A nurse is assessing a client who has cirrhosis.
Which of the following findings is the priority for the nurse to report?
Distended abdomen.
Clay-colored stools.
Platelets 70,000/mm.
Alkaline phosphatase 125 units/L.
The Correct Answer is C
Platelets 70,000/mm.
The priority finding for a nurse assessing a client who has cirrhosis to report is a platelet count of 70,000/mm.
A low platelet count (thrombocytopenia) can be a complication of cirrhosis and can increase the risk of bleeding.
A platelet count below 150,000/mm3 is considered low and should be reported to the provider.
Choice A is incorrect because while a distended abdomen can be a sign of ascites, a complication of cirrhosis, it is not the priority finding to report.
Choice B is incorrect because while clay-colored stools can be a sign of biliary obstruction, it is not the priority finding to report.
Choice D is incorrect because while an elevated alkaline phosphatase level can be a sign of liver damage, it is not the priority finding to report.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
One of the lifestyle changes that doctors recommend for managing symptoms of gastroesophageal reflux disease (GERD) is elevating the head during sleep by placing a foam wedge or extra pillows under the head and upper back to incline the body and raising the head off the bed 6 to 8 inches.
Choice A: “Increase your caloric intake by 250 calories per day” is not an answer because it is not mentioned as a self-management strategy for GERD in my sources.
Choice B: “Lie down for 30 minutes after each meal” is not an answer because it is not mentioned as a self-management strategy for GERD in my sources.
Choice C: “Eat a light meal 1 hour before bedtime” is not an answer because it is not mentioned
Correct Answer is A
Explanation
Thrombocytopenia, or low platelet count, is a contraindication to receiving heparin.
Rheumatoid arthritis is not a contraindication to receiving heparin.
Thalassemia is not a contraindication to receiving heparin.
COPD is not a contraindication to receiving heparin.
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