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 ["C","E"]

Explanation

Rationale:
A. The client should not infuse dextrose solution independently if TPN runs out; this could cause serious metabolic complications.
B. TPN should not be stopped abruptly once weight gain is achieved; discontinuation should be gradual to prevent hypoglycemia.
C. Maintaining the prescribed infusion rate is important to ensure proper nutrient delivery and prevent metabolic complications.
D. TPN should never be shaken if a precipitate is present; this can cause embolism or catheter occlusion.
E. TPN should be refrigerated when not in use to prevent bacterial contamination and preserve solution stability.

A. Instruct the client not to lift over 4.5 kg (10 lb). B. Encourage ambulation once fully awake. C. Place the client in a supine position postoperatively. D. Offer the client ice cream postoperatively.

Correct Answer is B

Explanation

Rationale:
A. Lifting restrictions are typically advised for 2–4 weeks after laparoscopic cholecystectomy, not immediately postoperatively.
B. Encouraging ambulation once the client is fully awake helps prevent complications such as atelectasis, deep vein thrombosis, and promotes bowel function.
C. Placing the client flat in a supine position can increase the risk of respiratory complications; semi-Fowler’s is preferred.
D. Offering ice cream is not appropriate immediately after surgery; clear liquids are usually initiated first to assess tolerance.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching to a client who will be receiving total parenteral nutrition (TPN) at home. Which of the following instructions should the nurse include? (Select all that apply.)

Correct Answer is ["C","E"]

Explanation

A nurse is providing care for a client who had a laparoscopic cholecystectomy. Which of the following is an appropriate nursing action?

Correct Answer is B

Explanation

A nurse is admitting a client with suspected appendicitis. Identify where the nurse will palpate to assess for pain at McBurney's point.

A nurse is preparing to discharge a client from a surgical unit. Exhibits Which 3 dietary strategies should the nurse recommend to prevent post- operative complications for this client?

Which of the following are contraindications for administering a tap water enerna? (Select all that apply)

What is the main pharmacological concern after performing a paracentesis?

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

A nurse is assessing a client who has advanced cirrhosis. Which of the following manifestations should the nurse expect?

A nurse is providing instructions for a 52-year-old client who is scheduled for a colonoscopy. The client reports that he has not had the procedure before and is very anxious about feeling pain during the procedure. Which of the following responses by the nurse is appropriate?