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.

Nursing Test Bank

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Correct Answer is B

Explanation

Rationale:
A. The color change of stool is not the purpose of the laxative.
B. A laxative is necessary to help eliminate barium from the gastrointestinal tract, preventing constipation or impaction.
C. The laxative is not used to prevent magnesium absorption; this is unrelated to a barium study.
D. While facilities have protocols, the explanation should focus on patient safety and the purpose of the intervention, not just policy.

A. Seizures B. Neurogenic shock C. Cardiac dysrhythmias D. Hypoglycemia

Correct Answer is C

Explanation

Rationale:

A. Seizures are more commonly associated with severe electrolyte imbalances like hyponatremia, not mild hypokalemia.

B. Neurogenic shock is related to spinal cord injury, not potassium imbalance.

C. Hypokalemia (potassium 3.3 mEq/L; normal 3.5–5.0 mEq/L) increases the risk of ventricular arrhythmias, palpitations, and potentially life-threatening cardiac complications, especially in clients taking diuretics like furosemide.

D. Low potassium does not directly cause hypoglycemia.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who is scheduled for a barium swallow asks the nurse why a laxative is necessary following the procedure. Which of the following responses should the nurse make?

Correct Answer is B

Explanation

A nurse in a provider's office is reviewing the laboratory results of a client who takes furosemide for hypertension. The nurse notes that the client's potassium level is 3.3 mEq/L. The nurse should monitor the client for which of the following complications?

Correct Answer is C

Explanation

In reviewing the medical record for a patient admitted with acute pancreatitis, the nurse sees that the patient has a positive Cullen's sign. Indicate the area in the accompanying figure where the nurse will assess for this change.

Which intervention is most effective in restoring healthy gut flora after antibiotic treatment has caused diarrhea?

What is the primary reason for administering isotonic crystalloid IV fluids to a client with fluid volume deficit?

A nurse is caring for a client who has diverticular disease. When palpating the client's abdomen, in which of the following locations should the nurse expect the client to report abdominal pain?

A nurse is caring for a client who has liver cirrhosis with ascites, bleeding esophageal varices, and portal hypertension. The nurse recognizes which of the following laboratory findings as indicating the client's gastrointestinal (GI) tract is digesting and absorbing blood?

A nurse admits a client to the emergency department who reports nausea and vomiting that worsens when he lies down. Antacids do not help. The provider suspects acute pancreatitis. Which of the following laboratory test results should the nurse expect to see?

A nurse is planning care for a client who is to start receiving total parenteral nutrition (TPN). Which of the following interventions should the nurse include in the plan of care?