Nokea
The nurse is caring for a client with advanced cirrhosis. Which of the following clinical manifestations should the nurse recognize as a serious complication of this condition?
- A. Frequent nosebleeds and bruising
- B. Urinary retention
- C. No bowel movement in three days
- D. Increased blood glucose
Correct Answer: A
Rationale: Coagulopathy (evidenced by bleeding) is serious in cirrhosis due to impaired clotting factor production.
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A nurse is caring for a client who has a chest tube. Which of the following actions should the nurse take?
- A. Tape the connections on the client's chest tube.
- B. Position the client in a supine position.
- C. Strip the client's chest tube every 2 hours.
- D. Place the chest tube drainage system above the level of the client's heart.
Correct Answer: A
Rationale: Taping connections maintains a closed system and prevents air leaks that could cause pneumothorax.
A client presents with a possible bowel obstruction, and the nurse completes a detailed abdominal assessment. Which of the following clinical manifestations are consistent with a large bowel obstruction? (Select all that apply).
- A. Profuse vomiting with fecal odor
- B. Epigastric abdominal distention
- C. Intermittent abdominal cramping
- D. Ribbon-like stools or diarrhea
- E. Metabolic acidosis
- F. Severe fluid and electrolyte imbalance
Correct Answer: A,B,C,D,E,F
Rationale: All are potential findings in LBO due to mechanical obstruction, bacterial overgrowth, and fluid shifts.
A nurse is caring for a client who has heart failure and a prescription for digoxin 125 mcg orally daily. Digoxin is available in 0.25 mg/tablet form. How many tablets should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 0.5
Rationale: Calculation: 125 mcg = 0.125 mg; 0.125 mg ÷ 0.25 mg/tablet = 0.5 tablets
The nurse would be most concerned about a prescription for a lipid emulsion for a client with which condition?
- A. Fractured femur
- B. Severe anorexia nervosa
- C. Gastrointestinal obstruction
- D. Chronic diarrhea and vomiting
Correct Answer: C
Rationale: Gastrointestinal obstruction contraindicates lipid emulsion administration as it could worsen the obstruction.
A nurse is assessing a client who has an obstruction of the common bile duct resulting from chronic cholecystitis. Which of the following findings should the nurse expect?
- A. Tenderness in the left upper abdomen
- B. Ecchymosis of the extremities
- C. Pale-colored urine
- D. Fatty stools
Correct Answer: D
Rationale: Fatty stools (steatorrhea) occur with common bile duct obstruction because bile cannot reach the intestine to emulsify fats.