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 C

Explanation

A) These symptoms are more indicative of chronic conditions.

B) These are not specific to acute pancreatitis.

C) Elevated lipase and Turner's sign (bruising around the flanks) strongly suggest acute pancreatitis.
D) Amylase within normal limits and steatorrhea do not support acute pancreatitis.

A. Weight loss B. Pedal edema C. Flushed skin D. Hematemesis

Correct Answer is B

Explanation

A) Ascites, the accumulation of fluid in the abdominal cavity, typically presents with weight gain rather than weight loss.
B) Ascites often accompanies peripheral edema, particularly in the lower extremities.

C) Ascites is not typically associated with flushed skin; rather, it may lead to pallor due to anemia or jaundice due to liver dysfunction.
D) Ascites is not directly associated with vomiting blood; hematemesis may indicate complications such as esophageal varices, which can occur in advanced liver disease.

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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

An adult client is admitted to the emergency department with symptoms of acute pancreatitis. Which data support this diagnosis?

Correct Answer is C

Explanation

The nurse is admitting a client diagnosed with ascites. Which assessment finding would the nurse anticipate?

Correct Answer is B

Explanation

While assessing the client with acute pancreatitis the nurse notes the following: skin warm and dry with inelastic turgor, hypoactive bowel sounds, nausea and vomiting for 24 hours, and amber-colored urine. Which action would the nurse take next?

The nurse notes these laboratory results for a client with cirrhosis: PT 20 seconds (11-12.5 sec) and serum ammonia 35 mcg/dL (15-45 mcg/dL). What action by the nurse would be a priority?

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A nurse is planning care for a client who has hepatitis B. Which of the following interventions should the nurse include in the plan?

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 the diagnosis of hepatic encephalopathy. Which assessment finding should the nurse anticipate?

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?

When planning care for a client receiving an enteral feeding via jejunostomy tube, which intervention would the nurse include?