A nurse is admitting a middle adult client who has cirrhosis.
Findings upon admission:

Exhibits

The nurse is assessing the client 24 hr later. How should the nurse interpret the findings?

For each finding, click to specify whether the finding is unrelated to the diagnosis, a sign of potential improvement, or a sign of potential worsening condition.

Findings 24 hr Later: Unrelated to Diagnosis /Indication of Potential Worsening/Indication of Potential Improvement Condition

Elevated iron levels

Increased albumin level

Productive cough

Ascites

Hematemesis

Spontaneous bruising

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"},"F":{"answers":"B"}}

A)   Elevated iron levels are directly related to hemochromatosis and could indicate a worsening condition if they continue to rise, as this condition causes iron to accumulate in the body, leading to further liver damage.
B)   An increased albumin level could be a sign of potential improvement, as low albumin levels are common in liver disease due to the liver's reduced ability to synthesize proteins.
C)   A productive cough may be unrelated to the diagnosis of cirrhosis but could be indicative of an additional respiratory issue that needs to be addressed.
D)   Ascites, the accumulation of fluid in the abdomen, is a common complication of cirrhosis and would suggest a potential worsening of the condition.
E)   Hematemesis is a serious symptom often associated with advanced liver disease and significant bleeding in the gastrointestinal tract, indicating a potential worsening of the patient's condition.
F)   Spontaneous bruising can occur due to decreased production of clotting factors by the liver, also suggesting a worsening condition.

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Correct Answer is C

Explanation

A) Increasing the ventilator flow rate may not address the cause of the low-pressure alarm and could potentially worsen the situation.
B) Emptying water from the ventilator tubing is not typically necessary when the low-pressure alarm sounds.
C) Evaluating the client for a cuff leak is essential because a leak in the endotracheal tube cuff can cause the low-pressure alarm to sound.
D) Suctioning the client's airway is not indicated unless there are signs of airway obstruction or secretions.

A. Skin breakdown B. Infection C. Neurogenic bladder D. Phlebitis

Correct Answer is B

Explanation

A) Skin breakdown could occur due to the catheter bag lying in bed, but it is not the primary risk associated with the observations noted.
B) A kinked IV tubing can lead to stasis of fluids, which increases the risk of infection. Additionally, if the urinary catheter bag is not positioned below the level of the bladder, urine can reflux back into the bladder, which also increases the risk of infection.
C) Neurogenic bladder is a condition typically associated with nerve damage, not directly related to the position of the catheter bag or kinked tubing.
D) Phlebitis is inflammation of a vein, which would not be directly caused by the issues noted with the urinary catheter.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving mechanical ventilation when the low pressure alarm sounds on the ventilator. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is assessing a client who has a urinary catheter. The nurse notes the client's IV tubing is kinked and the urinary catheter bag is lying next to the client in bed. The nurse should identify that the client is at risk for which of the following conditions?

Correct Answer is B

Explanation

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