While conducting a physical assessment, a client with cirrhosis of the liver reports to the nurse having had a 5 lb (2.3 kg) weight gain within the last week. Which assessment finding correlates with the client's comment?
Decreased bowel sounds.
Increased respiratory rate.
Increased abdominal girth.
Decreased level of consciousness.
The Correct Answer is C
Choice A reason: Decreased bowel sounds may be associated with cirrhosis due to altered digestion but do not directly correlate with weight gain.
Choice B reason: An increased respiratory rate can be a sign of many conditions, including fluid overload, but it is not a specific indicator of weight gain due to fluid accumulation.
Choice C reason: Increased abdominal girth is a common sign of ascites, which is fluid accumulation in the abdomen often seen in cirrhosis, correlating with the reported weight gain.
Choice D reason: Decreased level of consciousness may indicate hepatic encephalopathy in cirrhosis patients but does not directly correlate with the weight gain described.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Massaging the back to promote diaphragmatic excursion can be beneficial but is not the most effective intervention compared to early mobilization.
Choice B reason: Assisting the client to sit in a chair encourages lung expansion and sputum clearance, which are crucial for preventing atelectasis and pneumonia.
Choice C reason: Noting areas of atelectasis on chest x-rays is important for monitoring, but it is not an intervention that actively prevents respiratory complications.
Choice D reason: Providing ice or oral liquids when the client passes flatus is related to gastrointestinal recovery, not respiratory complications.
Correct Answer is ["400"]
Explanation
Step 1: Convert the volume of fluid to be infused from mL to L (since the rate is usually measured in mL/hr):
200 mL = 200 mL (No conversion needed as the volume is already in mL)
Step 2: Convert the time for infusion from minutes to hours (since the rate is usually measured in mL/hr):
30 minutes = 30 ÷ 60 = 0.5 hours
Step 3: Calculate the rate (volume ÷ time):
Rate = Volume ÷ Time
Rate = 200 mL ÷ 0.5 hours
Rate = 400 mL/hr
The nurse should program the infusion pump to deliver at a rate of 400 mL/hr.
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