NCLEX Questions

The nurse is caring for a client with cirrhosis. Which assessment findings indicate that the client has deficient vitamin K absorption caused by this hepatic disease?

Purpura and petechiae are s/s of bleeding. A hepatic disorder, such as cirrhosis, may disrupt the liver's normal use of vitamin K to produce prothrombin.

Why are antacids administered regularly, rather than as needed, in peptic ulcer disease?

To keep gastric pH at 3.0 to 3.5 To maintain a gastric pH of 3.0 to 3.5 throughout each 24-hour period, regular (not as needed) doses of an antacid are needed to treat peptic ulcer disease. Frequent administration of an antacid tends to decrease client compliance rather than promote it. Antacids don't regulate bowel patterns, and they decrease pepsin activity. (less)

A client with diverticulitis has developed peritonitis following diverticular rupture. When assessing the client, what should the nurse do? Select all that apply.

• Percuss the abdomen to note tympany. • Percuss the liver to note lack of dullness. • Monitor the vital signs for fever. • Auscultate bowel sounds to note frequency. Explanation: Percussion will show resonance and tympany indicating paralytic ileus. Lack of liver dullness may indicate free air in the abdomen. The client with peritonitis will have fever, tachypnea, and tachycardia. The abdomen becomes rigid with rebound tenderness and there will be absent bowel sounds. The client will not demonstrate excessive thirst but may have anorexia, nausea, and vomiting as peristalsis decreases