A nurse is caring for a client who has hepatic encephalopathy. Which of the following laboratory values should the nurse monitor?
Calcium
Potassium
Ammonia
Glucose
The Correct Answer is C
Rationale:
A. Calcium: While calcium is important for many bodily functions, it is not a primary indicator for monitoring hepatic encephalopathy. Calcium imbalances do not directly correlate with the severity or management of this condition.
B. Potassium: Potassium levels are important for overall electrolyte balance, but they are not specific to hepatic encephalopathy. Monitoring potassium is part of routine care but does not indicate the progression or severity of encephalopathy.
C. Ammonia: Elevated ammonia levels are a key contributor to hepatic encephalopathy. The liver normally converts ammonia to urea, and when liver function is impaired, ammonia accumulates, affecting neurological function. Monitoring ammonia helps assess severity and guide treatment interventions.
D. Glucose: While glucose monitoring is important in general care, it is not specific to hepatic encephalopathy. Hyper- or hypoglycemia may occur with liver disease but does not directly reflect the presence or progression of encephalopathy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Place the client in supine position: The supine position is not ideal for paracentesis. The procedure is typically performed with the client sitting upright on the edge of the bed or in a high Fowler’s position, allowing fluid to collect in the lower abdomen and reducing the risk of organ puncture.
B. Ensure the client has a full bladder: A full bladder increases the risk of bladder puncture during paracentesis. Clients are usually asked to void before the procedure to minimize this risk and promote safety.
C. Obtain a creatinine level: While kidney function may be relevant to overall health, measuring creatinine is not required specifically for paracentesis. The procedure focuses on removing ascitic fluid and assessing for infection or other complications, not directly on renal function.
D. Weigh the client: Weighing the client before the procedure establishes a baseline to evaluate the amount of fluid removed and monitor changes in fluid status. Pre- and post-procedure weights help assess effectiveness and detect complications such as hypotension or fluid shifts.
Correct Answer is D
Explanation
Rationale:
A. Place an ice pack directly on the skin of the affected joints: Ice should never be applied directly to the skin as it can cause frostbite or skin damage. It should be wrapped in a cloth or towel before use. While cold therapy can reduce inflammation and numb pain, safety precautions are essential.
B. Limit dietary intake of phosphorus: Phosphorus restriction is not relevant for osteoarthritis management. Dietary modifications for osteoarthritis focus more on maintaining a healthy weight and anti-inflammatory nutrients rather than phosphorus intake.
C. Place a large pillow under the knees when sleeping: Placing a large pillow under the knees can hyperflex the joints and increase strain on the knees and hips. Proper positioning involves keeping joints in a neutral or slightly extended position to reduce discomfort and prevent contractures.
D. Take a hot shower every day: Heat therapy helps relax muscles, relieve stiffness, and improve joint mobility in clients with osteoarthritis. Warm showers or moist heat applications are effective nonpharmacological interventions for managing pain and promoting comfort.
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