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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A) Pancreatic enzymes are typically used to aid in digestion rather than pain control in acute pancreatitis.
B) Decompression of the gastrointestinal tract through nasogastric suction can help reduce pancreatic stimulation and alleviate pain in acute pancreatitis.
C) While ambulation may help prevent complications, it is not directly related to pain control in acute pancreatitis.
D) A clear liquid diet may be initiated once the acute phase has resolved, but it does not directly contribute to pain control.

A. Request a dietary consult B. Order a 2 gram sodium restriction diet C. Initiate a fluid restriction D. Hold the spironolactone and furosemide

Correct Answer is D

Explanation

A) Requesting a dietary consult is useful but not the most immediate action needed.

B) Ordering a 2 gram sodium restriction diet is important but not addressing the immediate issue of electrolyte imbalance.
C) Fluid restriction may be considered but not before addressing the electrolyte issues.
D) Holding the spironolactone and furosemide is the correct action, as administering these could exacerbate the existing hypokalemia and hyponatremia, increasing the risk of adverse effects.

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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?

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Naxlex Comprehensive Predictor Exams

When planning care for a client with acute pancreatitis, which order would the nurse anticipate that will contribute to pain control?

Correct Answer is B

Explanation

The nurse is preparing to administer spironolactone (Aldactone) and furosemide (Lasix) at 0900 to a client diagnosed with ascites. Review of 0600 laboratory results shows serum sodium 130 mEq/L (136-145 mEq/L) and potassium 3.1 mEq/L (3.5-5.0 mEq/L). Which action should the nurse take first?

Correct Answer is D

Explanation

The nurse is making a home visit to a client with chronic pancreatitis. Which data is consistent with this diagnosis?

A nurse is admitting a client who has acute pancreatitis. Which of the following provider prescriptions should the nurse anticipate?

A female client is visiting the Medical Clinic with suspected hepatitis C. Which assessment question should the nurse ask this client?

The nurse is preparing a client presentation regarding pancrelipase (Viokase) therapy. Which information would the nurse include in the teaching session?

The nurse is admitting a client with liver disease who presents with dyspnea, weight gain and abdominal distention. Which order would the nurse anticipate?

The nurse is preparing a community presentation about hepatitis B virus (HBV). Which information should be included in the teaching session?

The nurse is providing care to a client admitted with chronic pancreatitis. Which items are appropriate to include in the discharge teaching for this client? Select all that apply.

A client with cirrhosis is scheduled to receive a third dose of lactulose (Cephulac) at 1800. Which current finding would cause the nurse to question administering this medication?