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The nurse assesses a client with cirrhosis and finds 4+ pitting edema of the feet and legs, and massive ascites. Which mechanism contributes to edema.Concurrent and ascites in clients with cirrhosis?
- A. Decreased renin-angiotensin response related to an increase in renal blood flow.
- B. Hypoalbuminemia that results in a decreased colloidal oncotic pressure.
- C. Hyperaldosteronism causing an increased sodium reabsorption in renal tubules.
- D. Decreased portacaval pressure with greater collateral circulation.
Correct Answer: B
Rationale: Hypoalbuminemia reduces oncotic pressure, causing fluid to leak into tissues and abdomen, leading to edema and ascites.
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A patient has arrived at the emergency department reporting intermittent fever and night sweats for the past three weeks and has developed a cough that is productive with small amounts of blood. What should be the nurse's priority intervention?
- A. Obtain a sputum sample.
- B. Arrange transport for radiographic imaging.
- C. Move the patient into airborne isolation.
- D. Collect specimens for blood cultures.
Correct Answer: C
Rationale: Symptoms suggestive of tuberculosis require immediate airborne isolation to prevent transmission.
A nurse is educating a patient with Type 2 diabetes mellitus and peripheral neuropathy. What advice should the nurse give?
- A. Shoes should be worn outside the house, but it is fine to be barefoot inside.
- B. Family members can assist with regular foot exams.
- C. Heating pads are useful if used on the lowest setting.
- D. Aching feet may be soaked in lukewarm water for one hour or more.
Correct Answer: B
Rationale: Family members assisting with regular foot exams helps detect early signs of injury or infection, critical for preventing complications in diabetic neuropathy.
An hour after administering 60 mg of furosemide intravenously (IV), which assessments should the nurse perform to determine the patient's response to treatment?
- A. Urinary output.
- B. Skin elasticity.
- C. Pain scale.
- D. Lung sounds.
- E. Oxygen saturation.
Correct Answer: A,D,E
Rationale: Assessing urinary output, lung sounds, and oxygen saturation evaluates furosemide's effectiveness in reducing fluid overload and improving respiratory status.
The nurse is assessing a patient's understanding of the DASH (Dietary Approaches to Stop Hypertension) diet. Which patient behavior suggests adherence to this diet?
- A. The patient exclusively consumes lactose-free dairy products.
- B. The patient meticulously cleans and peels all fresh fruits and vegetables.
- C. The patient enjoys fat-free yogurt as an occasional snack.
- D. The patient has eliminated grains from their diet.
Correct Answer: C
Rationale: Consuming fat-free yogurt aligns with the DASH diet's emphasis on low-fat dairy, supporting blood pressure control.
The nurse assesses a client with petechiae and ecchymosis scattered across the arms and legs. Which laboratory result should the nurse review?
- A. White blood cell count.
- B. Platelet count.
- C. Red blood cell count.
- D. Hemoglobin levels.
Correct Answer: B
Rationale: Platelet count is critical as low levels cause petechiae and ecchymosis due to bleeding tendencies.