The client with cirrhosis has developed spontaneous bacterial peritonitis (SBP). Which data indicates this complication of cirrhosis is occurring?
Petechiae
Increased abdominal pain
Jaundice
Blood in emesis
The Correct Answer is B
Choice A reason: Petechiae are small red or purple spots caused by bleeding into the skin, typically associated with platelet disorders, and are not a direct indicator of SBP.
Choice B reason: Increased abdominal pain is a common symptom of SBP, as the condition causes inflammation and irritation of the peritoneum, which can lead to significant discomfort.
Choice C reason: Jaundice is a sign of liver dysfunction but is not specific to SBP. It results from high levels of bilirubin in the blood and can occur in various liver diseases.
Choice D reason: Blood in emesis (vomiting) may indicate gastrointestinal bleeding, which can be a complication of cirrhosis but is not specific to SBP.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Assessing for hematuria is important but not the priority action. Hematuria can be a symptom of various conditions and does not directly address the abnormal laboratory results.
Choice B reason: Monitoring temperature is a routine action in sepsis management but does not address the immediate concern of the abnormal laboratory results, specifically the elevated aPTT and low platelet count.
Choice C reason: Evaluating skin turgor is a method to assess dehydration, which is not the immediate concern indicated by the laboratory results.
Choice D reason: The elevated aPTT and low platelet count suggest a potential coagulopathy, which could be a sign of disseminated intravascular coagulation (DIC), a complication of sepsis. Administering heparin may be part of the treatment for DIC to prevent further clotting and is a priority action in this context.
Correct Answer is C
Explanation
Choice A reason: An oral temperature of 99.8°F (37.7°C) post-operatively may not be unusual and does not necessarily indicate a complication.
Choice B reason: A post-operative hemoglobin of 10.9 g/dL is slightly below the normal range but may be expected after surgery due to blood loss.
Choice C reason: A client reporting a pressure sensation at the incision site could indicate bleeding or swelling under the incision, which can be a sign of a hematoma, a serious complication that needs immediate attention.
Choice D reason: Pain at the incision site is expected post-operatively and can be managed with pain relief measures.
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