Which potential complication would the nurse identify as a high risk for a patient admitted to the hospital with pancytopenia? Select all that apply.

Choice A reason: Insert indwelling urinary catheter. This task requires clinical judgment, sterile technique, and expertise. It is an invasive procedure that should be performed by a registered nurse or a physician.
Choice B reason: Monitor IV D5 1/2 NS with 20 mEq KCl at 75 m/hr. Monitoring IV fluids and medications involves assessing the patient’s response to treatment, recognizing potential complications, and making clinical decisions. This task requires the expertise of a registered nurse.
Choice C reason: Empty urinary catheter and measure the output. This task can be delegated to a nursing aide as it involves routine measurement and documentation, which does not require clinical judgment. It is a simple procedure that can be safely performed by a trained aide.
Choice D reason: Collect a stool sample for occult blood testing. This is a straightforward task that can be delegated to a nursing aide. It involves collecting and labeling the sample correctly, which does not require advanced clinical skills or judgment.
Choice E reason: Daily weights. This task can be safely delegated to a nursing aide. It involves measuring and recording the patient’s weight, which is a routine procedure and does not require clinical judgment.
Choice F reason: Notify the MD of any signs of bleeding. This task involves assessing the patient for signs of bleeding, which requires clinical judgment and should be performed by a registered nurse. The nurse must determine the significance of the findings and communicate them appropriately to the physician.
Choice G reason: Vital signs every 4 hours. Monitoring vital signs is a routine task that can be delegated to a nursing aide. It involves measuring and recording the patient’s blood pressure, heart rate, respiratory rate, and temperature, which does not require advanced clinical skills.

Choice A reason: Jaundice is a common finding in cirrhosis due to impaired liver function, which leads to the accumulation of bilirubin in the blood. This causes the skin and the whites of the eyes to turn yellow.
Choice B reason: Spider angiomas are dilated blood vessels that appear on the skin and are often seen in patients with cirrhosis. They are caused by increased estrogen levels due to impaired liver function.
Choice C reason: Lethargy is a symptom of cirrhosis as the liver's ability to detoxify the blood is compromised, leading to fatigue and weakness.
Choice D reason: An apical pulse regular with S1, S2 is not specifically associated with cirrhosis. While it may be a normal finding, it does not indicate the presence of cirrhosis.
Choice E reason: Abdomen moderately distended is consistent with cirrhosis due to the accumulation of fluid in the abdominal cavity (ascites), which is a common complication of advanced liver disease.
Choice F reason: Dark amber urine is a sign of cirrhosis as the liver's ability to process bilirubin is impaired, leading to the excretion of conjugated bilirubin in the urine, which gives it a dark color.
Choice G reason: Peripheral pulses are palpable is not specifically associated with cirrhosis. While it may be a normal finding, it does not indicate the presence of cirrhosis.
Choice H reason: 3+ pitting edema is consistent with cirrhosis due to the retention of sodium and water, leading to swelling in the lower extremities.