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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

The nurse should instruct the client to wash their perineal area two times each day with antimicrobial soap.
This is important because chemotherapy can weaken the immune system, making the client more susceptible to infections.
Choice B is wrong because washing a toothbrush in a dishwasher once a month is not an effective way to prevent infection.
Choice C is wrong because changing a pet’s litter box daily could expose the client to harmful bacteria and should be avoided.
Choice D is wrong because changing the water in a drinking glass every 4 hours is not necessary for preventing infection.

A. Apply pressure to venipuncture sites for 10 min. B. Move the client to a negative pressure room. C. Instruct the client to avoid eating raw fruit. D. Use contact isolation while providing care.

Correct Answer is C

Explanation

Instruct the client to avoid eating raw fruit.
A low white blood cell count can be caused by cancer or cancer treatment and can increase the risk of infection.
One precaution that can be taken is to avoid all pre-cut fresh fruits and vegetables in delis, restaurants, and grocery stores.
Choice A Applying pressure to venipuncture sites for 10 min is not necessary for a low WBC count.
Choice B Moving the client to a negative pressure room is not necessary for a low WBC count.
Choice D Contact isolation while providing care is not necessary for a low WBC count.

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A nurse is assessing a client who has cirrhosis. Which of the following findings is the priority for the nurse to report?

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A nurse is assessing a client who has cirrhosis.

Which of the following findings is the priority for the nurse to report?