While performing a physical examination on a client with cirrhosis, which of the following interventions should the nurse report immediately to the physician?
Pode the client with non-prescription laxatives.
Measure abdominal girth according to a set routine.
Ask the client about food intake.
Check for signs of hepatic encephalopathy.
The Correct Answer is A
Giving non-prescription laxatives to a client with cirrhosis can cause severe dehydration and electrolyte imbalances, which can be life-threatening. The nurse should report this intervention immediately to the physician.
Choice B is incorrect because measuring abdominal girth is a standard nursing intervention for clients with cirrhosis to assess for ascites.
Choice C is incorrect because asking the client about food intake is a standard nursing intervention for assessing nutritional status.
Choice D is incorrect because checking for signs of hepatic encephalopathy is a standard nursing intervention for clients with cirrhosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The tumor is confined to the prostate gland. Stage I prostate cancer means that the tumor is localized to the prostate gland and has not spread to other parts of the body.
B: This option is incorrect because it indicates that the tumor has expanded to the bladder, which is not indicative of stage I prostate cancer.
C: This option is partially correct, but it does not provide a complete picture of stage I prostate cancer.
D: This option is incorrect because it indicates that the tumor has spread beyond the prostate, which is not indicative of stage I prostate cancer.
Correct Answer is B
Explanation
Impaired Gas Exchange. Impaired gas exchange is the greatest concern in the immediate postoperative period for a client recovering from bariatric surgery, as the client may have difficulty breathing due to anesthesia, pain medication, or obesity-related respiratory problems.
Option A, Impaired Mobility, is a concern but not the greatest concern in the immediate postoperative period.
Option C, Self-Care Deficit, may be an issue but is not the greatest concern in the immediate postoperative period.
Option D, Diarrhea, may occur after bariatric surgery but is not the greatest concern in the immediate postoperative period.
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