A client with cirrhosis of the liver reports a 5 lb (2.3 kg) weight gain within the last week during a physical assessment. Which assessment finding correlates with the client's report?

Decreased bowel sounds.

Increased respiratory rate.

Increased abdominal girth.

Decreased level of consciousness.

Answer and Explanation

The Correct Answer is C

Choice A reason: Decreased bowel sounds may indicate gastrointestinal issues but are not directly related to weight gain associated with fluid accumulation in cirrhosis.

Choice B reason: An increased respiratory rate can be a sign of many conditions, including respiratory distress, but it does not correlate specifically with weight gain due to fluid retention in cirrhosis.

Choice C reason: Increased abdominal girth is a common finding in cirrhosis due to ascites, which is the accumulation of fluid in the peritoneal cavity and can lead to significant weight gain.

Choice D reason: Decreased level of consciousness may be a sign of hepatic encephalopathy in cirrhosis but is not a direct correlation to the weight gain reported by the client.

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Correct Answer is B

Explanation

Choice A reason: A blood pressure of 130/80 mm Hg is considered high normal and may not require immediate follow-up for a patient with a history of hypertension.

Choice B reason: A serum creatinine of 1.6 mg/dL is above the normal range for both males and females, indicating possible kidney dysfunction, which requires further follow-up.

Choice C reason: Dark yellow urine could be a sign of dehydration, which is common in diabetes, but it is not as concerning as an elevated serum creatinine level.

Choice D reason: Difficulty staying asleep could be related to various factors and may require follow-up, but it is not as urgent as abnormal laboratory values.

A. Washing for a total of 20 seconds. B. Turning the water off using bare hands. C. Holding hands below elbows when rinsing. D. Lathering using a circular movement.

Correct Answer is B

Explanation

Choice A reason: Washing hands for a total of 20 seconds is recommended by the CDC as part of proper hand hygiene to prevent the spread of germs.

Choice B reason: Turning the water off using bare hands after washing can re-contaminate the hands. The CDC recommends using a paper towel to turn off the tap to avoid re-contamination.

Choice C reason: Keeping hands below elbows when rinsing is the correct procedure to prevent water from running down the arms onto the cleaned hands.

Choice D reason: Lathering using a circular movement is a recommended technique to ensure all surfaces of the hands are cleaned thoroughly.

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A client with cirrhosis of the liver reports a 5 lb (2.3 kg) weight gain within the last week during a physical assessment. Which assessment finding correlates with the client's report?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

The nurse observes an unlicensed assistive personnel (UAP) washing hands prior to entering the client's room. Which action by the UAP requires additional teaching?

Correct Answer is B

Explanation

Patient Data Exhibits The nurse educates the parents on post discharge care for the child. What should the nurse include in post discharge care education? Select all that apply.

Patient Data Exhibits Review H and P, nurse's note, and laboratory results. Click to mark whether the client statement indicates understanding no understanding of the education given.

A client with cirrhosis of the liver reports a 5 lb (2.3 kg) weight gain within the last week during a physical assessment. Which assessment finding correlates with the client's report?

Patient Data Exhibits The nurse reviews the assessment findings along with the physician orders. Which immediate interventions would the nurse initiate? Select all that apply.

While the nurse is preparing a scheduled IV medication, the client states that the IV site hurts and refuses to allow the nurse to administer a flush to assess the site. Which intervention should the nurse implement?

Patient Data Exhibits Which interventions are indicated to promote positive outcomes for the patient? Select all that apply.

A new mother on the postpartum unit runs out of the room screaming that her newborn infant's crib is empty and the baby is missing. Which action should the nurse take first?