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?
Anorexia
Brown, foamy urine.
Clay-colored stool
Hematemesis
The Correct Answer is D
Choice A rationale:
Anorexia is a common symptom of cirrhosis, but it is not the most immediate concern in a client with esophageal varices.
Anorexia can result from various factors, including impaired liver function, hormonal imbalances, early satiety due to ascites,
and nausea.
While it's important to address anorexia to maintain nutritional status, it doesn't directly indicate a life-threatening
complication like bleeding varices.
Choice B rationale:
Brown, foamy urine is a characteristic of kidney problems, specifically proteinuria.
It's not directly associated with esophageal varices or their complications.
While cirrhosis can affect kidney function due to fluid imbalances and impaired filtering, brown, foamy urine wouldn't be the
primary indicator of bleeding varices.
Choice C rationale:
Clay-colored stool is a sign of biliary obstruction, which can occur in cirrhosis due to impaired bile flow.
However, it's not a direct indicator of bleeding varices.
Clay-colored stool results from a lack of bile pigments in the stool, which give it its typical brown color.
Choice D rationale:
Hematemesis, or vomiting of blood, is the most critical symptom to monitor in a client with esophageal varices.
Here's why:
Esophageal varices are enlarged, swollen veins in the esophagus that develop due to increased pressure in the portal venous
system, a common consequence of cirrhosis.
These varices are fragile and prone to rupture, which can lead to massive, life-threatening bleeding.
Hematemesis is a clear sign that variceal bleeding has occurred and requires immediate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Wild rice is naturally gluten-free. It is not a grain, but rather a semi-aquatic grass seed. It is safe for individuals with celiac disease to consume.
Wild rice is a good source of nutrients. It is high in fiber, protein, and antioxidants, and it contains a variety of vitamins and minerals, including manganese, phosphorus, magnesium, and zinc. These nutrients can help to support overall health and well-being.
Wild rice can be a versatile ingredient in many dishes. It can be used in salads, soups, stews, pilafs, and even desserts.
Choice B rationale:
Oatmeal is not gluten-free. It is made from oats, which are a type of cereal grain that contains gluten. Individuals with celiac disease must avoid gluten, as it can trigger an autoimmune reaction that damages the small intestine.
Even small amounts of gluten can cause harm. Consuming even a small amount of oatmeal can cause symptoms such as abdominal pain, bloating, diarrhea, fatigue, and headache in individuals with celiac disease.
Long-term damage can occur. If individuals with celiac disease continue to consume gluten, it can lead to long-term health problems, such as malnutrition, osteoporosis, and infertility.
Choice C rationale:
Corn chips are typically gluten-free. However, it is important to check the label to be sure, as some brands may contain gluten- containing ingredients, such as wheat flour or barley malt.
Reading labels is essential. Individuals with celiac disease should always read food labels carefully to ensure that products are gluten-free.
Choice D rationale:
Potatoes are naturally gluten-free. They are a safe and healthy food choice for individuals with celiac disease.
Potatoes are a versatile and nutritious food. They are a good source of carbohydrates, fiber, potassium, vitamin C, and other nutrients.
Correct Answer is ["38"]
Explanation
Here are the steps to calculate the IV flow rate:
Step 1: Calculate the volume to be infused per minute.
75 mL ÷ 30 minutes = 2.5 mL/minute
Step 2: Multiply the volume per minute by the drop factor to determine the drops per minute.
2.5 mL/minute × 15 gtt/mL = 37.5 gtt/minute
Step 3: Round the answer to the nearest whole number. The nurse should regulate the IV to deliver 38 gtt/minute.
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