a client with liver cirrhosis and severe ascites has a serum sodium level of 115 meql and is receiving 3 saline iv which assessment finding indicates
Logo

Nursing Elites

HESI RN

HESI RN Exit Exam 2024 Quizlet

1. A client with liver cirrhosis and severe ascites has a serum sodium level of 115 mEq/L and is receiving 3% saline IV. Which assessment finding indicates that the nurse should notify the healthcare provider?

Correct answer: D

Rationale: The presence of crackles in both lung bases and an increased respiratory rate indicates fluid overload, which can be exacerbated by hypertonic saline. This condition can worsen the client's respiratory status and lead to further complications. The other options do not directly relate to the fluid overload caused by the hypertonic saline. A serum sodium level of 130 mEq/L is within a normal range for treatment. A headache and a blood pressure of 140/90 are not specific indicators of worsening condition related to hypertonic saline. Shortness of breath and an O2 saturation of 92% could be related to other factors in a client with liver cirrhosis and ascites.

2. A client with cirrhosis is admitted with jaundice and ascites. Which clinical finding is most concerning?

Correct answer: B

Rationale: Confusion and altered mental status are concerning in a client with cirrhosis as they may indicate hepatic encephalopathy, a serious complication that requires immediate intervention. Increased abdominal girth can be seen in ascites, yellowing of the skin is due to jaundice, and peripheral edema is associated with fluid retention in cirrhosis, but confusion and altered mental status are more closely linked to hepatic encephalopathy, which can progress rapidly and needs urgent attention.

3. The nurse is assessing a client with right-sided heart failure. Which finding requires immediate intervention?

Correct answer: C

Rationale: In a client with right-sided heart failure, crackles in the lungs are the most concerning finding as they indicate pulmonary congestion, which requires immediate intervention. Crackles suggest fluid accumulation in the lungs, leading to impaired gas exchange and potential respiratory distress. Jugular venous distention (Choice A) and peripheral edema (Choice B) are common findings in right-sided heart failure but do not indicate acute deterioration requiring immediate intervention. Elevated liver enzymes (Choice D) may be seen in chronic heart failure but do not warrant immediate action compared to the urgent need to address pulmonary congestion indicated by crackles in the lungs.

4. A client with chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. Which intervention should the nurse implement first?

Correct answer: A

Rationale: In a client with COPD admitted with pneumonia, the priority intervention should be to administer oxygen therapy as prescribed. This is crucial to improve oxygenation, especially in a client with compromised respiratory function. Elevating the head of the bed can help with breathing but is secondary to ensuring adequate oxygenation. Obtaining a sputum culture and administering antibiotics are important steps in the treatment of pneumonia but come after ensuring adequate oxygen supply.

5. A client with atrial fibrillation is receiving digoxin (Lanoxin) and warfarin (Coumadin). Which assessment finding should the nurse report to the healthcare provider immediately?

Correct answer: B

Rationale: The correct answer is B. The presence of a new murmur in a client with atrial fibrillation may indicate a valvular problem or other complications, requiring immediate reporting. A heart rate of 58 beats per minute is within the normal range for some individuals with atrial fibrillation, so it is not an immediate concern. An INR of 2.5 is within the therapeutic range for a client on warfarin, indicating appropriate anticoagulation. A blood pressure of 110/70 mmHg is also within the normal range and does not pose an immediate threat to the client's health.

Similar Questions

A client with chronic obstructive pulmonary disease (COPD) is admitted with an exacerbation. Which intervention should the nurse implement first?
A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with an exacerbation. Which intervention should the nurse implement first?
A preschooler with constipation needs to increase fiber intake. Which snack suggestion should the nurse provide?
A client with cirrhosis is admitted with ascites and jaundice. Which clinical finding is most concerning?
A client with end-stage renal disease (ESRD) is scheduled for hemodialysis. Which laboratory value should the nurse report to the healthcare provider immediately?

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