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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Pancrelipase is an enzyme replacement therapy used to aid in the digestion of fats, proteins, and carbohydrates, and its use may lead to steatorrhea (fatty stools) as a common side effect.
B) Pancrelipase is typically administered with meals or snacks to aid in digestion; there is no need to administer it prior to antacids.
C) Pancrelipase is taken with meals or snacks to assist in digestion, so this statement is incorrect.
D) There is no need to rinse the mouth after taking pancrelipase; it is a medication designed for oral ingestion.
Correct Answer is A
Explanation
A) Chronic damage to the pancreas can lead to diabetes mellitus due to the destruction of insulin-producing cells.
B) Jaundice is typically associated with liver disease, not directly linked with chronic pancreatitis.
C) Ascites is a complication of liver disease, not typically a direct result of chronic pancreatitis.
D) While steatorrhea is a symptom of chronic pancreatitis due to malabsorption of fats, it is not a complication but rather a direct effect of the enzyme insufficiency.
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