Practice Question
A client with portal hypertension has been admitted to the medical floor. The nurse should prioritize what assessments?
Answer Choices:
Correct Answer:
Daily weights and abdominal girth measurement
Rationale:
🟦 Portal hypertension commonly causes ascites and fluid retention, making fluid monitoring the highest priority.
🟦 Daily weights help detect subtle changes in total body fluid that may signal worsening portal pressure.
🟦 Abdominal girth measurement tracks the accumulation of peritoneal fluid, which can impair breathing and mobility.
🟦 These assessments identify complications early, helping to prevent respiratory distress or circulatory compromise.
🟦 This approach directly targets the most dangerous consequences of portal hypertension.
❌ Incorrect Answers
Assess for venous thromboembolism
❌ Not the primary complication associated with portal hypertension.
❌ Ascites and varices take priority.
Blood glucose monitoring q4h
❌ Relevant in diabetes, not portal hypertension.
❌ Does not address main risks of fluid overload.
Blood pressure, headaches, visual changes
❌ These assess hypertension, not portal hypertension.
❌ Do not monitor liver-related fluid complications.
Want to practice more questions like this?
This question is from Examplify Exam IV Fall 25 which contains 49 questions.
More Questions from This Exam
A client's electronic health record notes that the client has hallux valgus. What signs and symptoms should the nurse expect this client to manifest?
Answer Choices:
A patient has an order for Zofran 20 mg IM BID. You're supplied with a vial that is labeled 40 mg/ml. How many mls will the registered nurse administer per dose? Round to the tenth place 1
Answer Choices:
A client presents at a clinic reporting back pain that goes all the way down the back of the leg to the foot. The nurse should document the presence of what type of pain?
Answer Choices:
A client diagnosed with transient ischemic attacks (TIAS) is scheduled for a carotid endarterectomy. The nurse explains that this procedure will be done for which purpose?
Answer Choices:
A client has developed hepatic encephalopathy secondary to cirrhosis and is receiving care on the medical unit. The client's current medication regimen includes lactulose four times daily. What desired outcome should the nurse relate to this pharmacologic intervention?
Answer Choices:
Question Details
- Category: RN Nursing Exam(s)
- Subcategory: Examplify Exam(s)
- Domain: Medical-Surgical
- Answer Choices: 4