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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1.2"]
Explanation
- Step 1: Identify the child's weight in pounds. The child weighs 33 lbs.
- Step 2: Convert the child's weight from pounds to kilograms. We know that 1 kg = 2.2 lbs. So, 33 lbs = 33 ÷ 2.2 kg. Calculating the division gives us approximately 15 kg.
- Step 3: Identify the prescribed dose in mcg/kg/day. The child is scheduled to receive 8 mcg/kg/day of digoxin, divided equally every 12 hours.
- Step 4: Calculate the total daily dose in mcg. We can do this by multiplying the child's weight in kg by the prescribed dose in mcg/kg:
- Total daily dose = 8 mcg/kg/day × 15 kg.
- Calculating the multiplication gives us: Total daily dose = 120 mcg/day.
- Step 5: Since the dose is divided equally every 12 hours, we divide the total daily dose by 2 to get the dose per administration:
- Dose per administration = Total daily dose ÷ 2.
- Dose per administration = 120 mcg ÷ 2.
- Calculating the division gives us: Dose per administration = 60 mcg.
- Step 6: Identify the concentration of the available solution. The available solution contains 0.05 mg/mL of digoxin. Convert this to mcg/mL for consistency with the dose per administration. We know that 1 mg = 1000 mcg. So, 0.05 mg = 0.05 × 1000 mcg = 50 mcg/mL.
- Step 7: Calculate the volume of solution needed to deliver the required dose. We can set up a proportion to solve for this:
- 50 mcg is to 1 mL as 60 mcg is to X mL.
- In other words, 50 mcg : 1 mL = 60 mcg : X mL.
- Step 8: Solve for X using cross-multiplication and division:
- Cross-multiplication gives us: 50 mcg × X mL = 60 mcg × 1 mL.
- Simplifying this gives us: 50X = 60.
- Dividing both sides by 50 gives us: X = 60 ÷ 50.
- Calculating the division gives us: X = 1.2.
Administer 1.2 mL of the digoxin elixir per dose.
Correct Answer is ["A","B","C","D","F"]
Explanation
Choice A: Administer antiemetics as needed Reason: Acute pancreatitis often causes severe nausea and vomiting. Antiemetics are administered to control these symptoms and prevent further complications such as dehydration and electrolyte imbalance.
Choice B: Administer analgesics as needed Reason: Pain management is a crucial part of the treatment for acute pancreatitis. The condition can cause severe abdominal pain, and analgesics are administered to provide relief.
Choice C: NPO (nothing by mouth) until pain-free Reason: The goal in treating acute pancreatitis is to allow the pancreas to rest and recover from the inflammation3. Keeping the patient NPO (nothing by mouth) helps achieve this by reducing the stimulation and workload of the pancreas.
Choice D: Monitor blood glucose and provide insulin as needed Reason: Acute pancreatitis can affect the pancreas’ ability to produce insulin, leading to elevated blood glucose levels. Therefore, monitoring blood glucose levels and administering insulin as needed is an important part of the management plan.
Choice E: Side-lying or fetal position Reason: While the side-lying or fetal position might help some patients with abdominal pain, it is not a standard intervention for acute pancreatitis. Therefore, this option is not correct.
Choice F: Monitor hydration status Reason: Patients with acute pancreatitis are at risk of dehydration due to symptoms like vomiting and decreased oral intake. Monitoring hydration status is crucial to ensure appropriate fluid replacement.
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