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 B

Explanation

A) Bradycardia is not typically associated with hepatic encephalopathy.

B) Asterixis is a characteristic finding in hepatic encephalopathy, known as "flapping tremor," indicating neuromuscular irritability due to elevated blood ammonia levels.
C) Fever is not a common direct symptom of hepatic encephalopathy.

D) Melena indicates gastrointestinal bleeding, which while possible in liver disease, is not specific to hepatic encephalopathy.

A. Gallstones B. Duodenitis C. Type 2 diabetes mellitus D. Hepatitis C

Correct Answer is A

Explanation

A) Gallstones are a leading cause of acute pancreatitis as they can block the pancreatic duct.
B) While inflammation of the duodenum can cause abdominal symptoms, it does not directly lead to acute pancreatitis.
C) Diabetes results from the dysfunction of the pancreas after damage but does not cause acute pancreatitis.
D) Hepatitis C affects the liver and does not directly cause pancreatitis.

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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

The nurse is admitting a client with the diagnosis of hepatic encephalopathy. Which assessment finding should the nurse anticipate?

Correct Answer is B

Explanation

The nurse is collecting a health history of a client admitted for possible acute pancreatitis. Which health history item would increase the client's risk for this diagnosis?

Correct Answer is A

Explanation

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 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?

While assessing the client with acute pancreatitis the nurse notes the following: skin warm and dry with inelastic turgor, hypoactive bowel sounds, nausea and vomiting for 24 hours, and amber-colored urine. Which action would the nurse take next?

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

Which question would the nurse ask to identify a risk factor for liver disease?

The nurse is admitting a client diagnosed with ascites. Which assessment finding would the nurse anticipate?

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 is preparing a community presentation about hepatitis B virus (HBV). Which information should be included in the teaching session?