The nurse is caring for a client with decompensated liver disease who is experiencing fever, chills, and abdominal tenderness.

Following a paracentesis, the nurse receives laboratory results of the ascitic fluid that show the polymorphonuclear leukocyte count is 425/mm (0.42 x 10/L). After notifying the healthcare provider, what action should the nurse take next?

Review serum protein levels

Begin abdominal girth measurements

Initiate antibiotic therapy

Assess neurological status

Answer and Explanation

The Correct Answer is C

Choice A rationale
Reviewing serum protein levels can provide valuable information about a client’s nutritional status and liver function. However, in the context of a client with decompensated liver disease who is experiencing fever, chills, and abdominal tenderness, and has a high polymorphonuclear leukocyte count in ascitic fluid, initiating antibiotic therapy is the priority.
Choice B rationale
Beginning abdominal girth measurements can be useful for monitoring the progression of ascites in a client with liver disease. However, in this scenario, the priority is to treat the potential infection indicated by the client’s symptoms and lab results.
Choice C rationale

Initiating antibiotic therapy is the correct intervention in this case. The client’s symptoms and the high polymorphonuclear leukocyte count in the ascitic fluid suggest spontaneous bacterial peritonitis, a serious complication of cirrhosis that requires immediate antibiotic treatment.
Choice D rationale
Assessing neurological status is important in clients with liver disease, as they are at risk for hepatic encephalopathy. However, in this scenario, the priority is to treat the potential infection indicated by the client’s symptoms and lab results.

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Correct Answer is A

Explanation

Choice A rationale

A firm crib mattress is crucial in reducing the risk of Sudden Infant Death Syndrome (SIDS). Soft surfaces can conform to the infant’s face and potentially block their airway, leading to suffocation.

Choice B rationale

Propping the infant with a pillow when in a side-lying position is not recommended as it increases the risk of SIDS. Infants should always be placed on their backs to sleep.

Choice C rationale

Swaddling the infant in a blanket for sleeping is not the most important measure to prevent SIDS. Overheating and loose bedding are risk factors for SIDS23.

Choice D rationale

Placing the infant in a prone position whenever possible is not recommended. Infants should always be placed on their backs to sleep to reduce the risk of SIDS23.

A. Initiate two large-bore IV catheters and review the inclusion criteria for IV fibrinolytic therapy. B. Begin continuous observation for transient episodes of neurological dysfunction. C. Elevate the head of the bed to 30 degrees, keeping the head and neck in neutral alignment. D. Administer aspirin to prevent further clot formation and platelet aggregation.

Correct Answer is A

Explanation

Choice A rationale
The symptoms described - right-sided numbness and weakness in the arm and leg, along with a distinct droop on the right side of the face - are indicative of a stroke. Immediate medical intervention is crucial in such cases. Initiating two large-bore IV catheters would allow for rapid administration of necessary medications and fluids. Reviewing the inclusion criteria for IV fibrinolytic therapy is also important, as this type of therapy can help dissolve the clot causing the stroke and restore blood flow to the brain.

Choice B rationale
While continuous observation for transient episodes of neurological dysfunction is important in the care of a patient with suspected stroke, it is not the first course of action. Immediate medical intervention to treat the stroke is the priority.
Choice C rationale
Elevating the head of the bed to 30 degrees can help reduce intracranial pressure in a patient with a stroke. However, this is not the first course of action. Immediate medical intervention to treat the stroke is the priority.
Choice D rationale
Administering aspirin can help prevent further clot formation and platelet aggregation in patients with certain types of stroke. However, aspirin is not typically the first line treatment in the acute phase of a stroke, especially when the type of stroke (ischemic or hemorrhagic) has not yet been determined.

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Naxlex Comprehensive Predictor Exams

The nurse is planning to teach infant care and preventive measures for sudden infant death syndrome (SIDS) to a group of new parents. Which information is most important for the nurse to include?

Correct Answer is A

Explanation

Correct Answer is A

Explanation

A client with chronic obstructive pulmonary disease (COPD) receives a prescription for chest physiotherapy (CPT) to help mobilize secretions. Following the therapy, which finding indicates to the nurse that the intervention was effective?

A client with influenza requires assistance in transferring to the bedside commode. The nurse observes the unlicensed assistive personnel (UAP) donning gloves and a gown to assist the client. What action should the nurse take?

The client is a 26-year-old female who fell from an apartment balcony. She was transported to the hospital via ambulance. The client enters the emergency room on a stretcher and is met in the trauma bay by the nurse. What two actions should the nurse take first during the primary survey?

An unlicensed assistive personnel (UAP) reports that a client’s right hand and fingers spasm when taking the blood pressure using the same arm. After confirming the presence of the spasms, which action should the nurse take?

The nurse is educating a patient who was admitted with a blood glucose level of 580 mg/dL on how to prevent complications related to diabetes mellitus. Which statement, if made by the patient, would indicate that they have understood the teaching?

The nurse is monitoring a patient with Cushing’s disease in the post-anesthesia care unit (PACU) following a hypophysectomy. Which intervention is most important for the nurse to include in the patient’s plan of care?