The nurse is reviewing laboratory test results for the client with liver disease and notes that the client's albumin level is low. Which nursing assessment indicates low albumin levels?
Evaluate for asterixis
Palpate for peripheral edema
Evaluate for decreased level of consciousness
Inspect for petechiae
The Correct Answer is B
Choice A reason: Asterixis, also known as “liver flap,” is a type of tremor characterized by rapid, nonrhythmic extensions and flexions in the wrist and fingers. It is associated with hepatic encephalopathy, a condition that can occur with severe liver disease, but it is not a direct indicator of low albumin levels.
Choice B reason: Peripheral edema is a common clinical finding in patients with hypoalbuminemia, which is a low level of albumin in the blood. When albumin levels are low, fluid from the bloodstream can leak into body tissues, causing swelling, especially in the lower limbs. When assessing a client with liver disease and low albumin levels, palpating for peripheral edema would be the most relevant nursing assessment, as it directly correlates with the effects of hypoalbuminemia on fluid balance in the body. Albumin is a protein made by the liver that helps keep fluid in your blood vessels and plays a role in transporting substances throughout your body. Low levels of albumin can lead to fluid leaking out of blood vessels into tissues, causing swelling or edema.
Choice C reason: Decreased level of consciousness can be a sign of various conditions, including hepatic encephalopathy or other complications of liver disease, but it is not specifically indicative of low albumin levels.
Choice D reason: Petechiae are small red or purple spots caused by bleeding into the skin and may be associated with various conditions, including liver disease, but they are not a specific sign of low albumin levels.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Atropine is not typically used for the treatment of pulmonary embolism. It is an anticholinergic drug that is primarily used to treat bradycardia (slow heart rate) and as part of the management of organophosphate poisoning. It does not have a role in the management of pulmonary embolism, which requires anticoagulation to prevent further clot formation.
Choice B reason: Furosemide is a loop diuretic commonly used to treat fluid overload conditions such as heart failure or edema. While it can help relieve symptoms associated with fluid accumulation, it does not treat the underlying cause of a pulmonary embolism, which is a blood clot in the pulmonary arteries.
Choice C reason: Heparin is an anticoagulant medication that is commonly used in the initial treatment of pulmonary embolism. It works by preventing the formation of new blood clots and stopping existing clots from getting bigger. Heparin is often administered intravenously or subcutaneously and is a key component in the management of pulmonary embolism.
Choice D reason: Dexamethasone is a corticosteroid that is used to reduce inflammation in various conditions, such as allergic reactions, asthma, and certain types of arthritis. It is not used as a primary treatment for pulmonary embolism, as it does not have anticoagulant properties.
Correct Answer is ["B","C","E","F"]
Explanation
Choice A: Hypokalemia, or low potassium levels in the blood, is not typically associated with CKD. In fact, patients with advanced CKD are more likely to experience hyperkalemia, which is an elevated potassium level, due to the kidneys’ decreased ability to excrete potassium. The normal range for serum potassium is 3.5 to 5.0 mmol/L.
Choice B: Anemia is a common finding in CKD and is due to the kidneys’ reduced production of erythropoietin, a hormone that stimulates the bone marrow to produce red blood cells. Symptoms of anemia include fatigue, weakness, and pale skin. The normal range for hemoglobin in adults is 13.8 to 17.2 grams per deciliter for men and 12.1 to 15.1 grams per deciliter for women.
Choice C: Hypertension, or high blood pressure, is both a cause and a complication of CKD. The kidneys play a crucial role in regulating blood pressure, and as their function declines, hypertension becomes more common. The normal range for blood pressure is typically considered to be 120/80 mmHg.
Choice D: Crackles in the lungs Crackles in the lungs are not a direct manifestation of CKD, but they can occur if the condition leads to fluid overload and heart failure, resulting in pulmonary edema. This is a secondary complication rather than a direct symptom of CKD.
Choice E: Lethargy and a general feeling of malaise are common in CKD due to the buildup of toxins and waste products in the blood that the kidneys can no longer effectively filter out. This can also lead to decreased mental sharpness and a reduced quality of life.
Choice F: Proteinuria, or the presence of excess protein in the urine, is a hallmark sign of CKD. It indicates damage to the kidneys’ filtering units, allowing protein that would normally be retained to leak into the urine. Persistent proteinuria is a sign of chronic kidney damage.
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