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.

Nursing Test Bank

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Correct Answer is C

Explanation

A) These symptoms are more indicative of chronic conditions.

B) These are not specific to acute pancreatitis.

C) Elevated lipase and Turner's sign (bruising around the flanks) strongly suggest acute pancreatitis.
D) Amylase within normal limits and steatorrhea do not support acute pancreatitis.

A. Auscultate lungs B. Monitor I&O C. Check stools for blood D. Initiate fall precautions

Correct Answer is C

Explanation

A) While important, it is not directly related to the coagulopathy indicated by the prolonged PT.
B) Important for overall fluid management but not directly related to the risk of bleeding.
C) With a significantly prolonged PT, assessing for signs of gastrointestinal bleeding is a priority.

D) Important for safety, but the immediate risk of bleeding due to coagulopathy takes precedence.

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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

An adult client is admitted to the emergency department with symptoms of acute pancreatitis. Which data support this diagnosis?

Correct Answer is C

Explanation

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?

Correct Answer is C

Explanation

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?

A female client is visiting the Medical Clinic with suspected hepatitis C. Which assessment question should the nurse ask this client?

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

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?

The nurse is preparing discharge teaching for a client who has had a paracentesis. What information should be included in the education session?

The nurse is providing care to a client admitted with chronic pancreatitis. Which items are appropriate to include in the discharge teaching for this client? Select all that apply.

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?

The nurse is admitting a client diagnosed with ascites. Which assessment finding would the nurse anticipate?