A nurse is assessing a client who has cirrhosis.
Which of the following findings is the priority for the nurse to report?
Distended abdomen.
Clay-colored stools.
Platelets 70,000/mm.
Alkaline phosphatase 125 units/L.
The Correct Answer is C
Platelets 70,000/mm.
The priority finding for a nurse assessing a client who has cirrhosis to report is a platelet count of 70,000/mm.
A low platelet count (thrombocytopenia) can be a complication of cirrhosis and can increase the risk of bleeding.
A platelet count below 150,000/mm3 is considered low and should be reported to the provider.
Choice A is incorrect because while a distended abdomen can be a sign of ascites, a complication of cirrhosis, it is not the priority finding to report.
Choice B is incorrect because while clay-colored stools can be a sign of biliary obstruction, it is not the priority finding to report.
Choice D is incorrect because while an elevated alkaline phosphatase level can be a sign of liver damage, it is not the priority finding to report.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Administering IV fluids can help maintain blood flow to the kidneys and prevent acute kidney failure.
Choice B is incorrect because inserting a urinary catheter does not prevent acute kidney failure.
Choice C is incorrect because an intravenous pyelogram is a diagnostic test and does not prevent acute kidney failure.
Choice D is incorrect because beta-blocker therapy is not used to prevent acute kidney failure.
Correct Answer is B
Explanation
After inhaling deeply using an incentive spirometer, you should hold your breath for 3 to 5 seconds before exhaling.
Choice A is wrong because exhaling slowly through pursed lips is not an instruction for using an incentive spirometer.
Choice C is wrong because placing hands on the upper abdomen during inhalation is not an instruction for using an incentive spirometer.
Choice D is wrong because positioning the mouthpiece.5 cm (1 in) from the mouth is not an instruction for using an incentive spirometer.
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