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 D

Explanation

A) Requesting a dietary consult is useful but not the most immediate action needed.

B) Ordering a 2 gram sodium restriction diet is important but not addressing the immediate issue of electrolyte imbalance.
C) Fluid restriction may be considered but not before addressing the electrolyte issues.
D) Holding the spironolactone and furosemide is the correct action, as administering these could exacerbate the existing hypokalemia and hyponatremia, increasing the risk of adverse effects.

A. Check blood glucose daily B. Monitor for dark color of urine C. Follow low carbohydrate diet D. Change positions slowly

Correct Answer is D

Explanation

A) Checking blood glucose daily is not directly relevant unless the client also has diabetes.

B) While this can indicate other health issues, it is not specific post-paracentesis advice.
C) A low carbohydrate diet is not typically related to post-paracentesis care unless specified by the healthcare provider for other underlying conditions.
D) Change positions slowly is important to prevent postural hypotension and falls after fluid removal during paracentesis. It prevent dizziness or lightheadedness due to fluid shifts or blood pressure changes after the procedure.

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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?

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Naxlex Comprehensive Predictor Exams

The nurse is preparing to administer spironolactone (Aldactone) and furosemide (Lasix) at 0900 to a client diagnosed with ascites. Review of 0600 laboratory results shows serum sodium 130 mEq/L (136-145 mEq/L) and potassium 3.1 mEq/L (3.5-5.0 mEq/L). Which action should the nurse take first?

Correct Answer is D

Explanation

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

Correct Answer is D

Explanation

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