A client with cirrhosis has the following laboratory results: albumin 4.9 g/dl. (3.5-5 g/dL), PT 13 seconds (11-12.5 sec), and serum ammonia 68 mcg/dL (15-45 mcg/dL). Based on this information, what is the nurse's next action?
Assess level of consciousness
Assess for bleeding
Measure abdominal girth
Auscultate bowel sounds
The Correct Answer is A
A) Elevated serum ammonia levels can lead to hepatic encephalopathy, which affects mental status and consciousness, making this the priority assessment.
B) The PT is slightly prolonged but not alarmingly high; bleeding is less of a concern compared to the elevated ammonia.
C) This action is important in assessing fluid accumulation but is not as critical as assessing mental status in this scenario.
D) While part of a comprehensive abdominal assessment, this is not the most critical action given the elevated ammonia level.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Omeprazole is not primarily prescribed to enhance nutrient absorption; its main action is to reduce gastric acid secretion.
B) Omeprazole does not specifically affect carbohydrate digestion.
C) Omeprazole is a proton pump inhibitor that reduces the production of gastric acid, which can help alleviate symptoms and promote healing in acute pancreatitis.
D) Omeprazole's primary action is not to reduce the risk of pancreatic infection; it is primarily used to decrease gastric acid production
Correct Answer is A
Explanation
A) Helps maintain muscle tone and promotes overall well-being without overstressing the body during recovery from hepatitis B.
B) Antibiotics are not effective against viruses like hepatitis B.
C) There is generally no need to restrict fluids in hepatitis B; adequate hydration supports overall health and liver function.
D) A high-fat diet is not recommended for liver disease; typically, a balanced, low-fat diet is more appropriate.
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