ATI Learning System PN Medical Surgical Final Quizlet

Correct Answer: B

Rationale: In this scenario, the immediate need is to provide passive immunity to the adolescent patient. Gamma globulin contains antibodies against hepatitis B, which can offer immediate protection. The hepatitis B vaccine provides active immunity over time but is not immediate. Fresh frozen plasma and corticosteroids are not indicated for immediate protection against hepatitis B infection.

Correct Answer: B

Rationale: Spironolactone is a potassium-sparing diuretic commonly used in patients with heart failure. The nurse should monitor for signs of hyperkalemia, which is a potential side effect of spironolactone therapy. Hyperkalemia can lead to serious cardiac arrhythmias, so close monitoring of potassium levels is essential to prevent complications.

Correct Answer: A

Rationale: The correct answer is A: Liver function tests. Patients on atorvastatin should have their liver function tests monitored periodically to detect any potential liver damage. Atorvastatin, a statin medication used to lower cholesterol levels, can rarely cause liver enzyme abnormalities, so regular monitoring is essential to identify any adverse effects early on.

Correct Answer: D

Rationale: The nurse's priority action in this situation is to notify the healthcare provider immediately. These symptoms, including severe pain, swelling, warmth, and redness in the leg, are indicative of deep vein thrombosis (DVT), a potentially serious condition. Prompt notification of the healthcare provider is crucial to initiate appropriate diagnostic tests and interventions to prevent complications associated with DVT.

Correct Answer: B

Rationale: Jaundice in a client with liver cirrhosis is primarily caused by increased bilirubin levels. In liver cirrhosis, the impaired liver function leads to the accumulation of bilirubin in the blood, resulting in jaundice. Bilirubin is a yellow pigment produced from the breakdown of red blood cells, and its elevation is a common manifestation of liver dysfunction.