A nurse is assessing a client who has cirrhosis. Which of the following is an expected finding for this client?
Blood in the urine
Spider angiomas
Tarry stools
Moist skin
The Correct Answer is B
Choice A reason:
Blood in the urine (hematuria) is not typically associated with cirrhosis. It may be related to other underlying conditions.
Choice B reason:
Spider angiomas (also known as spider nevi) are expected findings in clients with cirrhosis.
They are small, dilated blood vessels near the surface of the skin that resemble a spider's web. They can be found on the face, neck, upper trunk, and arms.
Choice C reason:
Tarry stools (melena) can occur in individuals with gastrointestinal bleeding, which can be a complication of cirrhosis. However, it is not a specific finding for cirrhosis itself.
Choice D reason:
Moist skin is not a characteristic finding associated with cirrhosis. It may be related to other factors such as environmental humidity or individual factors like sweating.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["437"]
Explanation
- To convert ounces to milliliters, multiply by 29.57
- 4 oz of Pedialyte = 118.28 mL
- 1/2 of an 8-oz cup of clear orange Jell-O = 118.28 mL
- 2 graham crackers = no liquid intake
- 200 mL of D 5-1/2 sodium chloride IV = 200 mL
- Total intake = 118.28 + 118.28 + 200 = 436.56 mL
- Round to the nearest whole number = 437 mL
- The nurse documents the client's intake as 437 mL
Correct Answer is C
Explanation
Choice A reason:
Keeping the patient in a low Fowler's position may be helpful for some patients with dysphagia, but it is not a specific intervention related to NG tube care.
Choice B reason:
Connecting the tube to continuous wall suction when not in use is not a standard practice for NG tube care. Continuous suction can cause mucosal damage and discomfort for the patient.
Choice C reason:
Confirming the placement of the NG tube prior to each medication administration is a crucial safety measure. Incorrect placement can lead to serious complications.
Choice D reason:
Sipping cool water to stimulate saliva production may be beneficial for some patients with dysphagia, but it is not a specific intervention related to NG tube care. The focus should be on confirming the placement of the tube.
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