. A nurse is caring for a client who has been admitted for the treatment of advanced cirrhosis. What assessment should the nurse prioritize in this client's plan of care?
Monitoring of results of liver function testing
Assessment for signs and symptoms of jaundice
Measurement of abdominal girth and body weight
Assessment for variceal bleeding
The Correct Answer is C
A. Monitoring of results of liver function testing: While important, monitoring liver function tests is a routine assessment rather than a prioritized one compared to assessing for complications like ascites.
B. Assessment for signs and symptoms of jaundice: Jaundice is a common finding in cirrhosis but does not necessarily indicate an acute complication.
C. Measurement of abdominal girth and body weight: In advanced cirrhosis, monitoring for ascites and fluid retention is critical as these indicate worsening disease and potential complications.
D. Assessment for variceal bleeding: Incorrect. While important, the priority in routine assessment is monitoring for ascites and fluid overload, which can be managed more readily.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
A. Auscultate the chest for bilateral breath sounds: Auscultating the chest immediately after intubation ensures that the endotracheal tube is correctly placed in the trachea and not in the esophagus or a bronchus.
B. Assess the patient's blood glucose: Blood glucose monitoring is not immediately necessary following intubation.
C. Determine the CO2 level: Measuring end-tidal CO2 (ETCO2) is crucial to confirm that the tube is in the trachea and that ventilation is occurring effectively.
D. Obtain a stat PCXR (Portable Chest X-ray): A chest X-ray is obtained to confirm the correct placement of the endotracheal tube, ideally 2-3 cm above the carina.
Correct Answer is B
Explanation
A. Imbalanced nutrition: Less than body requirements related to decreased oral intake: While this may be relevant, it is not the highest priority in acute appendicitis. Infection prevention is more critical.
B. Risk for infection related to possible rupture of appendix: The primary concern in appendicitis is the risk of rupture, leading to peritonitis and sepsis. This makes infection control the top priority.
C. Chronic pain related to appendicitis: Pain in appendicitis is acute, not chronic. Managing infection risk is more urgent.
D. Constipation related to decreased bowel motility and decreased fluid intake: Constipation is not a priority concern in the context of acute appendicitis. The risk of infection takes precedence.
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