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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Bowel pattern changes are not typically associated with hepatitis C.
B) Hepatitis C can be transmitted through blood transfusions received before widespread screening for the virus.
C) Travel history is not directly relevant to assessing for hepatitis C transmission.
D) While diabetes can be a comorbidity associated with hepatitis C, it is not a primary assessment question for suspected hepatitis C.
Correct Answer is A
Explanation
A) Helps maintain muscle tone and promotes overall well-being without overstressing the body during recovery from hepatitis B.
B) Antibiotics are not effective against viruses like hepatitis B.
C) There is generally no need to restrict fluids in hepatitis B; adequate hydration supports overall health and liver function.
D) A high-fat diet is not recommended for liver disease; typically, a balanced, low-fat diet is more appropriate.
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