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 B

Explanation

B. Postural drainage involves placing the client in various positions to help drain secretions from different lobes of the lungs. There are typically five standard positions: head-down, head-up, on the side with the affected lung uppermost, on the side with the affected lung lowermost, and lying prone.

A. Performing postural drainage immediately after meals is not recommended because it can increase the risk of vomiting or aspiration, especially in individuals with chronic obstructive pulmonary disease (COPD) who may already have compromised lung function.

C. In postural drainage, the client is typically instructed to breathe deeply and slowly to maximize the effectiveness of the technique.

D. While ABGs may be necessary for monitoring respiratory status in clients with COPD, they are not specifically required prior to performing postural drainage.

A. Insert a nasogastric tube (NGT) and attach to low intermittent suction. B. Place an indwelling urinary catheter and attach a bedside drainage unit. C. Send the client to x-ray for a flat plate of the abdomen. D. Give a prescribed analgesic for temperature above 101°F (38.3°C).

Correct Answer is A

Explanation

A. Inserting a nasogastric tube (NGT) and attaching it to low intermittent suction would be appropriate in this situation. Dark brown emesis could indicate gastrointestinal bleeding, which may require gastric decompression to prevent further vomiting and assess the volume and characteristics of the gastric contents.

B. Placing an indwelling urinary catheter and attaching a bedside drainage unit is not the priority intervention in this scenario.

C. Sending the client to x-ray for a flat plate of the abdomen may provide diagnostic information, but it is not the most immediate intervention needed in this situation.

D. Giving a prescribed analgesic for a temperature above 101°F (38.3°C) is not the priority intervention in this scenario.

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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

When performing postural drainage on a client with chronic obstructive pulmonary disease (COPD), which approach should the nurse use?

Correct Answer is B

Explanation

Correct Answer is A

Explanation

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