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 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.
Correct Answer is C
Explanation
A) These symptoms are more indicative of chronic conditions.
B) These are not specific to acute pancreatitis.
C) Elevated lipase and Turner's sign (bruising around the flanks) strongly suggest acute pancreatitis.
D) Amylase within normal limits and steatorrhea do not support acute pancreatitis.
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