A nurse is assisting with the care of a client.
The laboratory results indicate abnormalities.
Which of the following actions should the nurse take?

Place the client on NPO status.

Administer a prescribed medication.

Monitor the client for signs of dehydration.

Encourage oral fluid intake.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Placing the client on NPO status is required for some specific conditions, such as prior to surgery or when there is risk of aspiration. However, this should not be the first action unless the abnormalities clearly indicate such a need. Monitoring the client’s overall condition should take precedence.

Choice B rationale

Administering a prescribed medication could be helpful depending on the specific abnormality. However, this action depends on the nature of the abnormality and medical orders. It is not the initial step unless a clear order has been provided for a specific issue.

Choice C rationale

Monitoring for signs of dehydration is critical, as dehydration can exacerbate the abnormalities and negatively impact homeostasis. Ensuring the client’s condition does not worsen is a priority, as hydration status often affects laboratory values and overall well-being.

Choice D rationale

Encouraging oral fluid intake is important to prevent or correct dehydration, particularly if lab abnormalities suggest volume depletion. However, it is not the first step. Initial monitoring is required to guide further interventions like fluid intake recommendations.

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Correct Answer is C

Explanation

Choice A rationale

Honey has similar sugar content as white sugar and contributes to rapid gastric emptying, leading to dumping syndrome in postoperative bariatric surgery clients. Dumping syndrome results from a rapid influx of hyperosmolar contents into the intestines, causing osmotic fluid shifts and gastrointestinal symptoms.

Choice B rationale

Sucralfate is a medication used to treat ulcers and does not influence gastric emptying rates or reduce the risk of dumping syndrome. It does not mitigate the physiological process leading to dumping syndrome.

Choice C rationale

Lying down after meals slows gastric emptying and reduces the rapid movement of food into the small intestine. This decreases the risk of dumping syndrome by mitigating osmotic fluid shifts and symptoms such as nausea and diarrhea.

Choice D rationale

Drinking liquids with meals accelerates gastric emptying by diluting stomach contents, increasing the risk of dumping syndrome. The rapid transit of liquids and food promotes hyperosmolarity in the intestines and associated symptoms.

A. Fecal-to-oral route. B. In utero from mother to infant. C. Sexual contact. D. Blood transfusion.

Correct Answer is A

Explanation

Choice A rationale

Hepatitis A virus is transmitted through the fecal-oral route via contaminated food or water. The virus replicates in hepatocytes and spreads through feces, causing acute liver inflammation.

Choice B rationale

Hepatitis A is not transmitted in utero from mother to infant. Vertical transmission is associated with other viruses such as hepatitis B or C, but not hepatitis A.

Choice C rationale

Sexual contact is not a typical transmission route for hepatitis A virus. Hepatitis A does not rely on sexual fluids for transmission.

Choice D rationale

Blood transfusion is not a recognized transmission route for hepatitis A. The virus is enteric, favoring gastrointestinal spread rather than bloodborne transmission.

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A nurse is assisting with the care of a client.
The laboratory results indicate abnormalities.
Which of the following actions should the nurse take?