A nurse is collecting data from a client who has hepatitis A. Which of the following findings should the nurse expect?
Splenomegaly
Abdominal pain
Irregular heart rate
Tarry stools
The Correct Answer is B
A nurse collecting data from a client who has hepatitis A should expect to find that the client may have abdominal pain. Hepatitis A is a liver infection that can cause inflammation and discomfort in the abdomen.
The other options are not typical symptoms of hepatitis
a) Splenomegaly is an enlargement of the spleen and is not a typical symptom of hepatitis A.
c) An irregular heart rate is not a typical symptom of hepatitis A.
d) Tarry stools may indicate bleeding in the digestive tract and is not a typical symptom of hepatitis A.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A nurse collecting data from a client who reports having diarrhea for the past 3 days should identify that muscle weakness is a symptom of hypokalemia. Hypokalemia is a condition in which the blood potassium level is low and can be caused by excessive fluid loss through diarrhea. Potassium helps regulate muscle contractions, so when blood potassium levels are low, muscles may produce weaker contractions which result in muscle weakness.
The other options are not typical symptoms of hypokalemia.
a) Pitting edema is not a typical symptom of hypokalemia.
b) Diplopia is not a typical symptom of hypokalemia.
d) Hyperactive bowel sounds are not a typical symptom of hypokalemia.
Correct Answer is B
Explanation
Answer: B. Compare the result with the baseline reading
Rationale:
A. Check the client's heart rate on the oximeter:
Although checking the heart rate may provide context for assessing the client's overall status, it does not address the primary concern of the low oxygen saturation. Understanding the client's baseline saturation level takes priority to guide further actions effectively.
B. Compare the result with the baseline reading:
Comparing the reading with the client's baseline is essential. For clients with chronic respiratory conditions, baseline oxygen levels may naturally be lower. Identifying if this 88% saturation is typical or unusual for the client helps determine the need for further intervention or adjustment.
C. Decrease the amount of oxygen administered:
Reducing oxygen flow when the saturation is low is contraindicated, as it could worsen hypoxia. Instead, increasing oxygen may be warranted if the reading remains below the baseline after further assessment.
D. Perform another reading while the client ambulates:
Repeating the reading during ambulation may worsen hypoxia and is not ideal without understanding baseline oxygenation at rest. Re-evaluation at rest or in a different position may be more appropriate for accurate assessment.
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