After traveling to a country with a tropical climate, a young adult is diagnosed with a liver abscess and is taking antimicrobial therapy as an outpatient.
During a follow-up visit at the community clinic, the nurse observes that the patient has developed jaundice.
Which action should the nurse take?

Prepare the patient for repeat blood cultures.

Arrange emergency transport to an inpatient facility.

Explain the need to evaluate liver function.

Instruct the patient to increase protein intake.

Answer and Explanation

The Correct Answer is C

Choice A rationale

While repeat blood cultures could potentially provide useful information, they are not the immediate priority when a patient develops jaundice. Jaundice is a sign of liver dysfunction, and further evaluation of liver function is needed to determine the cause and appropriate treatment.

Choice B rationale

Arranging emergency transport to an inpatient facility may be necessary in some cases, but it is not the immediate action required in this situation. The development of jaundice indicates a need for further evaluation, but it does not necessarily indicate an emergency situation.

Choice C rationale

Explaining the need to evaluate liver function is the most appropriate action in this situation. Jaundice is a sign of liver dysfunction, and further evaluation of liver function is needed to determine the cause and appropriate treatment.

Choice D rationale

While increasing protein intake can be beneficial for some patients with liver disease, it is not the immediate priority in this situation. The development of jaundice indicates a need for further evaluation of liver function.

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Correct Answer is B

Explanation

Choice A rationale

Prompting the nurse to apply povidone to the site is not the correct action in this scenario. Povidone-iodine is an antiseptic used for skin disinfection before and after surgery. It is not typically used in the process of irrigating an intravenous catheter.

Choice B rationale

Directing the nurse to attach the luer-lock tip to the irrigation port is the correct action. A luer-lock syringe is commonly used in medical procedures, including the irrigation of an intravenous catheter. The luer-lock tip provides a secure connection to prevent leaks and ensure that the irrigation solution is delivered directly to the catheter.

Choice C rationale

Sending an unlicensed assistive personnel to gather equipment is not the most appropriate action in this scenario. The new nurse has already gathered the necessary equipment for the procedure.

Choice D rationale

Instructing the nurse to use water with 5% dextrose (D5W) is not the correct action. D5W is a type of intravenous fluid used to correct dehydration and provide calories to the patient. It is not typically used for irrigating an intravenous catheter.

A. Instruct the patient that it is important to reduce the dose of the medication gradually. B. Advise the patient to stop taking the medication immediately. C. Encourage the patient to obtain a prescription for a benzodiazepine antagonist. D. Discuss with the patient that there may be a need for additional sleep if the feeling of fatigue is present the next day.

Correct Answer is A

Explanation

Choice A rationale

Instructing the patient that it is important to reduce the dose of the medication gradually is the best course of action. Temazepam is a benzodiazepine, and abrupt discontinuation can lead to withdrawal symptoms, which can be severe and include seizures. Therefore, it’s crucial to taper off the medication under the supervision of a healthcare provider.

Choice B rationale

Advising the patient to stop taking the medication immediately is not recommended due to the risk of withdrawal symptoms.

Choice C rationale

Encouraging the patient to obtain a prescription for a benzodiazepine antagonist is not typically the first line of action when discontinuing temazepam.

Choice D rationale

Discussing with the patient that there may be a need for additional sleep if the feeling of fatigue is present the next day is not directly addressing the issue. The patient’s feelings of being “hungover” are likely due to the effects of the medication, not a lack of sleep.

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After traveling to a country with a tropical climate, a young adult is diagnosed with a liver abscess and is taking antimicrobial therapy as an outpatient.During a follow-up visit at the community clinic, the nurse observes that the patient has developed jaundice.Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The charge nurse observes a new nurse preparing to irrigate an intravenous catheter.The new nurse has a luer-lock tipped syringe.What action should the charge nurse take?

Correct Answer is B

Explanation

A patient taking temazepam informs you, the nurse, of plans to quit taking the medication due to feelings of being “hungover” the next day.What action should you implement?

Correct Answer is A

Explanation

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