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 A

Explanation

A) Weight loss is a common symptom of chronic pancreatitis due to malabsorption and decreased appetite.
B) Cool, clammy skin is not typically associated with chronic pancreatitis; it may indicate other conditions such as shock or hypotension.
C) Bruising on the flank is not a typical finding in chronic pancreatitis; it may suggest trauma or other underlying conditions.
D) Ascites, the accumulation of fluid in the abdominal cavity, is more commonly associated with advanced liver disease rather than chronic pancreatitis.

A. Monitor for hypertension B. Measure residual every 24 hours C. Check stools for diarrhea D. Check blood glucose every 12 hours

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.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is A

Explanation

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

Correct Answer is C

Explanation

The client with cirrhosis is at risk for developing complications. Which condition is the most serious and potentially life-threatening?

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

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 is admitting a client with the diagnosis of hepatic encephalopathy. Which assessment finding should the nurse anticipate?

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?

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

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

A client with cirrhosis has the following current assessment data: jaundice, decreased appetite, hemoglobin 15 g/dL (14-18 g/dL) and PT of 20.6 seconds (11-12.5 sec). What does the nurse identify as the priority problem for this client?