While conducting a physical assessment, a client with cirrhosis of the liver reports to the nurse having had a 5 lb (2.3 kg) weight gain within the last week. Which assessment finding correlates with the client's comment?

Decreased bowel sounds.

Increased respiratory rate.

Increased abdominal girth.

Decreased level of consciousness.

Answer and Explanation

The Correct Answer is C

Choice A reason: Decreased bowel sounds may be associated with cirrhosis due to altered digestion but do not directly correlate with weight gain.

Choice B reason: An increased respiratory rate can be a sign of many conditions, including fluid overload, but it is not a specific indicator of weight gain due to fluid accumulation.

Choice C reason: Increased abdominal girth is a common sign of ascites, which is fluid accumulation in the abdomen often seen in cirrhosis, correlating with the reported weight gain.

Choice D reason: Decreased level of consciousness may indicate hepatic encephalopathy in cirrhosis patients but does not directly correlate with the weight gain described.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason: While living in older housing projects can pose a risk, the age of the child and their behaviors, such as hand-to-mouth activities, make younger children more susceptible.

Choice B reason: A 2-year-old is at the highest risk due to their developmental stage, which includes frequent hand-to-mouth activity and the likelihood of playing in soil or dust that may be contaminated with lead.

Choice C reason: Adolescents working in a paint factory may be exposed to lead; however, they are less likely to engage in hand-to-mouth behaviors that lead to ingestion, which is the primary route of lead poisoning in children.

Choice D reason: A 10-year-old with Type 1 diabetes mellitus does not have an increased risk of lead poisoning based on their condition alone.

A. Prepare for a cesarean delivery B. Administer calcium gluconate C. Obtain blood pressure D. Stop infusion of magnesium E. Increase IV fluids F. Administer oxygen G. Obtain serum magnesium level H. Make preparations to prevent cardiac arrest

Correct Answer is ["B","C","F","G","H"]

Explanation

Choice A reason: Preparing for a cesarean delivery is not indicated solely based on the information provided. The patient is at 36 weeks with moderate pre-eclampsia and there are no immediate signs of fetal distress or a need for emergency delivery based on the nurse’s notes.
Choice B reason: Administering calcium gluconate is appropriate if there are signs of magnesium sulfate toxicity, as it acts as an antidote. The patient’s decreased level of consciousness and absent DTRs may suggest magnesium toxicity, making this a correct intervention.
Choice C reason: Obtaining blood pressure is a standard and ongoing requirement for monitoring a pre-eclampsia patient, especially after noting a significant drop in blood pressure from 170/98 mm Hg to 118/78 mm Hg, which could indicate an overcorrection or other issues.
Choice D reason: Stopping the infusion of magnesium sulfate is not indicated at this time. While the patient’s decreased LOC and absent DTRs are concerning, magnesium sulfate is critical for preventing seizures in pre-eclampsia and should not be stopped without clear signs of overdose and physician consultation.
Choice E reason: Increasing IV fluids is not indicated and could be harmful. The patient already has pulmonary edema and increasing fluids could exacerbate this condition, especially in the context of pre-eclampsia where fluid management needs to be carefully balanced.
Choice F reason: Administering oxygen is correct as the patient’s oxygen saturation has dropped from 98% to 93%, and the goal is to maintain it above 96% as per the physician’s orders.
Choice G reason: Obtaining serum magnesium level is correct because it is necessary to monitor for signs of magnesium sulfate toxicity given the patient’s symptoms of decreased LOC and absent DTRs.
Choice H reason: Preparing to prevent respiratory or cardiac arrest is correct as the patient has signs that may suggest impending magnesium sulfate toxicity, which can lead to respiratory depression or cardiac arrest.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

While conducting a physical assessment, a client with cirrhosis of the liver reports to the nurse having had a 5 lb (2.3 kg) weight gain within the last week. Which assessment finding correlates with the client's comment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is conducting intake interviews of children at a city clinic. Which child is most susceptible to contracting lead poisoning?

Correct Answer is B

Explanation

Patient Data Exhibits The nurse reviews the assessment findings along with the physician orders. Which immediate interventions would the nurse initiate? Select all that apply.

Correct Answer is ["B","C","F","G","H"]

Explanation

One hour following cardiac catheterization via the left femoral site, a client reports feeling weak and dizzy. Assessment reveals that the client's dressing is dry and intact. Which action should the nurse take next?

Which is the primary goal when planning nursing care for a client with degenerative joint disease (DJD)?

An older adult client is being admitted to a short-term rehabilitation facility after a long hospitalization. The nurse is performing a functional assessment with the client. Which action should the nurse implement?

Patient Data Exhibits Review H and P, nurse's note, and laboratory results. Click to mark whether the client statement indicates understanding no understanding of the education given.

The nurse is assisting the healthcare provider with a wound debridement at the bedside of a client who is mildly confused. The client is draped and a sterile field is created. Which nursing intervention should the nurse implement for client safety?

Patient Data Exhibits The nurse educates the parents on post discharge care for the child. What should the nurse include in post discharge care education? Select all that apply.

A client who recently received a prescription for ramelteon to treat sleep deprivation reports experiencing several side effects since taking the drug. Which side effect should the nurse report to the healthcare provider?

The nurse administers an antibiotic to a client with a respiratory tract infection. To evaluate the medication's effectiveness, what laboratory values should the nurse monitor? Select all that apply.