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

Explanation

Rationale:
A. Baked potato is low in sodium if prepared without added salt, making it safe for a client on a diuretic.
B. Milkshake is generally safe unless it contains added sodium; in most cases, it is allowed.
C. Ham is high in sodium, which is contraindicated for a client taking bumetanide, a loop diuretic, as high sodium intake can counteract the diuretic effect and worsen fluid retention.
D. Stewed tomatoes can be included if unsalted; they are generally safe in moderation.

A. Disinfect equipment in the client's room daily. B. Use alcohol hand sanitizer after completing tasks for the client. C. Place the client in a protective environment. D. Have the client wear a mask when out of the room.

Correct Answer is A

Explanation

Rationale:
A. Clostridium difficile spores are resistant to alcohol and can persist on surfaces. Daily disinfection with a sporicidal agent is essential to prevent transmission.

B. Alcohol-based hand sanitizers are ineffective against C. difficile spores. Handwashing with soap and water is required after contact with the client or contaminated surfaces.

C. A protective environment is used for immunocompromised clients, not for those with C. difficile.

D. Masks are not necessary for routine C. difficile care because the bacteria are spread via the fecal-oral route, not airborne.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has cirrhosis and has a prescription for bumetanide. When delivering the client's lunch tray, which of the following items should the nurse identify as contraindicated for the client?

Correct Answer is C

Explanation

A nurse is admitting a client who was prescribed antibiotic therapy and now has a Clostridium difficile infection. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse on the day shift is preparing to change a client's total parenteral nutrition (TPN) solution, but the new TPN solution has not arrived from the pharmacy. The client receives additional IV fat emulsion during the night shift. Which of the following actions should the nurse take?

A nurse is teaching a client who has a hiatal hernia about dietary recommendations. Which of the following client statements indicates an understanding of the teaching? (Select all that apply.)

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?

A nurse is teaching a client who has a prescription of a nasogastric tube (NG) to treat a pyloric obstruction. Which of the following rationales for the use of the nasogastric tube should the nurse include in the teaching?

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.

A nurse in an emergency department is caring for a client who has abdominal pain. Exhibits A nurse is providing teaching to a client who has constipation. Which of the following information should the nurse include? (Select all that apply.)

A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for continued mechanical ventilation. How should the nurse interpret the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg. PaCO2 32 mm Hg, and HCO3 25 mEq/L?