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 A

Explanation

A) These are dilated veins in the esophagus that can rupture and lead to life- threatening bleeding.
B) While concerning and indicative of hepatic encephalopathy, it is not immediately life-threatening like a variceal bleed.
C) Indicates poor nutritional status and liver function but is not as acutely dangerous as bleeding varices.
D) This is a concern but does not represent an immediate life-threatening condition like esophageal varices.

A. Check blood glucose every 4 hours B. 2 gram sodium diet C. Bedrest D. Insert indwelling urinary catheter

Correct Answer is B

Explanation

A) Monitoring blood glucose is more relevant for diabetic care.

B) A sodium diet is appropriate for managing fluid retention associated with liver disease.
C) Bedrest may be prescribed but not as specific to the management of fluid retention.
D) Insertion of an indwelling urinary catheter is not a standard intervention without additional justification.

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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

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

Correct Answer is A

Explanation

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

Correct Answer is B

Explanation

An adult client is admitted to the emergency department with symptoms of acute pancreatitis. Which data support 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 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 should evaluate results of which laboratory tests while caring for a client who has cirrhosis of the liver? Select all that apply.

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

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?

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

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?