a client with cirrhosis is admitted with jaundice and ascites which assessment finding is most concerning
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Nursing Elites

HESI RN

HESI 799 RN Exit Exam Quizlet

1. A client with cirrhosis is admitted with jaundice and ascites. Which assessment finding is most concerning?

Correct answer: C

Rationale: In a client with cirrhosis presenting with jaundice and ascites, yellowing of the skin (icterus) is the most concerning assessment finding. This indicates significant liver dysfunction and a high level of bilirubin in the blood. Yellowing of the skin suggests a severe impairment of the liver's ability to process bilirubin, which can lead to serious complications. Peripheral edema and increased abdominal girth are common manifestations of cirrhosis but are not as acutely concerning as skin yellowing. Confusion and altered mental status are also critical findings in cirrhosis, indicating hepatic encephalopathy, but skin yellowing is more closely associated with the severity of liver dysfunction in this scenario.

2. The nurse notes that a client has been receiving hydromorphone (Dilaudid) every six hours for four days. What assessment is most important for the nurse to complete?

Correct answer: A

Rationale: The correct answer is to auscultate the client's bowel sounds. Hydromorphone is a potent opioid analgesic that can slow peristalsis and commonly cause constipation. By assessing the client's bowel sounds, the nurse can monitor for any signs of decreased bowel motility or potential constipation. Observing for edema (Choice B) is not directly related to hydromorphone administration. Measuring capillary glucose levels (Choice C) is not the priority in this situation. Counting the apical and radial pulses simultaneously (Choice D) is not specifically indicated in this scenario involving hydromorphone administration.

3. A client with chronic kidney disease (CKD) is admitted with hyperkalemia. Which laboratory value is most concerning?

Correct answer: A

Rationale: A serum potassium level of 6.5 mEq/L is concerning in a client with CKD as it indicates hyperkalemia, which requires immediate intervention to prevent cardiac complications. Hyperkalemia can lead to life-threatening arrhythmias, particularly in patients with impaired kidney function. Serum sodium, creatinine, and blood glucose levels, while important, are not as acutely dangerous as severe hyperkalemia in this context.

4. Which statement by the client indicates an understanding of the dietary modifications required with Cushing syndrome?

Correct answer: B

Rationale: The correct answer is B: 'I should avoid foods with high sodium content.' Clients with Cushing syndrome need to limit their sodium intake to help reduce fluid retention and manage hypertension, which are common complications of the syndrome. Increasing calcium intake (choice A) is not specifically indicated for Cushing syndrome. Decreasing vitamin D intake (choice C) is not a typical dietary modification for this condition. Consuming more potassium-rich foods (choice D) is not a primary focus of dietary modifications for Cushing syndrome.

5. While taking vital signs, a critically ill male client grabs the nurse's hand and asks the nurse not to leave. What action is best for the nurse to take?

Correct answer: A

Rationale: The best action for the nurse to take in this situation is to pull up a chair and sit beside the client's bed. By doing so, the nurse can provide emotional support and comfort to the critically ill patient who is feeling vulnerable. Sitting with the client also shows empathy and a willingness to listen to the client's needs. Reassuring the client that the nurse will return shortly (Choice B) may not address the immediate need for emotional support. Asking another nurse to stay with the client (Choice C) may not establish the same level of connection and comfort as sitting with the client personally. Continuing to take vital signs and then leaving the room (Choice D) disregards the client's emotional needs in that moment.

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