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) Monitoring for hypertension is not directly related to caring for a client with enteral feeding via a jejunostomy tube.
B) Measuring residual volume is a nursing intervention for clients with gastric feeding tubes, not jejunostomy tubes.
C) Diarrhea is a potential complication of enteral feeding, and monitoring stool output is essential to assess for this complication and adjust feeding accordingly.
D) Monitoring blood glucose levels is important for clients with diabetes but is not specific to caring for a client with enteral feeding via a jejunostomy tube.
Correct Answer is A
Explanation
A) Chronic pancreatitis can lead to a decrease in enzyme production necessary for digestion, leading to malabsorption.
B) This does not typically cause malabsorption associated with chronic pancreatitis.
C) While it can occur with chronic pancreatitis, it does not directly cause malabsorption.
D) This is not related to the digestive malabsorption seen in chronic pancreatitis.
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