The nurse is caring for a client with a history of liver cirrhosis. Which complication should the nurse monitor for?

Ascites

Peripheral neuropathy

Pulmonary edema

Kidney stones

Answer and Explanation

The Correct Answer is A

Choice A reason: Ascites, fluid accumulation in the peritoneal cavity, is a common complication of liver cirrhosis due to portal hypertension and hypoalbuminemia. It increases infection risk and discomfort, making it the priority to monitor, as early detection guides diuretic therapy and paracentesis.

Choice B reason: Peripheral neuropathy is not a primary cirrhosis complication, though it may occur in alcoholic liver disease. Ascites is more common, resulting from portal hypertension, making it the priority to monitor, as it directly reflects liver dysfunction and requires urgent management.

Choice C reason: Pulmonary edema is associated with heart failure, not cirrhosis. Ascites is a hallmark of cirrhosis, caused by portal hypertension and low albumin, making it the priority complication to monitor, as it indicates worsening liver function and requires immediate intervention.

Choice D reason: Kidney stones are unrelated to cirrhosis, which primarily causes ascites due to portal hypertension. Monitoring ascites is critical, as it reflects liver decompensation, increasing risks like spontaneous bacterial peritonitis, making it the priority over unrelated renal conditions.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A reason: Teaching mask use, hand washing, and distancing is important for preventing COVID-19 spread but is secondary to immediate isolation. Suspected cases require prompt separation to minimize transmission risk, as symptoms like fever and anosmia suggest high infectivity, making isolation the priority action.

Choice B reason: Counseling family to monitor symptoms is a follow-up measure, not the immediate priority. Isolation prevents active transmission in the emergency department, where the client is currently located. Family monitoring is relevant post-discharge but secondary to containing the virus in the acute setting.

Choice C reason: Isolation is the most critical action for a suspected COVID-19 case, as symptoms like fever, anosmia, and aches indicate potential infectivity. Separating the client from others without proper PPE prevents airborne and droplet transmission, protecting patients and staff in the emergency department, making it the priority.

Choice D reason: Reporting COVID-19 results to health authorities is mandatory but occurs after test confirmation. Immediate isolation prevents transmission in the emergency department while awaiting results. Reporting is a secondary administrative action, as the priority is containing the virus in the acute care setting.

A. Remove ties to secure a disposable, soft foam collar with hook and loop fastener B. Secure tracheostomy ties by making knots close to the tube C. Leave the old ties in place until the new ones are secure D. Place knots of the ties lateral to prevent irritation and pressure

Correct Answer is C

Explanation

Choice A reason: Using a soft foam collar may reduce skin irritation but risks dislodging the tracheostomy tube if not secured properly. Leaving old ties in place until new ones are secure ensures tube stability, preventing accidental decannulation, which is critical in early tracheostomy care.

Choice B reason: Knots close to the tracheostomy tube increase pressure on the skin, risking irritation or necrosis. This is incorrect, as ties should allow slight movement. Maintaining old ties until new ones are secure prevents tube displacement, prioritizing airway safety during the procedure.

Choice C reason: Leaving old ties in place until new ones are secure prevents tracheostomy tube dislodgement, a life-threatening risk. This ensures continuous airway patency during tie changes, especially in fresh tracheostomies, making it the safest and most critical action to maintain tube stability.

Choice D reason: Placing knots laterally reduces irritation but does not address the risk of tube dislodgement during tie changes. Keeping old ties in place until new ones are secure is the priority, as it ensures the tube remains stable, preventing airway compromise.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse is caring for a client with a history of liver cirrhosis. Which complication should the nurse monitor for?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client presents to the emergency department with muscle aches, headache, fever, and describes a recent loss of taste and smell. The nurse obtains a nasal swab for COVID-19 testing. Which action is most important for the nurse to take?

Correct Answer is C

Explanation

The nurse is securing a tracheostomy tube for a client post-procedure. Which action should the nurse take to ensure proper tracheostomy care?

Correct Answer is C

Explanation

Which of the following best describes the primary source of energy for Earth's climate system?

Which intervention should the nurse implement to manage a client’s fluid and electrolyte balance?

A client with chronic obstructive pulmonary disease receives a new prescription for an ipratropium inhaler. Which action indicates to the nurse that additional teaching is needed?

The nurse is caring for a client who fell while walking to the bathroom. Upon transfer to the intensive care unit, the client is provided with a history of vomiting twice. Which intervention should the nurse implement first?

The nurse is caring for a client who is taking diclofenac for rheumatoid arthritis. During a clinic visit, the client appears pale and reports increasing fatigue. Which of the client’s serum laboratory values is most important for the nurse to review?

The nurse notes that a client has been receiving hydromorphone every six hours for four days. Which assessment is most important for the nurse to complete?

An older adult female client is hospitalized with a fractured femur. During a routine nursing assessment, she repeatedly asks the nurse to “speak up” so that she can hear the questions. Which action is best for the nurse to take?