A client with chronic cirrhosis has esophageal varices. It is most important for the nurse to monitor the client for the onset of which problem?

Hematemesis

Brown, foarmy urine.

Clay-colored stool.

Anorexia.

Answer and Explanation

The Correct Answer is A

A Hematemesis refers to vomiting blood, which can occur when esophageal varices rupture and bleed into the gastrointestinal tract. It is a hallmark sign of upper gastrointestinal bleeding and requires immediate medical attention. Monitoring for hematemesis allows for early detection of variceal bleeding and prompt intervention to prevent further complications.

B Brown, foamy urine may indicate the presence of blood or protein in the urine, which can occur in various kidney and urinary tract disorders.

C Clay-colored stool may indicate a lack of bile in the stool, which can occur in conditions affecting the liver or bile ducts, such as obstructive jaundice.

D Anorexia, or loss of appetite, is a common symptom in clients with chronic liver disease, including cirrhosis. However, while anorexia may impact nutritional status and overall health, it is not directly related to the complications of esophageal varices.

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Correct Answer is A

Explanation

A. According to the usage guidelines for ipratropium inhalers, priming the inhaler typically requires only two sprays into the air, away from the face, before the first use to ensure proper medication dosage.

B. Rinsing the mouth after each use is a recommended practice to prevent irritation and infection.

C. Storing the medication at room temperature is correct, as extreme temperatures can affect the medication's efficacy.

D. Attaching a spacer device to the inhaler is also a recommended practice to improve medication delivery and reduce the risk of side effects.

A. Raise hands above the head to expand the diaphragm. B. Increase breathing rate for a full 30 seconds. C. Draw air in through nose and exhale slowly through pursed lips. D. Lay down on each side with knees bent and breathe from abdomen.

Correct Answer is C

Explanation

C. This technique, known as pursed lip breathing, can help improve gas exchange by slowing down the respiratory rate, promoting more efficient exhalation, and reducing air trapping in the lungs.

A. While raising the hands above the head can help expand the chest and improve lung expansion to some extent, it may not be as effective as pursed lip breathing in improving gas exchange or alleviating dyspnea.

B. Increasing the breathing rate for a full 30 seconds may not be beneficial and could potentially worsen dyspnea, especially in individuals with emphysema or other respiratory conditions.

D. While changing positions and focusing on diaphragmatic breathing can be helpful techniques in managing dyspnea, lying down on each side with knees bent may not be practical for a client who is ambulatory and experiencing mild dyspnea after ambulation.

To assess the quality of an adult client's pain, which approach should the nurse use?

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A client with chronic cirrhosis has esophageal varices. It is most important for the nurse to monitor the client for the onset of which problem?

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Naxlex Comprehensive Predictor Exams

A client with a history of chronic obstructive pulmonary disease (COPD) receives a new prescription for an ipratropium inhaler. Which action indicates to the nurse that additional teaching is needed?

Correct Answer is A

Explanation

The nurse is caring for a client with emphysema who is mildly dyspneic after ambulation. Which instruction should the nurse provide to the client to improve gas exchange?

Correct Answer is C

Explanation

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