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?

Auscultate lungs

Monitor I&O

Check stools for blood

Initiate fall precautions

Answer and Explanation

The Correct Answer is C

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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Correct Answer is D

Explanation

A) Breath with fecal odor could indicate hepatic encephalopathy, for which lactulose is indicated.
B) Increasing confusion is a symptom of hepatic encephalopathy suggests a need for lactulose.
C) Elevated ammonia levels indicate hepatic encephalopathy hence the need for lactulose.
D) If the client already has diarrhea, additional doses of lactulose (which acts as a laxative) could exacerbate this condition and might need to be adjusted or halted based on clinical judgment.

A. Administer pancreatic enzymes B. Maintain nasogastric tube to intermittent suction C. Encourage ambulation D. Provide clear liquid diet

Correct Answer is B

Explanation

A) Pancreatic enzymes are typically used to aid in digestion rather than pain control in acute pancreatitis.
B) Decompression of the gastrointestinal tract through nasogastric suction can help reduce pancreatic stimulation and alleviate pain in acute pancreatitis.
C) While ambulation may help prevent complications, it is not directly related to pain control in acute pancreatitis.
D) A clear liquid diet may be initiated once the acute phase has resolved, but it does not directly contribute to pain control.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is D

Explanation

When planning care for a client with acute pancreatitis, which order would the nurse anticipate that will contribute to pain control?

Correct Answer is B

Explanation

When reviewing a client's health history, which information does the nurse identify as a risk factor for development of chronic pancreatitis?

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?

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 client with acute pancreatitis asks why she is taking omeprazole. What is the nurse's best response?

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?

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

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