys.

Choice D rationale
Striking a flat hand over the costovertebral angle is the correct method for assessing flank tenderness in cases of suspected pyelonephritis. This technique, known as costovertebral angle tenderness, elicits pain when the kidneys are inflamed, which is a common sign of pyelonephritis.

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A nurse is teaching a client who has hepatitis A about preventing the transmission of the virus. Which of the following strategies should the nurse include in the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient admitted with acute kidney injury due to dehydration has oliguria, anemia, and hyperkalemia. Which prescribed action should the nurse take first?

Correct Answer is A

Explanation

How will the nurse assess for flank tenderness in a patient with suspected pyelonephritis?

Correct Answer is D

Explanation

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