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. The colon does not secrete bile; bile is produced by the liver and stored in the gallbladder.
B. The colon does absorb electrolytes, but its primary function is water absorption, which helps form solid stool.
C. The colon does not secrete digestive enzymes; enzyme secretion occurs primarily in the stomach and small intestine.
D. The colon's primary function is absorbing large amounts of water, which helps maintain fluid balance and form feces. Disruptions, such as in colon cancer, can lead to diarrhea or constipation.

A. Lithotomy B. Dorsal recumbent C. Sim's position D. Prone

Correct Answer is B

Explanation

A. Lithotomy position is used for gynecologic, rectal, or urologic exams and would not be comfortable for a client with low back pain.
B. Dorsal recumbent position is correct because it allows the client to lie on their back with knees bent, reducing strain on the lower back while facilitating assessment of the chest, extremities, and peripheral pulses.
C. Sim’s position is used for rectal examinations or enemas and is not ideal for assessing the chest and extremities.
D. Prone position (lying face down) would exacerbate low back pain and make it difficult to examine the chest and extremities.

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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 caring for a client who has been diagnosed with colon cancer. When planning the client's care, the nurse should be aware of what function of the colon?

Correct Answer is D

Explanation

A nurse is preparing to examine the chest, extremities, and peripheral pulses of a client who has low back pain. What is the best position to place this client in to assure they are comfortable for the exam?

Correct Answer is B

Explanation

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