A nurse is evaluating a client admitted to the emergency unit.

Exhibits
Which nursing interventions are appropriate for managing a patient with cirrhosis experiencing fluid volume excess?

Advise strict bed rest

Encourage high-sodium diet

Administer diuretics as prescribed

Monitor abdominal girth daily

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"}}

Rationale

Advise strict bed rest → Contraindicated
Strict bed rest is not necessary unless the patient is severely compromised; mobility is encouraged to prevent complications.
Encourage high-sodium diet → Contraindicated
A low-sodium diet is essential to reduce fluid retention and ascites; high sodium worsens edema.
Administer diuretics as prescribed → Anticipated
Diuretics (e.g., spironolactone, furosemide) help reduce ascites and edema.
Monitor abdominal girth daily → Anticipated
Helps track fluid accumulation and assess effectiveness of interventions.

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Correct Answer is ["B","E","F"]

Explanation

Rationale:
A. Family history increases risk for heart disease and arthritis but is not a direct risk factor for peptic ulcer disease.
B. Smoking increases gastric acid secretion, reduces mucosal healing, and significantly raises PUD risk.
C. Alcohol use is denied by the client and therefore is not a contributing factor in this case.
D. Adalimumab use (an immunosuppressant for rheumatoid arthritis/psoriasis) does not directly increase PUD risk.
E. NSAIDs inhibit prostaglandin synthesis, reducing the gastric mucosal barrier and predisposing to ulcer formation.
F. H. pylori infection is a primary cause of peptic ulcers due to its damaging effect on gastric mucosa.

A. Epigastrium B. Umbilical C. Flank D. Subumbilical

Correct Answer is B

Explanation

Rationale:
A. Epigastrium refers to the upper central region of the abdomen, just below the sternum; Cullen’s sign does not appear here.
B. Umbilical region (around the navel) is where Cullen’s sign appears as a bluish discoloration due to subcutaneous fat necrosis or retroperitoneal bleeding associated with acute pancreatitis. This is the correct site.
C. Flank discoloration is known as Grey Turner’s sign, another indicator of retroperitoneal bleeding, but distinct from Cullen’s sign.
D. Subumbilical refers to the area below the umbilicus, not the typical site for Cullen’s sign.

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A nurse is evaluating a client admitted to the emergency unit. Exhibits Which nursing interventions are appropriate for managing a patient with cirrhosis experiencing fluid volume excess?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a provider's office is caring for a client. Exhibits Select the 3 findings from the client's medical record that increase their risk for peptic ulcer disease (PUD).

Correct Answer is ["B","E","F"]

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.

Correct Answer is B

Explanation

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

Which of the following laboratory findings is most indicative of fluid volume excess in a client with liver cirrhosis?

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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?

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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.)

A nurse is evaluating a client admitted to the emergency unit.

Exhibits
Which nursing interventions are appropriate for managing a patient with cirrhosis experiencing fluid volume excess?