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.

Nursing Test Bank

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

No explanation

A. It reduces the amount of HCl secreted by the parietal cells in the stomach. B. It destroys the microorganisms causing inflammation in the stomach. C. It neutralizes hydrochloric acid (HCl) in the stomach. D. It inhibits the action of acetylcholine by blocking parasympathetic nerve endings.

Correct Answer is A

Explanation

Choice A rationale
Histamine H2-receptor antagonists, also known as H2 blockers, are medications that help reduce the production of gastric acid. They achieve this by blocking H2 receptors in the parietal cells of the stomach, which are responsible for secreting hydrochloric acid (HCl)12. This reduction in acid secretion can help treat conditions such as peptic ulcers, gastroesophageal reflux disease (GERD), and Zollinger-Ellison syndrome, which are all conditions that can be exacerbated by excessive stomach acid.
Choice B rationale
While H2 blockers do help manage the symptoms of peptic ulcer disease, they do not directly destroy the microorganisms causing inflammation in the stomach. The primary cause of peptic ulcers is a bacterium called Helicobacter pylori, and the treatment for an H. pylori infection typically involves a combination of antibiotics and proton pump inhibitors, not H2 blockers.
Choice C rationale
H2 blockers do not neutralize hydrochloric acid (HCl) in the stomach. Instead, they work by reducing the amount of acid produced by the stomach. Antacids, not H2 blockers, are the class of drugs that work by neutralizing stomach acid.
Choice D rationale
H2 blockers do not inhibit the action of acetylcholine by blocking parasympathetic nerve endings. Anticholinergic medications are the ones that work by blocking the action of acetylcholine, a neurotransmitter that transmits signals in the nervous system.

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Naxlex Comprehensive Predictor Exams

Mark whether the statements by the new graduate nurse indicate understanding or no understanding of the use of the face mask in the care of this client.

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

The nurse is about to administer a histamine 2-receptor antagonist to a patient with peptic ulcer disease. What is the primary purpose of this class of medication?

Correct Answer is A

Explanation

A client who follows Mormon beliefs is on a clear liquid diet following abdominal surgery. Which menu items should the nurse request for this client? Select all that apply.

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An older adult with a terminal illness is receiving hospice care and is having difficulty coping with feelings related to death and dying. What interventions should the nurse include in this client’s plan of care? Select all that apply.

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A client is experiencing severe agitation and tremors due to withdrawal from the benzodiazepine alprazolam. What is the best initial nursing action?