Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assessing a client who has cirrhosis. Which of the following is an expected finding for this client?
A. Blood in the urine
Blood in the urine (hematuria) is not typically associated with cirrhosis. It may be related to other underlying conditions.
B. Spider angiomas
Spider angiomas (also known as spider nevi) are expected findings in clients with cirrhosis. They are small, dilated blood vessels near the surface of the skin that resemble a spider's web. They can be found on the face, neck, upper trunk, and arms.
C. Tarry stools
Tarry stools (melena) can occur in individuals with gastrointestinal bleeding, which can be a complication of cirrhosis. However, it is not a specific finding for cirrhosis itself.
D. Moist skin
Moist skin is not a characteristic finding associated with cirrhosis. It may be related to other factors such as environmental humidity or individual factors like sweating.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Med Surg Proctored Exam 6. Take the full exam now
Full Explanation
Choice A reason:
Blood in the urine (hematuria) is not typically associated with cirrhosis. It may be related to other underlying conditions.
Choice B reason:
Spider angiomas (also known as spider nevi) are expected findings in clients with cirrhosis.
They are small, dilated blood vessels near the surface of the skin that resemble a spider's web. They can be found on the face, neck, upper trunk, and arms.
Choice C reason:
Tarry stools (melena) can occur in individuals with gastrointestinal bleeding, which can be a complication of cirrhosis. However, it is not a specific finding for cirrhosis itself.
Choice D reason:
Moist skin is not a characteristic finding associated with cirrhosis. It may be related to other factors such as environmental humidity or individual factors like sweating.
Similar Questions
The management of the patient's gastrostomy is an assessment priority for the home care nurse. What statement would indicate that the patient is managing the tube correctly?
A. "The only time I flush my tube is when I'm putting in medications."
Flushing the tube only when administering medications is not sufficient for proper maintenance. Regular flushing with water helps prevent clogs and ensures tube patency.
B. "I clean my stoma twice a day with alcohol."
Cleaning the stoma with alcohol is not necessary and can be irritating to the skin. Mild soap and water are typically recommended for stoma care.
C. "I try to stay still most of the time to avoid dislodging my tube."
While being cautious to avoid dislodging the tube is important, it is not the primary indicator of correct tube management. Proper flushing and care are essential components of tube maintenance.
D. "I flush my tube with water before and after each of my medications."
Flushing the tube with water before and after each medication administration is a crucial step in maintaining tube patency and preventing clogs. This indicates that the patient is managing the tube correctly.
Full Explanation
Choice A reason:
Flushing the tube only when administering medications is not sufficient for proper maintenance. Regular flushing with water helps prevent clogs and ensures tube patency.
Choice B reason:
Cleaning the stoma with alcohol is not necessary and can be irritating to the skin. Mild soap and water are typically recommended for stoma care.
Choice C reason:
While being cautious to avoid dislodging the tube is important, it is not the primary indicator of correct tube management. Proper flushing and care are essential components of tube
maintenance.
Choice D reason:
Flushing the tube with water before and after each medication administration is a crucial step in maintaining tube patency and preventing clogs. This indicates that the patient is managing the
tube correctly.
A patient, admitted with a head injury, has an order for DSNS at 125 ml/hour. The IV tubing has a calibration of 15gtt/mL.
What is the correct rate of flow for this patient in gtt/min?
Full Explanation
- To calculate the correct rate of flow for this patient, we need to use the formula: Rate (gtt/min) = Volume (mL) x Calibration (gtt/mL) / Time (min)
- Plugging in the given values, we get: Rate (gtt/min) = 125 mL x 15 gtt/mL / 60 min
- Simplifying, we get: Rate (gtt/min) = 31.25 gtt/min
- Therefore, the correct rate of flow for this patient is 31.25 gtt/min
A nurse is caring for a client who has ulcerative colitis and is teaching the client about the common link with Crohn's disease. Which of the following information should the nurse
include?
A. Both require frequent surgery
Both ulcerative colitis and Crohn's disease can require surgery in some cases, but it is not a common link that defines both conditions.
B. Both are inflammatory
This is the correct answer. Both ulcerative colitis and Crohn's disease are types of inflammatory bowel disease (IBD). They share the common feature of chronic inflammation of the digestive tract.
C. Both manifest fistula formation
Fistula formation is more commonly associated with Crohn's disease than ulcerative colitis. It is not a defining characteristic of both conditions.
D. Both begin in the rectum
Ulcerative colitis primarily affects the colon and rectum, but Crohn's disease can affect any part of the digestive tract from the mouth to the anus. Therefore, both conditions do not necessarily begin in the rectum.
Full Explanation
Choice A reason:
Both ulcerative colitis and Crohn's disease can require surgery in some cases, but it is not a common link that defines both conditions.
Choice B reason:
This is the correct answer. Both ulcerative colitis and Crohn's disease are types of inflammatory bowel disease (IBD). They share the common feature of chronic inflammation of the digestive tract.
Choice C reason:
Fistula formation is more commonly associated with Crohn's disease than ulcerative colitis. It is not a defining characteristic of both conditions.
Choice D reason:
Ulcerative colitis primarily affects the colon and rectum, but Crohn's disease can affect any part of the digestive tract from the mouth to the anus. Therefore, both conditions do not necessarily begin in the rectum.