A client has advanced cirrhosis of the liver. The client's spouse asks

NCLEX RN Med Surg Questions

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Question 1 of 5.

A client has advanced cirrhosis of the liver. The client's spouse asks the nurse why his abdomen is swollen, making it very difficult for him to fasten his pants. How should the nurse respond to provide the most accurate explanation of the disease process?

A. It must have been eating too many foods with salt in them. Salt pulls water with it.'

B. The swelling in his ankles must have moved up closer to his heart so the fluid circulates better.'

C. He must have forgotten to take his daily water pill.'

D. Blood is not able to flow readily through the liver now, and the liver cannot make protein to keep fluid inside the blood vessels.'

Explanation: Cirrhosis causes portal hypertension and hypoalbuminemia, leading to ascites (D). Salt intake (A) may worsen but isn't the primary cause. Ankle edema (B) and diuretics (C) are secondary factors.

Question 2 of 5.

A 65-year-old client is admitted to the emergency department with a fractured hip. The client has chest pain and shortness of breath. The health care provider orders nitroglycerin tablets. Which should the nurse instruct the client to do?

A. Put the tablet under the tongue until it is dissolved.

B. Swallow the tablet with 120 mL of water.

C. Chew the tablet until it is dissolved.

D. Place the tablet between his cheek and gums.

Explanation: Sublingual nitroglycerin is administered under the tongue for rapid absorption to relieve chest pain. Other methods (swallowing, chewing, or buccal placement) are incorrect for this medication.

Question 3 of 5.

After a myocardial infarction, the hospitalized client is taught to move the legs while resting in bed. This type of exercise is recommended primarily to help:

A. Prepare the client for ambulation.

B. Promote urinary and intestinal elimination.

C. Prevent thrombophlebitis and blood clot formation.

D. Decrease the likelihood of pressure ulcer formation.

Explanation: Leg exercises prevent venous stasis, reducing the risk of thrombophlebitis and deep vein thrombosis, common complications post-MI due to immobility.

Question 4 of 5.

The client who experiences angina has been told to follow a low-cholesterol diet. Which of the following meals should the nurse tell the client would be best on her low-cholesterol diet?

A. Hamburger, salad, and milkshake.

B. Baked liver, green beans, and coffee.

C. Spaghetti with tomato sauce, salad, and coffee.

D. Fried chicken, green beans, and skim milk.

Explanation: Spaghetti with tomato sauce, salad, and coffee is low in cholesterol, unlike hamburger, liver, or fried chicken, which contain higher cholesterol or saturated fats.

Question 5 of 5.

Which of the following foods should the nurse teach a client with heart failure to limit when following a 2-g sodium diet?

A. Apples.

B. Tomato juice.

C. Whole wheat bread.

D. Beef tenderloin.

Explanation: Tomato juice is high in sodium, which should be limited on a 2-g sodium diet to prevent fluid retention in heart failure.