The nurse is inspecting a new client's abdomen and notes the presence of a tight, distended abdomen and visible arterioles on the abdominal skin surface. What would the nurse do next?

Review the client's blood work for sodium and bicarbonate levels.

Assess the client for signs and symptoms of peptic ulcer disease.

Assess the client's nutritional status.

Assess the client for other signs and symptoms of liver disease.

Answer and Explanation

The Correct Answer is D

A. Reviewing sodium and bicarbonate levels is not the most immediate action. While these lab values may provide useful information, they do not directly assess the suspected condition.
B. Assessing for peptic ulcer disease is incorrect because a tight, distended abdomen with visible arterioles (caput medusae) is more indicative of liver disease, such as cirrhosis or portal hypertension, rather than a gastric ulcer.
C. Assessing the client’s nutritional status may be important, but it is not the priority in this situation. Malnutrition can be a consequence of liver disease, but the nurse should first focus on identifying the underlying condition.
D. Assessing the client for other signs and symptoms of liver disease is correct. A distended abdomen and visible arterioles suggest possible ascites and portal hypertension, both of which are common in liver disease. Further assessment for jaundice, hepatic encephalopathy, or changes in liver enzyme levels would be appropriate.

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Correct Answer is D

Explanation

A. Consulting clinical resources is helpful but should be done after reviewing the client’s specific information.
B. Performing a mini overview of body systems occurs during the assessment, not before meeting the client.
C. Gathering materials is important but comes after understanding the client’s history.
D. Reviewing the client’s medical record is correct because it helps the nurse gather baseline information, understand past medical history, and prepare for the assessment effectively.

A. Have the client cough, then listen again B. Teach patient pursed-lip breathing C. Check O₂ saturation and apply O₂ D. Administer nebulizer treatment

Correct Answer is A

Explanation

A. Having the client cough, then listening again is correct. Sometimes wheezing can be due to mucus or secretions in the airways, and coughing can help clear them. If wheezing persists, further assessment and interventions may be needed.
B. Teaching pursed-lip breathing is beneficial for chronic obstructive pulmonary disease (COPD) patients but is not the first action in an acute assessment.
C. Checking O₂ saturation and applying O₂ is important but not the first step. Oxygen therapy is not indicated unless there is evidence of hypoxia.
D. Administering a nebulizer treatment should only be done if wheezing persists and is causing respiratory distress, but the nurse should first confirm that the wheezing is not due to mucus plugging, which may resolve with coughing.

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The nurse is inspecting a new client's abdomen and notes the presence of a tight, distended abdomen and visible arterioles on the abdominal skin surface. What would the nurse do next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to meet a client and perform a comprehensive health assessment. Which action should the nurse perform first?

Correct Answer is D

Explanation

A nurse is auscultating a client's lungs during the initial assessment of the patient in the emergency room. The nurse hears wheezes on expiration in the lower posterior lobes bilaterally. Which of the following actions should the nurse do first?

Correct Answer is A

Explanation

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