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 C

Explanation

A) Pancrelipase may be prescribed to aid in digestion in chronic pancreatitis but is not typically used in the acute phase.
B) While ambulation may be encouraged as tolerated, it is not a specific prescription for acute pancreatitis.
C) Pantoprazole, a proton pump inhibitor, is often prescribed in acute pancreatitis to reduce gastric acid secretion, thereby reducing pancreatic stimulation and promoting healing.
D) In acute pancreatitis, dietary intake is typically restricted initially, often starting with nothing by mouth (NPO) and progressing to a clear liquid diet as tolerated; a low-residue diet is usually introduced at a later stage.

A. “Do you consume a high carbohydrate diet?" B. "Do you have a history of heart disease?" C. "Have you had a flu shot this year?" D. "Have you ever used IV drugs?"

Correct Answer is D

Explanation

A) While a high carbohydrate diet can contribute to fatty liver disease, it is less direct and specific compared to other risk factors.
B) Heart disease is not directly linked to liver disease risk.

C) Having a flu is unrelated to liver disease risk.

D) Intravenous drug use is a known risk factor for hepatitis B and C, both of which can lead to liver disease.

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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 nurse is admitting a client who has acute pancreatitis. Which of the following provider prescriptions should the nurse anticipate?

Correct Answer is C

Explanation

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

Correct Answer is D

Explanation

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

When planning care for a client receiving an enteral feeding via jejunostomy tube, which intervention would the nurse include?

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

A female client is visiting the Medical Clinic with suspected hepatitis C. Which assessment question should the nurse ask this client?

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

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?

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