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 A
Explanation
A) HBV can be transmitted from an infected mother to her child during childbirth.
The importance of screening and vaccination should be emphasized.
B) While important for general health, this is not specifically related to the transmission of HBV, which is primarily spread through blood and bodily fluids.
C) These are not typical symptoms of HBV; common symptoms include jaundice, fatigue, and abdominal pain.
D) History of gallstones is not a risk factor for HBV.
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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