A nurse is admitting a middle adult client who has cirrhosis.
Findings upon admission:

Exhibits

The nurse is assessing the client 24 hr later. How should the nurse interpret the findings?

For each finding, click to specify whether the finding is unrelated to the diagnosis, a sign of potential improvement, or a sign of potential worsening condition.

Findings 24 hr Later: Unrelated to Diagnosis /Indication of Potential Worsening/Indication of Potential Improvement Condition

Elevated iron levels

Increased albumin level

Productive cough

Ascites

Hematemesis

Spontaneous bruising

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"},"F":{"answers":"B"}}

A)   Elevated iron levels are directly related to hemochromatosis and could indicate a worsening condition if they continue to rise, as this condition causes iron to accumulate in the body, leading to further liver damage.
B)   An increased albumin level could be a sign of potential improvement, as low albumin levels are common in liver disease due to the liver's reduced ability to synthesize proteins.
C)   A productive cough may be unrelated to the diagnosis of cirrhosis but could be indicative of an additional respiratory issue that needs to be addressed.
D)   Ascites, the accumulation of fluid in the abdomen, is a common complication of cirrhosis and would suggest a potential worsening of the condition.
E)   Hematemesis is a serious symptom often associated with advanced liver disease and significant bleeding in the gastrointestinal tract, indicating a potential worsening of the patient's condition.
F)   Spontaneous bruising can occur due to decreased production of clotting factors by the liver, also suggesting a worsening condition.

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Correct Answer is D

Explanation

A) Instructing the client to sit on a rubber ring may provide comfort for those with hemorrhoids or perineal discomfort but is not directly related to managing hemiplegia.
B) Raising the head of the client's bed to a 90° angle may be uncomfortable and may not address the specific needs related to hemiplegia.
C) Using moisturizing lotion while massaging the client's bony prominences is important for skin integrity but does not directly address the positioning needs of a client with hemiplegia.
D) Placing pillows between the client's knees when in a side-lying position helps maintain proper alignment, prevents pressure ulcers, and promotes comfort for the client with hemiplegia.

A. Administer the transfusion through a 25-gauge saline lock. B. Administer the plasma immediately after thawing. C. Transfuse the plasma over 4 hr. D. Hold the transfusion if the client is actively bleeding.

Correct Answer is B

Explanation

A) Administering the transfusion through a 25-gauge saline lock might not be appropriate as it may cause hemolysis or obstruct the flow of plasma.
B) Administering the plasma immediately after thawing is crucial to ensure the effectiveness of the transfusion and to prevent degradation of the plasma components.
C) Transfusing the plasma over 4 hours is a standard practice, but the priority is administering it promptly after thawing.
D) Holding the transfusion if the client is actively bleeding is inappropriate since the client is losing blood which needs to be replaced. Furthermore, fresh frozen plasma contains clotting factors which are beneficial for a client whose cause of bleeding is clotting factor deficiencies.

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Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has hemiplegia. Which of the following interventions should the nurse include?

Correct Answer is D

Explanation

A nurse is preparing to administer fresh frozen plasma to a client. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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