A client with chronic cirrhosis has esophageal varices. It is most important for the nurse to monitor the client for the onset of which problem?

Hematemesis

Brown, foarmy urine.

Clay-colored stool.

Anorexia.

Answer and Explanation

The Correct Answer is A

A Hematemesis refers to vomiting blood, which can occur when esophageal varices rupture and bleed into the gastrointestinal tract. It is a hallmark sign of upper gastrointestinal bleeding and requires immediate medical attention. Monitoring for hematemesis allows for early detection of variceal bleeding and prompt intervention to prevent further complications.

B Brown, foamy urine may indicate the presence of blood or protein in the urine, which can occur in various kidney and urinary tract disorders.

C Clay-colored stool may indicate a lack of bile in the stool, which can occur in conditions affecting the liver or bile ducts, such as obstructive jaundice.

D Anorexia, or loss of appetite, is a common symptom in clients with chronic liver disease, including cirrhosis. However, while anorexia may impact nutritional status and overall health, it is not directly related to the complications of esophageal varices.

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Correct Answer is D

Explanation

D. Vancomycin is primarily excreted by the kidneys, and monitoring serum creatinine levels helps assess renal function. Impaired renal function can affect vancomycin clearance and increase the risk of toxicity.

A. Measuring oxygen saturation is not directly related to the administration of vancomycin for Clostridium difficile infection.

B. Assessing body temperature may not be the most pertinent action before administering vancomycin for Clostridium difficile infection.

C. Auscultating bowel sounds is also not directly related to the administration of vancomycin for Clostridium difficile infection.

A. Place client on oxygen 2 10 4 liters and maintain oxygen saturation at or above, 959%. B. Start the client on antibiotic therapy C. STAT complete blood count (CBC), basic metabolic panel (BMP), and blood cultures D. Stat ventilation/perfusion (V/Q) of chest E. Send sputumn for culture & sensitivity F. STAT 2 views chest x-ray

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

Explanation

B. Start the client on antibiotic therapy - Antibiotics are typically prescribed to treat bacterial pneumonia, which is a common cause of pneumonia.

C. STAT complete blood count (CBC), basic metabolic panel (BMP), and blood cultures - These tests help in assessing the severity of the infection, evaluating electrolyte balance, and identifying the causative organism respectively.

E. Send sputum for culture & sensitivity - This helps in identifying the specific organism causing the pneumonia and determining the most effective antibiotic for treatment.

A. At an oxygen saturation above 90%, the client does not necessarily require oxygen supplementation

D. A ventilation/ perfusion scan is needed in cases of suspected pulmonary embolism which is unlikely in this case.

F. Another chest X ray is not important as a recent one is present. No much changes is expected in the period of the few hours.

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A client with chronic cirrhosis has esophageal varices. It is most important for the nurse to monitor the client for the onset of which problem?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client with Clostridium difficile in the stool receives a prescription for vancomycin PO. Which action should the nurse take before administering the first dose?

Correct Answer is D

Explanation

Patient Data Exhibits Which physician orders would the nurse anticipate being prescribed after reporting findings? (Select all that apply).

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

Explanation

Patient Data Exhibits What actions can the nurse do to assist the client in improving their ventilation and oxygenation? Select all that apply.

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