The nurse prepares to do a focused assessment on a client who was successfully treated for bleeding esophageal varices yesterday.
Which body system should the nurse prioritize?
Neurological.
Integumentary.
Gastrointestinal.
Renal.
The Correct Answer is C
Post-procedure assessment for esophageal varices requires prioritizing the system most likely to experience re-bleeding. Knowledge of portal hypertension and gastrointestinal assessment is necessary to monitor for therapeutic success or acute recurrence of life-threatening hemorrhage after treatment.
Choice A rationale
While neurological status is important to assess for hepatic encephalopathy in liver patients, it is not the primary system for a focused assessment immediately following a successful intervention for an active gastrointestinal bleed unless symptoms arise.
Choice B rationale
Integumentary assessment might show jaundice or bruising in liver disease, but it does not provide critical information regarding the immediate stability of the esophageal varices or the potential for a sudden recurrence of internal bleeding.
Choice C rationale
The gastrointestinal system is the priority because the client is at high risk for re-bleeding. Monitoring for hematemesis, melena, and abdominal girth helps detect early signs of failure in the variceal ligation or sclerotherapy treatment provided.
Choice D rationale
Renal function is monitored in liver failure due to the risk of hepatorenal syndrome, but it remains secondary to the gastrointestinal system during the immediate twenty-four-hour post-procedure window focused on stabilizing the variceal hemorrhage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Management of full-thickness burns requires precise monitoring and clinical judgment. This scenario evaluates delegation principles, distinguishing between complex assessment or titration tasks reserved for licensed nurses and routine data collection tasks suitable for unlicensed assistive personnel to ensure safe client care.
Choice A rationale
Titration of intravenous fluids requires complex clinical judgment and continuous assessment of hemodynamic status and renal perfusion. This task exceeds the scope of unlicensed personnel as it involves pharmacological management and critical data interpretation.
Choice B rationale
Recording output from an indwelling catheter is a routine, technical task involving data collection without interpretation. Unlicensed personnel are trained to perform non-invasive measurements, making this appropriate for delegation to support nursing workflow.
Choice C rationale
Assessing wounds for infection involves identifying subtle clinical indicators like erythema, exudate, or malodor. This requires specialized nursing knowledge and diagnostic reasoning to differentiate between normal healing and pathological processes in burn patients.
Choice D rationale
Evaluating the effectiveness of analgesics is a key component of the nursing process. It requires reassessing pain levels and monitoring for adverse effects, tasks that necessitate the clinical expertise and accountability of a nurse.
Correct Answer is B
Explanation
Identifying appropriate placement for infectious clients requires understanding transmission-based precautions. Tuberculosis is an airborne pathogen requiring specialized ventilation to prevent the spread of droplet nuclei. Knowledge of negative pressure systems and environmental safety standards is essential for preventing nosocomial transmission to others.
Choice A rationale
Placing a client with active tuberculosis in a semi-private room violates airborne precautions. This increases the risk of horizontal transmission to immunocompromised roommates via microscopic droplet nuclei that remain suspended in the air for several hours.
Choice B rationale
Airborne infection isolation rooms require a minimum of 6 to 12 air exchanges per hour. Exhausting air directly outdoors or through HEPA filters prevents contaminated air from recirculating into common hallways or other patient care areas.
Choice C rationale
Admission to an intensive care unit is reserved for hemodynamically unstable clients or those requiring advanced mechanical ventilation. Tuberculosis alone is not an indication for critical care unless the client exhibits acute respiratory failure or septic shock.
Choice D rationale
While proximity to the nurses' station allows for frequent observation, it does not address the physiological requirement for negative pressure ventilation. Standard medical-surgical rooms lack the engineering controls necessary to contain airborne bacilli within the specific room.
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