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

Answer and Explanation

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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Correct Answer is ["60"]

Explanation

- Step 1: Identify the required dose in grams. The client is scheduled to receive 30 grams of lactulose.

- Step 2: Identify the concentration of the available solution. The available solution contains 5 grams of lactulose per 10 mL.

- Step 3: Calculate the volume of solution needed to deliver the required dose. We can set up a proportion to solve for this:

- 5 grams is to 10 mL as 30 grams is to X mL.

- In other words, 5 g : 10 mL = 30 g : X mL.

- Step 4: Solve for X using cross-multiplication and division:

- Cross-multiplication gives us: 5 g × X mL = 30 g × 10 mL.

- Simplifying this gives us: 5X = 300.

- Dividing both sides by 5 gives us: X = 300 ÷ 5.

- Calculating the division gives us: X = 60.

60 mL of the lactulose solution should be poured into the medication cup to administer the required dose of 30 grams.

A. Hypermagnesemia B. Hyponatremia C. Hyperkalemia D. Hypophosphatemia

Correct Answer is D

Explanation

Choice A reason: Hypermagnesemia, or high levels of magnesium in the blood, is not typically associated with refeeding syndrome. Instead, refeeding syndrome can lead to hypomagnesemia, which is a low level of magnesium in the blood, due to shifts of magnesium into the cells during insulin secretion in the refeeding process.

Choice B reason: Hyponatremia, or low levels of sodium in the blood, is not a hallmark of refeeding syndrome. While fluid shifts can affect sodium levels, the key electrolyte disturbances in refeeding syndrome involve phosphorus, potassium, and magnesium.

Choice C reason: Hyperkalemia, or high levels of potassium in the blood, is not a common finding in refeeding syndrome. Similar to magnesium, potassium can shift into cells during refeeding, which can actually lead to hypokalemia, or low levels of potassium in the blood.

Choice D reason: Hypophosphatemia, or low levels of phosphorus in the blood, is the hallmark of refeeding syndrome. When a malnourished individual is refed, insulin secretion is stimulated by the increased carbohydrate intake. Insulin promotes cellular uptake of glucose, which is accompanied by phosphate, potassium, and magnesium, leading to a decrease in the serum levels of these electrolytes. Phosphorus is critical for cellular processes, and its deficiency can lead to muscle weakness, respiratory failure, hemolysis, and impaired cardiac function. During refeeding, careful monitoring of electrolytes is essential to prevent and manage refeeding syndrome. Hypophosphatemia is the most significant laboratory finding to anticipate in a patient with refeeding syndrome, and it requires prompt recognition and treatment to prevent serious complications.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client is scheduled to receive 30 grams of lactulose orally every 12 hours. An oral solution containing 5 g/10 mL is available. How many mL should be poured into the medication cup to administer the required dose?

Correct Answer is ["60"]

Explanation

A nurse is caring for a client who is receiving continuous enteral nutrition and develops refeeding syndrome. The nurse should expect which of the following laboratory findings?

Correct Answer is D

Explanation

The nurse would be most concerned about a prescription for a lipid emulsion for a client with which condition?

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