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?

Request a dietary consult

Order a 2 gram sodium restriction diet

Initiate a fluid restriction

Hold the spironolactone and furosemide

Answer and Explanation

The Correct Answer is D

A) Requesting a dietary consult is useful but not the most immediate action needed.

B)   Ordering a 2 gram sodium restriction diet is important but not addressing the immediate issue of electrolyte imbalance.
C)   Fluid restriction may be considered but not before addressing the electrolyte issues.
D)   Holding the spironolactone and furosemide is the correct action, as administering these could exacerbate the existing hypokalemia and hyponatremia, increasing the risk of adverse effects.

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Correct Answer is D

Explanation

A) While a high carbohydrate diet can contribute to fatty liver disease, it is less direct and specific compared to other risk factors.
B) Heart disease is not directly linked to liver disease risk.

C) Having a flu is unrelated to liver disease risk.

D) Intravenous drug use is a known risk factor for hepatitis B and C, both of which can lead to liver disease.

A. Monitor I&O B. Check blood pressure C. Assess pain level D. Measure oxygen saturation

Correct Answer is B

Explanation

A) Monitoring intake and output (I&O) is crucial for understanding the patient's fluid balance, especially after 24 hours of vomiting, which could lead to dehydration. However, it is important for fluid balance but not the immediate next step.
B) Checking blood pressure can provide immediate information on the patient's hemodynamic status and potential hypovolemia due to fluid loss; thus, it should be assessed immediately.
C) Assessing pain level is important for comfort, but stabilization of vital signs takes precedence.
D) Measuring oxygen saturation is useful but less critical than assessing for potential hypotension due to dehydration.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which question would the nurse ask to identify a risk factor for liver disease?

Correct Answer is D

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?

Correct Answer is B

Explanation

A client with cirrhosis is scheduled to receive a third dose of lactulose (Cephulac) at 1800. Which current finding would cause the nurse to question administering this medication?

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

The nurse should evaluate results of which laboratory tests while caring for a client who has cirrhosis of the liver? Select all that apply.

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

The nurse is caring for a client with chronic pancreatitis who exhibits signs of malabsorption. The nurse recognizes that this is due to which pathophysiology process?

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?

A client with a history of chronic pancreatitis reports weight loss of 10 pounds over the last month and foul smelling stools. What would be a priority action for the nurse to take?