The nurse is caring for a client with decompensated liver disease who is experiencing fever, chills, and abdominal tenderness.
Following a paracentesis, the nurse receives laboratory results of the ascitic fluid that show the polymorphonuclear leukocyte count is 425/mm (0.42 x 10/L). After notifying the healthcare provider, what action should the nurse take next?
Review serum protein levels
Begin abdominal girth measurements
Initiate antibiotic therapy
Assess neurological status
The Correct Answer is C
Choice A rationale
Reviewing serum protein levels can provide valuable information about a client’s nutritional status and liver function. However, in the context of a client with decompensated liver disease who is experiencing fever, chills, and abdominal tenderness, and has a high polymorphonuclear leukocyte count in ascitic fluid, initiating antibiotic therapy is the priority.
Choice B rationale
Beginning abdominal girth measurements can be useful for monitoring the progression of ascites in a client with liver disease. However, in this scenario, the priority is to treat the potential infection indicated by the client’s symptoms and lab results.
Choice C rationale
Initiating antibiotic therapy is the correct intervention in this case. The client’s symptoms and the high polymorphonuclear leukocyte count in the ascitic fluid suggest spontaneous bacterial peritonitis, a serious complication of cirrhosis that requires immediate antibiotic treatment.
Choice D rationale
Assessing neurological status is important in clients with liver disease, as they are at risk for hepatic encephalopathy. However, in this scenario, the priority is to treat the potential infection indicated by the client’s symptoms and lab results.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
A blood glucose level of 90 mg/dL (5 mmol/L) is within the normal range and would not need to be reported to the surgeon.
Choice B rationale
A serum creatinine level of 5 mg/dL (442 µmol/L) is significantly elevated, indicating impaired kidney function. This is a critical lab value that should be reported to the surgeon immediately, as it could impact the patient’s ability to safely undergo surgery and recover postoperatively.
Choice C rationale
A hemoglobin level of 13 g/dL (130 g/L) is within the normal range and would not need to be reported to the surgeon.
Choice D rationale
A potassium level of 4 mEq/L (4 mmol/L) is within the normal range and would not need to be reported to the surgeon.
Correct Answer is D
Explanation
Choice D rationale
Scheduling frequent rest periods can help manage the fatigue and concentration problems reported by the client. These symptoms are common in clients with CKD and elevated BUN and serum creatinine levels.
Choice A rationale
Administering PRN oxygen may not be necessary unless the client is showing signs of respiratory distress or hypoxia. There is no indication of this in the question.
Choice B rationale
Providing high protein snacks is not recommended for clients with CKD. High protein diets can increase the workload on the kidneys and worsen kidney function.
Choice C rationale
Monitoring glucose levels every 4 hours is not directly related to the client’s reported symptoms or the elevated BUN and serum creatinine levels.
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