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.

Spontaneous bruising

Ascites

Increased albumin level

Hematemesis

Elevated iron levels

Answer and Explanation

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

Liver cirrhosis interferes with the synthesis of clotting factors in the liver leading to bleeding as evidence by the spontaneous bruises

The development of ascites occurs as the cirrhotic process progresses leading to increased extravasation of fluid in the splanchnic circulation.

Increased albumin indicates that the synthetic role of the liver is improving. Albumin is synthesized in the liver parenchyma.

Hematemesis occurs due to the presence of esophageal varices as a complication of advanced liver cirrhosis

The liver plays a key role in formation of ferritin which binds iron. Decreased levels of ferritin may lead to increased levels of free iron in the blood

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Correct Answer is C

Explanation

C. Oliguria can occur in severe cases of left-sided heart failure. When the heart's ability to pump blood forward is compromised, blood flow to the kidneys decreases, leading to decreased urine production.
A. Pedal edema is more commonly associated with right-sided heart failure.
B. Neck vein distention is typically associated with right-sided heart failure where increased pressure in the right side of the heart leads to jugular venous distention
D. Enlarged liver, or hepatomegaly, can occur in right-sided heart failure due to congestion and backup of blood in the hepatic circulation.

A. Sore throat B. SaO, 92% C. Stridor D. Rhonchi

Correct Answer is C

Explanation

C. Stridor is a high-pitched, crowing sound that occurs during inspiration and indicates upper airway obstruction. Stridor following extubation is a concerning finding and requires immediate intervention to ensure adequate airway patency and prevent respiratory compromise. The nurse should notify the healthcare provider immediately and be prepared to provide interventions such as airway suctioning, supplemental oxygen, or reintubation if necessary.

A. While a sore throat is a common complaint after extubation due to irritation from the endotracheal tube, it does not typically require immediate intervention unless it is severe or accompanied by other concerning symptoms. The nurse should provide comfort measures and monitor for worsening symptoms.
B. An SPO2 of 92% is within normal rage and requires no immediate intervention.
D. While rhonchi may require intervention, they are not typically as immediately concerning as stridor, which indicates upper airway obstruction.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has left-sided heart failure. Which of the following manifestations should the nurse expect?

Correct Answer is C

Explanation

A nurse is assessing a client following extubation from a Ventilator. For which of the following findings should the nurse intervene immediately?

Correct Answer is C

Explanation

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