A client with cirrhosis has the following laboratory results: albumin 4.9 g/dl. (3.5-5 g/dL), PT 13 seconds (11-12.5 sec), and serum ammonia 68 mcg/dL (15-45 mcg/dL). Based on this information, what is the nurse's next action?

Assess level of consciousness

Assess for bleeding

Measure abdominal girth

Auscultate bowel sounds

Answer and Explanation

The Correct Answer is A

A)   Elevated serum ammonia levels can lead to hepatic encephalopathy, which affects mental status and consciousness, making this the priority assessment.
B)   The PT is slightly prolonged but not alarmingly high; bleeding is less of a concern compared to the elevated ammonia.
C)   This action is important in assessing fluid accumulation but is not as critical as assessing mental status in this scenario.
D)   While part of a comprehensive abdominal assessment, this is not the most critical action given the elevated ammonia level.

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Correct Answer is ["C","D","E"]

Explanation

A) Limited activity is not typically necessary unless specified by a physician.

B) A low-fat diet is usually recommended for a client with chronic pancreatitis.

C) Weight loss in chronic pancreatitis is common due to the risk of malnutrition and malabsorption.
D) Administration of pancrelipase is essential for aiding digestion if the pancreas is not producing enough enzymes.
E) Elimination of alcohol intake is critical to prevent further damage to the pancreas.

A. Administer pancreatic enzymes B. Maintain nasogastric tube to intermittent suction C. Encourage ambulation D. Provide clear liquid diet

Correct Answer is B

Explanation

A) Pancreatic enzymes are typically used to aid in digestion rather than pain control in acute pancreatitis.
B) Decompression of the gastrointestinal tract through nasogastric suction can help reduce pancreatic stimulation and alleviate pain in acute pancreatitis.
C) While ambulation may help prevent complications, it is not directly related to pain control in acute pancreatitis.
D) A clear liquid diet may be initiated once the acute phase has resolved, but it does not directly contribute to pain control.

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A client with cirrhosis has the following laboratory results: albumin 4.9 g/dl. (3.5-5 g/dL), PT 13 seconds (11-12.5 sec), and serum ammonia 68 mcg/dL (15-45 mcg/dL). Based on this information, what is the nurse's next action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing care to a client admitted with chronic pancreatitis. Which items are appropriate to include in the discharge teaching for this client? Select all that apply.

Correct Answer is ["C","D","E"]

Explanation

When planning care for a client with acute pancreatitis, which order would the nurse anticipate that will contribute to pain control?

Correct Answer is B

Explanation

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?

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

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

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?

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

The nurse is preparing a client presentation regarding pancrelipase (Viokase) therapy. Which information would the nurse include in the teaching session?

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

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?