Nokea
The nurse is reviewing laboratory test results for the client with liver disease and notes that the client's albumin level is low. Which nursing assessment indicates low albumin levels?
- A. Evaluate for asterixis
- B. Palpate for peripheral edema
- C. Evaluate for decreased level of consciousness
- D. Inspect for petechiae
Correct Answer: B
Rationale: Peripheral edema occurs with hypoalbuminemia due to decreased oncotic pressure causing fluid leakage into tissues.
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The nurse is monitoring a client who just finished a meal for vasomotor manifestations of dumping syndrome. Which of the following findings indicate this occurrence?
- A. Dizziness and pallor
- B. Abdominal cramping and pain
- C. Bradycardia and indigestion
- D. Double vision and chest pain
Correct Answer: A
Rationale: Vasomotor symptoms (dizziness, pallor, diaphoresis) occur from rapid fluid shifts in dumping syndrome.
A nurse is completing an assessment of a client who has a gastric ulcer. Which of the following findings should the nurse expect? (Select all that apply).
- A. The client states that pain occurs 30 minutes to 60 minutes after a meal.
- B. The client states that pain often occurs at night.
- C. The client reports a sensation of bloating.
- D. The client reports pain relieved by eating.
- E. The client experiences pain upon palpation of the epigastric region.
Correct Answer: A,B,C,D,E
Rationale: All options are common findings in gastric ulcer patients due to gastric acid secretion patterns and mucosal irritation.
A client is admitted to the emergency department after sustaining multiple rib fractures in a motor vehicle accident. Upon assessment, the nurse notes that the client has flail chest. Which of the following signs and symptoms are associated with this condition? (Select all that apply.)
- A. Bradycardia
- B. Anxiety
- C. Dyspnea
- D. Unequal chest expansion
- E. Hypotension
- F. Paradoxical chest movement
Correct Answer: B,C,D,E,F
Rationale: Flail chest causes respiratory distress, paradoxical movement, and can lead to shock.
A nurse is caring for a client who has a chest tube in place connected to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client's lung has re-expanded?
- A. Occasional bubbling in the water-seal chamber
- B. No reports of pleuritic chest pain
- C. No tidaling in the water-seal chamber
- D. Oxygen saturation of 95%
Correct Answer: C
Rationale: Absence of tidaling indicates lung re-expansion as intrapleural pressure equalizes.
A nurse is reviewing the laboratory values of a client who had a myocardial infarction 3 hours ago. The nurse should expect which of the following laboratory values to be elevated?
- A. Troponin
- B. Aspartate aminotransferase (AST)
- C. Serum amylase
- D. Unconjugated bilirubin
Correct Answer: A
Rationale: Troponin rises within 3-12 hours post-MI and is the most specific marker for myocardial injury.