Try Naxlex NCLEX-RN (Free-Trial)

A nurse is caring for a client in the emergency room.

Exhibits
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Rationale:

  • Potential Condition: The client presents with jaundice, ascites, abdominal distention, confusion, and abnormal liver function tests (elevated AST, ALT, and bilirubin, with low albumin), consistent with cirrhosis and fluid volume excess.
  • Actions to Take:
    • Administer diuretics (such as spironolactone or furosemide) to reduce fluid retention and help manage ascites.
    • Monitor fluid intake and output to evaluate fluid balance and effectiveness of diuretic therapy.
  • Parameters to Monitor:
    • Blood pressure is important because hypotension is present and can worsen with fluid shifts and diuretic therapy.
    • Abdominal girth is monitored to track the progression or reduction of ascites.


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is D

Explanation

Rationale:

A. Used to visualize the upper gastrointestinal tract (esophagus, stomach, duodenum). It does not provide information about bowel obstruction in the large intestine.

B. Allows direct visualization of the colon mucosa but is not typically used initially in suspected acute bowel obstruction due to the risk of perforation.

C. Useful for evaluating gallbladder, liver, kidneys, and sometimes bowel, but it is less sensitive for detecting large bowel obstruction.

D. A plain abdominal X-ray (KUB) is often the first-line diagnostic study for suspected large bowel obstruction. It can show dilated bowel loops, air-fluid levels, and fecal loading, which correlate with the patient’s symptoms of bloating, distention, and relief after flatulence.

Correct Answer is C

Explanation

Rationale:
A. Pain assessment is important but not the immediate priority following an EGD. Discomfort is expected after the procedure, yet it does not pose the greatest risk to airway safety.

B. Nausea should be monitored, especially since sedation and irritation of the upper GI tract can cause vomiting, but this is not the most critical concern immediately after the procedure.

C. The gag reflex must be assessed first because topical anesthetics used during the EGD suppress the swallowing and protective airway reflexes. If oral fluids or food are given before the gag reflex returns, the client is at high risk for aspiration, which can lead to pneumonia or airway obstruction. Ensuring the gag reflex has returned is the priority safety measure before advancing the diet or giving oral medications.

D. Level of consciousness should also be assessed, since sedatives are commonly used during the procedure. However, the risk of aspiration from an absent gag reflex presents a more immediate threat to life and therefore takes priority.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Register