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

HESI RN

HESI 799 RN Exit Exam

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

Correct answer: C

Rationale: An ammonia level of 80 mcg/dL is elevated and concerning in a client with liver cirrhosis, as it may indicate hepatic encephalopathy. Elevated ammonia levels can lead to cognitive impairment, altered mental status, and even coma. Serum albumin, bilirubin, and prothrombin time are also important markers in liver cirrhosis but are not as directly associated with the risk of hepatic encephalopathy as elevated ammonia levels.

2. An elderly female client with osteoarthritis reports increasing pain and stiffness in her right knee and asks how to reduce these symptoms. In responding to the client, the nurse recognizes what pathology as the cause of her symptoms?

Correct answer: A

Rationale: Corrected Rationale: Osteoarthritis typically involves the destruction of joint cartilage, leading to pain and stiffness. This destruction of joint cartilage results in bone rubbing against bone, causing pain and reduced mobility. Choices B, C, and D are incorrect. Inflammation of the synovial membrane (choice B) is more commonly associated with rheumatoid arthritis. Formation of bone spurs (choice C) and reduction of joint space (choice D) are manifestations that can occur as a result of osteoarthritis but are not the primary pathology responsible for the symptoms of pain and stiffness.

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 mm Hg, a pulse rate of 118 beats per minute, and a respiratory rate of 8 breaths per minute. What assessment should the nurse perform next?

Correct answer: D

Rationale: In this scenario, the client is presenting with signs of potential opioid overdose, such as lethargy, hypotension, tachycardia, and bradypnea. The next assessment the nurse should perform is to observe the amount and dose of morphine in the PCA pump syringe. This evaluation is crucial in determining if the client is receiving an excessive amount of morphine, leading to the observed symptoms. Checking the PCA pump syringe will provide essential information to address the client's condition promptly and prevent further complications. Choices A, B, and C are not the priority in this situation as they do not directly address the potential cause of the client's symptoms related to morphine administration.

4. A client with a history of chronic heart failure is admitted with shortness of breath. Which assessment finding is most concerning?

Correct answer: C

Rationale: Elevated liver enzymes are concerning in a client with chronic heart failure as they may indicate liver congestion or worsening heart failure, requiring immediate intervention. While crackles in the lungs and shortness of breath are common in heart failure, elevated liver enzymes specifically point towards possible liver involvement due to heart failure. A heart rate of 100 beats per minute can be expected in a client with heart failure due to compensatory mechanisms, but elevated liver enzymes signal a more severe condition.

5. A healthcare provider is assessing a client with a history of hypertension who is currently taking a diuretic. Which assessment finding is most important to report to the healthcare provider?

Correct answer: A

Rationale: A potassium level of 3.2 mEq/L is low and places the client at risk for cardiac arrhythmias, requiring immediate intervention. Hypokalemia can result from diuretic use and can lead to serious complications such as irregular heart rhythms. Monitoring and correcting potassium levels are crucial in preventing adverse cardiac events. The other options, though important, do not pose an immediate life-threatening risk compared to the low potassium level.

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