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Questions 157

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Question 1 of 5

A 48-year-old male client is hospitalized with mild ascites, bruising, and jaundice. He has a 20-year history of alcohol abuse. The client is diagnosed with cirrhosis. His serum ammonia level is high, indicating hepatic encephalopathy. He has esophageal varices. Which of the following may cause the varices to rupture?

Correct Answer: A

Rationale: Lifting heavy objects will increase intrathoracic pressure, thus placing the client at risk for rupturing esophageal varices.

Question 2 of 5

The client is receiving a continuous infusion of insulin for diabetic ketoacidosis. Which laboratory value should the nurse monitor most closely?

Correct Answer: A

Rationale: Insulin therapy in diabetic ketoacidosis shifts potassium into cells, risking hypokalemia, which can cause arrhythmias. Sodium, BUN, and A1C are monitored but are less critical during acute treatment.

Question 3 of 5

A client with a history of a kidney transplant is receiving Prednisone. The nurse should monitor the client for:

Correct Answer: A

Rationale: Prednisone, a corticosteroid, suppresses immunity, increasing infection risk. Hypotension, hyperkalemia, and weight loss are not primary concerns; weight gain is more common.

Question 4 of 5

The nurse is caring for a client with a diagnosis of gestational trophoblastic disease. Which intervention is most appropriate?

Correct Answer: A

Rationale: Gestational trophoblastic disease requires monitoring hCG levels to assess for resolution or progression to malignancy (e.g. choriocarcinoma).
Tocolytics fetal monitoring and vaginal delivery are not indicated as there is no viable fetus.

Question 5 of 5

A client has been diagnosed with congestive heart failure. His fluid intake and output are strictly regulated. For lunch, he drank 8 oz of milk, 4 oz of tea, and 6 oz of coffee. His intake would be recorded as:

Correct Answer: B

Rationale: 1 oz = 30 mL; therefore, 18 oz = 540 mL.

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