Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assessing a client who has cirrhosis.
Which of the following findings is the priority for the nurse to report?
A. Distended abdomen.
Choice A is incorrect because while a distended abdomen can be a sign of ascites, a complication of cirrhosis, it is not the priority finding to report.
B. Clay-colored stools.
Choice B is incorrect because while clay-colored stools can be a sign of biliary obstruction, it is not the priority finding to report.
C. Platelets 70,000/mm.
Platelets 70,000/mm. The priority finding for a nurse assessing a client who has cirrhosis to report is a platelet count of 70,000/mm. A low platelet count (thrombocytopenia) can be a complication of cirrhosis and can increase the risk of bleeding. A platelet count below 150,000/mm3 is considered low and should be reported to the provider.
D. Alkaline phosphatase 125 units/L.
Choice D is incorrect because while an elevated alkaline phosphatase level can be a sign of liver damage, it is not the priority finding to report.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Adult Medical Surgical 2019 Proctored Exam. Take the full exam now
Full Explanation
Platelets 70,000/mm.
The priority finding for a nurse assessing a client who has cirrhosis to report is a platelet count of 70,000/mm.
A low platelet count (thrombocytopenia) can be a complication of cirrhosis and can increase the risk of bleeding.
A platelet count below 150,000/mm3 is considered low and should be reported to the provider.
Choice A is incorrect because while a distended abdomen can be a sign of ascites, a complication of cirrhosis, it is not the priority finding to report.
Choice B is incorrect because while clay-colored stools can be a sign of biliary obstruction, it is not the priority finding to report.
Choice D is incorrect because while an elevated alkaline phosphatase level can be a sign of liver damage, it is not the priority finding to report.
Similar Questions
A nurse is caring for a client who had a total hip arthroplasty.
Which of the following actions should the nurse take to prevent hip dislocation?
A. Place two-bed pillows between the legs when in bed.
Place two-bed pillows between the legs when in bed. To prevent hip dislocation after total hip arthroplasty, the nurse should place two-bed pillows between the client’s legs when in bed. This helps maintain proper alignment and prevent the hip from dislocating.
B. Encourage the client to lean forward when attempting to stand.
Choice B is incorrect because leaning forward when attempting to stand can increase the risk of hip dislocation.
C. Remove the wedge device when turning.
Choice C is incorrect because removing the wedge device when turning can increase the risk of hip dislocation.
D. Elevate the knees higher than the hips when sitting.
Choice D is incorrect because elevating the knees higher than the hips when sitting can increase the risk of hip dislocation.
Full Explanation
Place two-bed pillows between the legs when in bed.
To prevent hip dislocation after total hip arthroplasty, the nurse should place two-bed pillows between the client’s legs when in bed.
This helps maintain proper alignment and prevent the hip from dislocating.
Choice B is incorrect because leaning forward when attempting to stand can increase the risk of hip dislocation.
Choice C is incorrect because removing the wedge device when turning can increase the risk of hip dislocation.
Choice D is incorrect because elevating the knees higher than the hips when sitting can increase the risk of hip dislocation.
A nurse is caring for a client who is experiencing a hypertensive crisis. Which of the following actions should the nurse take?
A. Initiate an IV dopamine infusion.
Choice A is incorrect because dopamine is not typically used to treat hypertensive crises.
B. Begin an IV bolus of lactated Ringer's.
Choice B is incorrect because lactated Ringer’s solution is not typically used to treat hypertensive crises.
C. Perform neurological assessments.
A hypertensive crisis is an emergent situation in which a marked elevation in diastolic blood pressure can cause end-organ damage. The nurse should perform neurological assessments to monitor for any changes in the patient’s level of consciousness and other neurological symptoms.
D. Place the client supine.
Choice D is incorrect because placing the client supine may not be appropriate and could potentially worsen their condition.
Full Explanation
A hypertensive crisis is an emergent situation in which a marked elevation in diastolic blood pressure can cause end-organ damage.
The nurse should perform neurological assessments to monitor for any changes in the patient’s level of consciousness and other neurological symptoms.
Choice A is incorrect because dopamine is not typically used to treat hypertensive crises.
Choice B is incorrect because lactated Ringer’s solution is not typically used to treat hypertensive crises.
Choice D is incorrect because placing the client supine may not be appropriate and could potentially worsen their condition.
A nurse is administering potassium chloride via IV infusion to a client who has severe hypokalemia. Which of the following actions should the nurse take?
A. Check the infusion site at least every 4 hr.
Choice A is incorrect because the infusion site should be checked more frequently than every 4 hours.
B. Start the infusion at 30 mEq/hr.
Choice B is incorrect because the maximum recommended rate of infusion for potassium chloride is 10 mEq/hr.
C. Assess the client for a positive Chvostek sign.
Choice C is incorrect because Chvostek’s sign is used to assess for hypocalcemia, not hypokalemia.
D. Monitor the client for adequate urine output.
Monitor the client for adequate urine output. When administering potassium chloride via IV infusion to a client who has severe hypokalemia, it is important for the nurse to monitor the client’s urine output to ensure that their kidneys are functioning properly and that they are able to excrete excess potassium.
Full Explanation
Monitor the client for adequate urine output.
When administering potassium chloride via IV infusion to a client who has severe hypokalemia, it is important for the nurse to monitor the client’s urine output to ensure that their kidneys are functioning properly and that they are able to excrete excess potassium.
Choice A is incorrect because the infusion site should be checked more frequently than every 4 hours.
Choice B is incorrect because the maximum recommended rate of infusion for potassium chloride is 10 mEq/hr.
Choice C is incorrect because Chvostek’s sign is used to assess for hypocalcemia, not hypokalemia.