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 A

Explanation

A. Pulse oximetry measures the oxygen saturation of arterial blood, which is a crucial parameter to assess in clients with respiratory distress. Obtaining a pulse oximetry reading will provide information about the client's oxygenation status and help guide further interventions.

B. Huff coughing may be helpful for airway clearance but it may not be the most immediate intervention needed to address the client's respiratory distress.

C. Humidification may be beneficial for airway clearance in the long term but it may not be the most immediate intervention needed to address the client's acute respiratory distress.

D. Nebulizer breathing treatments, such as bronchodilators or corticosteroids, are commonly used to relieve bronchospasm and improve airflow in clients with COPD. However, in this scenario, the client's primary symptoms are dyspnea and tachypnea, indicating acute respiratory distress.

A. Hemoccult test on sputum collected from hemoptysis. B. Chest x ray or computed tomography (CT). C. Positive purified protein derivative (PPD) skin test. D. Sputum culture positive for Mycobacterium tuberculosis.

Correct Answer is D

Explanation

D. Sputum culture is the gold standard diagnostic test for confirming the diagnosis of tuberculosis. It involves culturing the bacteria from sputum samples to identify the presence of Mycobacterium tuberculosis, the causative organism of TB.

A. The Hemoccult test is used to detect occult (hidden) blood in stool samples, not sputum.

B. Chest x-ray or CT imaging is commonly used in the diagnosis of tuberculosis. However, imaging findings alone are not sufficient to confirm the diagnosis of TB.

C. The PPD skin test is a screening test for tuberculosis infection. A positive PPD test indicates exposure to TB bacteria but does not distinguish between latent TB infection and active TB disease.

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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 nurse is caring for a client with chronic obstructive pulmonary disease who develops an onset of dyspnea, tachypnea with coughing. After positioning the client upright, which action should the nurse take next?

Correct Answer is A

Explanation

The nurse is admitting a client with possible tuberculosis (TB). The client is placed in a private room with airborne precautions pending diagnostic test results. Which diagnostic test should the nurse review to confirm the diagnosis of TB?

Correct Answer is D

Explanation

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