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
Thrombocytopenia, or low platelet count, is a contraindication to receiving heparin.
Rheumatoid arthritis is not a contraindication to receiving heparin.
Thalassemia is not a contraindication to receiving heparin.
COPD is not a contraindication to receiving heparin.
Correct Answer is D
Explanation
A pacemaker sends electrical signals to the heart to regulate the heartbeat.
On an electrocardiogram (ECG), these signals appear as small spikes followed by a QRS complex, which represents the contraction of the ventricles.
Choice A, A regular sinus rhythm, is not the correct answer because a regular sinus rhythm is a normal heart rhythm that originates from the sinoatrial (SA) node and does not involve a pacemaker.
Choice B, A chaotic, irregular rhythm, is not the correct answer because a pacemaker is designed to regulate the heartbeat and prevent chaotic or irregular rhythms.
Choice C, the Absence of any electrical activity, is not the correct answer because a pacemaker sends electrical signals to the heart to regulate its activity.
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