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 C
Explanation
The first step when finding an unresponsive person is to check their breathing by tilting their head back and looking and feeling for breaths.
When a person is unresponsive, their muscles relax and their tongue can block their airway so they can no longer breathe.
Tilting their head back opens the airway by pulling the tongue forward.
Palpating for the client’s carotid pulse is a way to check if the client has a pulse and is still breathing.
Choice A: Initiating cardiac monitoring for the client is not an answer because it is not mentioned as the first action to take in my sources.
Choice B: Apply a blood pressure cuff is not an answer because it is not mentioned as the first action to take in my sources.
Choice D: Establishing an IV access is not an answer because it is not mentioned as the first action to take in my sources.
Correct Answer is C
Explanation
This statement indicates an understanding of the teaching because shaking the inhaler helps to mix the medicine inside the canister.
Choice A is incorrect because it is not necessary to clean the cap of the inhaler once per week.
Instead, it is important to clean the inhaler at least once a week or as directed.
Choice B is incorrect because one should inhale the medication slowly, not quickly.
Choice D is incorrect because one should wait 1 minute between puffs, not 15 seconds.
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