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.

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Correct Answer is B

Explanation

Choice A reason: Washing hands for a total of 20 seconds is recommended by the CDC as part of proper hand hygiene to prevent the spread of germs.

Choice B reason: Turning the water off using bare hands after washing can re-contaminate the hands. The CDC recommends using a paper towel to turn off the tap to avoid re-contamination.

Choice C reason: Keeping hands below elbows when rinsing is the correct procedure to prevent water from running down the arms onto the cleaned hands.

Choice D reason: Lathering using a circular movement is a recommended technique to ensure all surfaces of the hands are cleaned thoroughly.

A. Advise the UAP to resume positioning the client on schedule. B. Encourage the UAP to provide comfort care measures only. C. Assume total care of the client to monitor neurologic function. D. Assign a practical nurse to assist the UAP in turning the client.

Correct Answer is A

Explanation

Choice A: Advise the UAP to resume positioning the client on schedule.

Reason: Turning the client from side to side is a critical nursing intervention to prevent complications such as pressure ulcers, pneumonia, and other issues related to immobility. Even though the client has a “Do Not Resuscitate” (DNR) order, it does not mean that comfort and preventive care measures should be stopped. The nurse should advise the UAP to continue with the scheduled positioning to ensure the client’s comfort and prevent further complications.

Choice B: Encourage the UAP to provide comfort care measures only.

Reason: While providing comfort care is essential, it does not mean that other necessary interventions, such as turning the client, should be neglected. Comfort care measures should include turning the client to prevent pressure ulcers and other complications. Therefore, this option is not the best choice as it may lead to neglecting important preventive care.

Choice C: Assume total care of the client to monitor neurologic function.

Reason: Assuming total care of the client is not practical and may not be necessary. The nurse should delegate tasks appropriately and ensure that the UAP is performing their duties correctly. Monitoring neurologic function is important, but it does not require the nurse to take over all aspects of the client’s care.

Choice D: Assign a practical nurse to assist the UAP in turning the client.

Reason: While assigning a practical nurse to assist the UAP might be helpful, it is not necessary if the UAP can resume the scheduled positioning on their own. The nurse should first advise the UAP to continue with the scheduled positioning before considering additional assistance.

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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 observes an unlicensed assistive personnel (UAP) washing hands prior to entering the client's room. Which action by the UAP requires additional teaching?

Correct Answer is B

Explanation

Correct Answer is A

Explanation

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