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.

Spontaneous bruising

Ascites

Increased albumin level

Hematemesis

Elevated iron levels

Answer and Explanation

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

Liver cirrhosis interferes with the synthesis of clotting factors in the liver leading to bleeding as evidence by the spontaneous bruises

The development of ascites occurs as the cirrhotic process progresses leading to increased extravasation of fluid in the splanchnic circulation.

Increased albumin indicates that the synthetic role of the liver is improving. Albumin is synthesized in the liver parenchyma.

Hematemesis occurs due to the presence of esophageal varices as a complication of advanced liver cirrhosis

The liver plays a key role in formation of ferritin which binds iron. Decreased levels of ferritin may lead to increased levels of free iron in the blood

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Correct Answer is A

Explanation

A. Turning the client on their side helps prevent aspiration (inhaling fluid or vomit into the lungs) and promotes drainage of oral secretions, reducing the risk of airway obstruction during the seizure.
B. While assessing neurological status is important, it should be done after ensuring the client's safety during the seizure. This can be done after the seizure has stopped.
C. While obtaining vital signs is important for assessing the client's overall condition, it is not the immediate priority during an active seizure. Vital signs can be assessed once the seizure has stopped and the client's safety has been ensured.
D. Notifying the rapid response team may be necessary if the seizure persists beyond a certain duration (status epilepticus) or if there are complications. However, the first action should be to ensure the client's immediate safety by turning them onto their side to prevent aspiration.

A. Monitor vital signs at least every 4 hr. B. Insert an indwelling urinary catheter. C. Change the client's linens three times a day. D. Place the client in a room with negative airflow.

Correct Answer is A

Explanation

A. Frequent vitals monitoring to allow for early detection of infection. Clients with neutropenia are at increased risk of infections.
B. Indwelling catheter and other devices should be avoided in individuals with neutropenia die to risk of sepsis.
C. Changing the client’s linen is important. However, doing it 3 times a day is not necessary.
D. Clients should be placed in a positive airflow room to prevent contracting infections from infected persons

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Naxlex Comprehensive Predictor Exams

A nurse enters a client's room and observes the client having a tonic-clonic seizure. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse is admitting a client who has neutropenia. Which of the following precautions should the nurse take?

Correct Answer is A

Explanation

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