The nurse is caring for a client with decompensated liver disease who is experiencing fever, chills, and abdominal tenderness.

Following a paracentesis, the nurse receives laboratory results of the ascitic fluid that show the polymorphonuclear leukocyte count is 425/mm (0.42 x 10/L). After notifying the healthcare provider, what action should the nurse take next?

Review serum protein levels

Begin abdominal girth measurements

Initiate antibiotic therapy

Assess neurological status

Answer and Explanation

The Correct Answer is C

Choice A rationale
Reviewing serum protein levels can provide valuable information about a client’s nutritional status and liver function. However, in the context of a client with decompensated liver disease who is experiencing fever, chills, and abdominal tenderness, and has a high polymorphonuclear leukocyte count in ascitic fluid, initiating antibiotic therapy is the priority.
Choice B rationale
Beginning abdominal girth measurements can be useful for monitoring the progression of ascites in a client with liver disease. However, in this scenario, the priority is to treat the potential infection indicated by the client’s symptoms and lab results.
Choice C rationale

Initiating antibiotic therapy is the correct intervention in this case. The client’s symptoms and the high polymorphonuclear leukocyte count in the ascitic fluid suggest spontaneous bacterial peritonitis, a serious complication of cirrhosis that requires immediate antibiotic treatment.
Choice D rationale
Assessing neurological status is important in clients with liver disease, as they are at risk for hepatic encephalopathy. However, in this scenario, the priority is to treat the potential infection indicated by the client’s symptoms and lab results.

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Correct Answer is B

Explanation

Choice A rationale

Suggesting that the child participate in a team sport to encourage socialization is not the best response. Duchenne muscular dystrophy (DMD) is a progressive disease that causes muscle weakness and loss of muscle mass. Participating in a team sport could be physically challenging for the child and could potentially lead to injury.
Choice B rationale
Encouraging the parents to allow the child to continue attending swimming lessons with supervision is the best response. Swimming is a low-impact exercise that can help maintain muscle strength and flexibility in children with DMD. It also provides an opportunity for socialization.
Choice C rationale
Explaining that the child is too young to understand the risks associated with swimming is not the best response. Children with DMD can participate in swimming with appropriate supervision and safety measures in place.
Choice D rationale
Providing a list of alternative activities that are less likely to cause the child to experience fatigue is not the best response. While it’s important to consider activities that are appropriate for the child’s physical abilities, it’s also important to consider the child’s interests. The child has expressed a desire to continue swimming, and with appropriate supervision, this activity can be beneficial.

A. Monitor for bleeding side effects related to heparin therapy. B. Promote movement to prevent a pulmonary embolism. C. Check blood pressure and heart rate at least every 4 hours. D. Measure the circumference of each calf to assess for leg edema.

Correct Answer is A

Explanation

Choice A rationale
The most crucial intervention for a nurse to include in the care plan of a client with a deep vein thrombosis (DVT) in the left leg who is on a heparin protocol is to monitor for bleeding side effects related to heparin therapy. Heparin is an anticoagulant medication that prevents the formation of blood clots. While it is an effective treatment for DVT, it can also increase the risk of bleeding. Therefore, it is essential for the nurse to closely monitor the client for any signs of bleeding, such as unusual bruising, blood in urine or stool, or bleeding gums.
Choice B rationale
While promoting movement can help prevent a pulmonary embolism (a potential complication of DVT), it is not the most crucial intervention when a client is on a heparin protocol. Excessive movement can potentially dislodge the clot, leading to a pulmonary embolism. Therefore, while movement is important, it should be done under the guidance of a healthcare professional.
Choice C rationale
Checking blood pressure and heart rate at least every 4 hours is a standard nursing intervention for many clients, not just those with DVT. While it is important to monitor these vital signs, it is not the most crucial intervention for a client with DVT on a heparin protocol.
Choice D rationale

Measuring the circumference of each calf can help assess for leg edema, which can be a sign of DVT. However, this is not the most crucial intervention for a client on a heparin protocol. The priority is to monitor for bleeding side effects related to the heparin therapy.

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Naxlex Comprehensive Predictor Exams

The parents of a 6-year-old child recently diagnosed with Duchenne muscular dystrophy express that their child wants to continue attending swimming classes. How should the nurse respond?

Correct Answer is B

Explanation

A client with a deep vein thrombosis (DVT) in the left leg is on a heparin protocol. What is the most crucial intervention for the nurse to include in this client’s care plan?

Correct Answer is A

Explanation

The unlicensed assistive personnel (UAP) reports that a client’s blood pressure cannot be measured in the arms because the client has casts on both arms and is unable to be measured in the legs because the client is in the supine position. Which action should the nurse implement?

A client is admitted for an exacerbation of heart failure (HF) and is being treated with diuretics for fluid volume excess. In planning nursing care, which interventions should the nurse include? Select all that apply.

An unlicensed assistive personnel (UAP) reports that a client’s right hand and fingers spasm when taking the blood pressure using the same arm. After confirming the presence of the spasms, which action should the nurse take?

The nurse is about to administer a histamine 2-receptor antagonist to a patient with peptic ulcer disease. What is the primary purpose of this class of medication?

A client with deep vein thrombosis (DVT) in the left leg is on a heparin protocol. Which intervention is most important for the nurse to include in this client’s plan of care?

A client with a right hemopneumothorax has a chest tube connected to suction. While turning to the left side, the client becomes suddenly short of breath and anxious. What should the nurse do next?