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 A
Explanation
A) Chronic and excessive alcohol consumption is a well-established risk factor for the development of chronic pancreatitis.
B) While contributing to other health issues, it is not directly linked to chronic pancreatitis.
C) Smoking is a risk factor, but alcohol abuse is more significantly associated with chronic pancreatitis.
D) Although it contributes to various health problems, it is not as directly linked to chronic pancreatitis as alcohol abuse.

Correct Answer is D
Explanation
A) While a high carbohydrate diet can contribute to fatty liver disease, it is less direct and specific compared to other risk factors.
B) Heart disease is not directly linked to liver disease risk.
C) Having a flu is unrelated to liver disease risk.
D) Intravenous drug use is a known risk factor for hepatitis B and C, both of which can lead to liver disease.
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