Esophagus and if the tube migrates the airway can be

esophagus, and if the tube migrates, the airway can be obstructed. Decreased level of consciousness may indicate
hypoxia and is the priority for follow-up.
Rationale 4 : A darkened area on the heel may indicate a pressure ulcer. This is not the highest-priority finding.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 38-1
Question 12
Type: MCMA
The nurse is caring for a patient with severe liver disease. The nurse notes new ecchymotic areas on the patient’s
arms and legs. Which laboratory results will the nurse analyze regarding this finding?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Reduction of Risk Potential
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 38-3
Question 13

Type: MCSA
The nurse assesses a patient who has cirrhosis secondary to liver failure. Which finding would require immediate
follow-up by the nurse?
4
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 38-3