a client with chronic liver disease develops jaundice what is the most important assessment the nurse should perform
Logo

Nursing Elites

HESI RN

HESI RN Exit Exam 2023 Capstone

1. A client with chronic liver disease develops jaundice. What is the most important assessment the nurse should perform?

Correct answer: D

Rationale: In a client with chronic liver disease developing jaundice, the most important assessment the nurse should perform is to monitor the client’s urine output closely. Jaundice can indicate worsening liver function, so monitoring urine output helps assess kidney function and fluid balance, which are critical in chronic liver disease. Assessing the client’s skin for lesions or sores (Choice A) may be relevant for dermatological conditions but is not the priority in this case. Monitoring liver function tests (Choice B) is important but may not provide immediate information on the client’s current status. Assessing for changes in mental status and behavior (Choice C) is important for detecting hepatic encephalopathy but does not directly address the immediate concern of fluid balance and kidney function in the presence of jaundice.

2. A client with chronic obstructive pulmonary disease (COPD) is experiencing difficulty breathing. What is the nurse's priority intervention?

Correct answer: B

Rationale: In clients with COPD experiencing difficulty breathing, increasing the client's oxygen flow rate is the priority intervention. This action helps to improve oxygenation and relieve shortness of breath. While bronchodilators and other medications may be necessary, providing immediate oxygen support is crucial. Elevating the head of the bed and repositioning the client can assist with breathing comfort but do not address the immediate need for improved oxygenation in COPD exacerbation.

3. Which self-care measure is most important for the nurse to include in the plan of care of a client recently diagnosed with type 2 diabetes mellitus?

Correct answer: C

Rationale: Blood glucose monitoring is crucial for managing diabetes effectively. By monitoring blood sugar levels, individuals can understand how their lifestyle choices, medications, and diet affect their glucose levels. This information helps in making necessary adjustments to control blood sugar levels and prevent complications. While maintaining a low-sugar diet, foot care, and daily exercise are all important aspects of managing diabetes, blood glucose monitoring takes precedence as it provides real-time data for informed decision-making.

4. During a neurologic assessment of a client with a suspected stroke, which finding is most concerning?

Correct answer: D

Rationale: Sudden loss of consciousness in a client with a suspected stroke is the most concerning finding as it indicates a more severe neurological event, such as brain stem involvement or hemorrhage, requiring immediate intervention. While unilateral facial droop, slurred speech, and weakness in one arm are all common signs of a stroke, sudden loss of consciousness signifies a critical condition that needs urgent attention and evaluation to prevent further complications.

5. The nurse is preparing a female client for discharge after being treated for a urinary tract infection (UTI). Which statement by the client indicates a need for further teaching?

Correct answer: A

Rationale: The correct answer is A. Using douches is not recommended as it can disrupt the natural flora and increase the risk of infections. Choices B, C, and D are all correct statements that can help prevent UTIs. Drinking an adequate amount of water helps flush out bacteria, avoiding tight-fitting clothing promotes ventilation and reduces moisture, and wiping from front to back prevents the spread of bacteria from the anal region to the urethra.

Similar Questions

A client with a prescription for DNR begins to manifest signs of impending death. After notifying the family of the client's status, what priority action should the nurse implement?
Which intervention should be prioritized by the nurse when assessing tissue perfusion post-above knee amputation (AKA)?
A client with diabetes mellitus is experiencing hyperglycemia. What laboratory value should the nurse monitor to evaluate long-term glucose control?
A client with chronic kidney disease is prescribed erythropoietin. What lab value should the nurse monitor to evaluate the effectiveness of the therapy?
A client scheduled for a bronchoscopy in the morning is anxious and asking the nurse numerous questions about the procedure. Which intervention has the highest priority in preparing the client for the procedure?

Access More Features

HESI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses