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The nurse cares for a client who had a liver transplant 48 hours ago. It would be a priority for the nurse to notify the healthcare provider (HCP) if the client has
- A. An increase in oral temperature from 97.8°F (36.6°C) to 98.6°F (37°C).
- B. Rising aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels.
- C. A moderate amount of serosanguinous drainage to the incision.
- D. Nausea following the administration of oral pain medication.
Correct Answer: B
Rationale: Rising AST and ALT levels (B) indicate possible liver graft dysfunction or rejection, a critical finding requiring immediate HCP notification post-transplant.
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A nurse is conducting a dysphagia screening on a client who was recently extubated. Which assessment finding requires intervention?
- A. Slight cough after sipping water.
- B. Hoarseness of voice during speech.
- C. Reports of mild throat discomfort when swallowing.
- D. Presence of a wet, gurgling cough after drinking water.
Correct Answer: D
Rationale: A wet, gurgling cough after drinking water (D) indicates possible aspiration, requiring immediate intervention to prevent complications like pneumonia. Slight cough (A), hoarseness (B), and mild discomfort (C) are less urgent.
The nurse is performing an assessment on a client being admitted for acute pancreatitis. Which assessment finding would support a diagnosis of acute pancreatitis?
- A. Homan's sign
- B. Cullen's sign
- C. Hyperactive bowel sounds
- D. Kernig's sign
Correct Answer: B
Rationale: Cullen's sign (B), periumbilical bruising, is associated with acute pancreatitis due to retroperitoneal hemorrhage. Homan's (A) and Kernig's (D) signs are unrelated, and bowel sounds (C) are typically hypoactive.
The nurse is caring for a client receiving total parenteral nutrition (TPN), which was initiated twelve hours ago. The priority assessment for this client is which of the following?
- A. Urine output
- B. Oral temperature
- C. Weight
- D. Capillary blood glucose
Correct Answer: D
Rationale: TPN contains high concentrations of glucose, which can lead to hyperglycemia, especially in the early stages of administration. Monitoring capillary blood glucose is critical to detect and manage this potential complication.
Which of the following clients does the nurse suspect would benefit most from placement of a nasogastric tube?
- A. A 9-year-old client with a femur fracture.
- B. An 82-year-old client with congestive heart failure.
- C. A 65-year-old client on dialysis.
- D. A 52-year-old client with leukemia who is receiving chemotherapy.
Correct Answer: D
Rationale: A client receiving chemotherapy (D) may experience severe nausea and vomiting, necessitating an NG tube for decompression or feeding. The other conditions are less likely to require NG tube placement.
The following scenario applies to the next 1 items
The emergency department (ED) nurse is caring for a client with liver cirrhosis
Item 1 of 1
Nurses' Note
57-year-old male reporting increasing dyspnea and abdominal pressure after missing his previously scheduled paracentesis. The client reports he feels 'uncomfortable.' He is alert and oriented x 4; sclera is yellow along with jaundice skin appearance. Respirations were labored, tachypnea, and clear breath sounds. Abdominal distention noted, hypoactive bowel sounds in all four quadrants. Ascites and dependent edema were noted. Peripheral pulses were intact.
Vital Signs
• Oral Temperature 101 o F (38.3o C)
• Heart rate 94/minute
• Respirations 24/minute
• Blood pressure 104/68 mm Hg
• Oxygen saturation 95% on room air
Medical History
• Hepatitis C
• Liver cirrhosis
• Substance use disorder
• Hyperlipidemia
Which assessment findings require follow-up? Select all that apply.
- A. Jaundice
- B. Labored breathing
- C. Hypoactive bowel sounds
- D. Respiratory rate
- E. Oral temperature
- F. Yellow sclera
Correct Answer: B,D,E
Rationale: Labored breathing (B), elevated respiratory rate (D), and fever (E) indicate potential complications like infection or respiratory compromise in liver cirrhosis, requiring urgent follow-up. Jaundice and yellow sclera (A, F) are expected, and hypoactive bowel sounds (C) are less urgent.