a 38 year old patient with cirrhosis has ascites and 4 edema of the feet and legs which nursing action will be included in the plan of care a 38 year old patient with cirrhosis has ascites and 4 edema of the feet and legs which nursing action will be included in the plan of care
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NCLEX RN Exam Questions

1. A 38-year-old patient with cirrhosis has ascites and 4+ edema of the feet and legs. Which nursing action will be included in the plan of care?

Correct answer: Place the patient on a pressure-relieving mattress.

Rationale: Placing the patient on a pressure-relieving mattress is crucial to decrease the risk of skin breakdown, especially with significant edema and ascites. Adequate dietary protein intake is essential in patients with ascites to improve oncotic pressure and prevent malnutrition. Repositioning the patient every 4 hours alone may not be sufficient to prevent skin breakdown, especially in areas prone to pressure ulcers. Performing passive range of motion exercises is important for maintaining joint mobility but does not directly address the risk of skin breakdown associated with prolonged pressure on vulnerable areas.

2. A nurse is providing discharge instructions for a client who had back surgery. All of the following indicate that the client is ready for discharge EXCEPT:

Correct answer: The client has a temperature of 100.8°F

Rationale: When determining if a client is ready for discharge after back surgery, it is essential to ensure that there are no signs of complications or emerging issues. A postoperative temperature of 100.8°F may indicate a developing infection, and the client should not be discharged until this is further evaluated by the physician. Choices A, B, and C are indicators that the client is progressing well and ready for discharge, as having sutures, being able to shower, and using an ice pack are typically expected postoperative activities without indicating a need for further hospitalization.

3. Which of the following is an example of whistle-blowing?

Correct answer: A nurse contacts administration about a colleague who takes supplies to use for a mission trip

Rationale: Whistle-blowing involves notifying administration or a supervisor about unethical or illegal activities. In this scenario, the nurse reporting a colleague taking supplies for personal use is an example of whistle-blowing as it involves reporting behavior that is dishonest and potentially harmful. Choices B, C, and D do not represent whistle-blowing. Choice B involves a legal action by a client against a nurse, choice C is a situation where immediate care is provided, and choice D is a case of neglect that should have been prevented.

4. A patient diagnosed with epilepsy is receiving discharge education from a nurse. Which of the following teachings should be emphasized the most?

Correct answer: Continue taking anticonvulsants, even if seizures have ceased

Rationale: The most critical teaching that the nurse should stress to a patient with epilepsy is to continue taking anticonvulsants even if seizures have stopped. Suddenly stopping antiepileptic drugs can lead to seizures and an increased risk of status epilepticus, a life-threatening condition. Choice A, advising to avoid alcohol and drugs, is important but not as crucial as maintaining anticonvulsant therapy. Choice B, emphasizing follow-up appointments, is essential but ensuring medication compliance is more critical to prevent seizure recurrence. Choice D, wearing a medical alert bracelet, is important for emergency identification but does not directly impact the patient's immediate safety like medication adherence does.

5. What should the nurse anticipate or expect of an American Indian woman seeking help to regulate her diabetes?

Correct answer: May also be seeking the assistance of a shaman or medicine man.

Rationale: When caring for an American Indian patient seeking help for diabetes, the nurse should anticipate that the patient may also seek the assistance of a shaman or medicine man in addition to biomedical treatment. This cultural practice is common among American Indians who believe in holistic healing involving body, mind, and spirit. It is important for the nurse to acknowledge and respect these cultural beliefs and practices. Choice A is incorrect because patients from different cultures may not always comply with prescribed treatments due to various factors, including cultural beliefs. Choice B is incorrect as patients seeking traditional healing methods do not necessarily give up their beliefs in naturalistic causes of disease; instead, they often complement biomedical care. Choice D is incorrect as assuming the patient is experiencing a crisis of faith is not appropriate; it is more about respecting and understanding the patient's cultural background and beliefs.

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