a client with cirrhosis is admitted with jaundice and ascites which assessment finding requires immediate intervention

HESI RN

HESI RN Exit Exam

1. A client with cirrhosis is admitted with jaundice and ascites. Which assessment finding requires immediate intervention?

A. Peripheral edema
B. Confusion and altered mental status
C. Yellowing of the skin
D. Increased abdominal girth

Correct answer: B

Rationale: Confusion and altered mental status are the most critical assessment findings in a client with cirrhosis. These symptoms may indicate hepatic encephalopathy, a serious complication that requires immediate intervention. Yellowing of the skin (jaundice) is a common manifestation of cirrhosis and does not necessitate immediate intervention. Peripheral edema and increased abdominal girth are associated with fluid retention in cirrhosis but are not as urgent as addressing altered mental status and confusion.

2. Following a gunshot wound to the abdomen, a young adult male had an emergency bowel resection and received multiple blood products while in the operating room. His current blood pressure is 78/52 mm Hg, he is being mechanically ventilated, and his oxygen saturation is 87%. His laboratory values include hemoglobin 7.0 g/dL, platelets 20,000/mm³, and white blood cells 1,500/mm³. Based on these assessment findings, which intervention should the nurse implement first?

A. Transfuse packed red blood cells.
B. Obtain blood and sputum cultures.
C. Infuse 1000 ml of normal saline.
D. Titrate oxygen to keep O2 saturation at 90%.

Correct answer: A

Rationale: The client is exhibiting signs of severe anemia and hypovolemic shock, indicated by low hemoglobin levels and hypotension. The first priority is to address the low hemoglobin by transfusing packed red blood cells to improve oxygen-carrying capacity and perfusion to vital organs. While obtaining blood and sputum cultures is important for identifying potential infections, infusing normal saline can help with volume expansion but does not address the primary issue of severe anemia. Titrating oxygen to maintain an oxygen saturation of 90% is crucial but should follow the administration of packed red blood cells to optimize oxygen delivery.

3. In caring for a client with a PCA infusion of morphine sulfate through the right cephalic vein, the nurse assesses that the client is lethargic with a blood pressure of 90/60, pulse rate of 118 beats per minute, and respiratory rate of 8 breaths per minute. What assessment should the nurse perform next?

A. Note the appearance and patency of the client's peripheral IV site.
B. Palpate the volume of the client's right radial pulse.
C. Auscultate the client's breath sounds bilaterally.
D. Observe the amount and dose of morphine in the PCA pump syringe.

Correct answer: D

Rationale: In this scenario, the nurse is dealing with a lethargic client with concerning vital signs after a PCA infusion of morphine sulfate. The next assessment the nurse should perform is to observe the amount and dose of morphine in the PCA pump syringe. This is crucial to evaluate for possible overdose, as the client's symptoms could be indicative of opioid toxicity. Checking the morphine amount and dose will help the nurse adjust the treatment accordingly. Choices A, B, and C do not directly address the potential cause of the client's lethargy and abnormal vital signs related to the morphine infusion.

4. A client is admitted with a diagnosis of diabetic ketoacidosis (DKA). Which clinical finding is most concerning to the nurse?

A. Kussmaul respirations
B. Blood glucose level of 300 mg/dl
C. Serum potassium of 3.2 mEq/L
D. Positive urine ketones

Correct answer: C

Rationale: The correct answer is C: Serum potassium of 3.2 mEq/L. A low serum potassium level in a client with DKA is concerning due to the risk of cardiac arrhythmias. Kussmaul respirations (choice A) are a compensatory mechanism for metabolic acidosis in DKA. A blood glucose level of 300 mg/dl (choice B) is elevated but expected in DKA. Positive urine ketones (choice D) are a classic finding in DKA and not as concerning as low serum potassium.

5. The nurse is caring for a client with acute kidney injury (AKI) secondary to gentamicin therapy. The client's serum blood potassium is elevated. Which finding requires immediate action by the nurse?

A. Anuria for the last 12 hours.
B. Tachycardia and hypotension.
C. Decreased urine output.
D. Elevated blood urea nitrogen (BUN) levels.

Correct answer: A

Rationale: The correct answer is A. Anuria for the last 12 hours. Anuria, the absence of urine output, indicates complete kidney failure and is a medical emergency that requires immediate attention. In acute kidney injury (AKI), the kidneys are unable to filter waste from the blood effectively, leading to a buildup of toxins and electrolyte imbalances like elevated blood potassium levels. Tachycardia and hypotension (choice B) can be seen in AKI but do not reflect the urgency of addressing anuria. Decreased urine output (choice C) is concerning but not as critical as the absence of urine production. Elevated blood urea nitrogen (BUN) levels (choice D) are indicative of kidney dysfunction but do not demand immediate action as anuria does.