A nurse is caring for a client who has advanced liver disease. Which of the following laboratory results should the nurse monitor when assessing this client?
Serum ammonia
Phosphate level
Serum troponin
Glucose level
The Correct Answer is A
Rationale:
A. Serum ammonia: In advanced liver disease, the liver's ability to detoxify ammonia is impaired. Ammonia can accumulate in the bloodstream, leading to hepatic encephalopathy, which can cause confusion, lethargy, or even coma. Monitoring serum ammonia levels is essential.
B. Phosphate level: Phosphate levels are not a primary concern in advanced liver disease. Although abnormalities in electrolyte balance can occur, phosphate levels are not directly impacted by liver function in the same way as ammonia or other liver-related markers.
C. Serum troponin: Serum troponin is primarily used to assess for myocardial injury, such as in the case of a heart attack. It is not a relevant marker for liver disease. While cardiac complications can occur in liver disease, troponin levels are not a priority.
D. Glucose level: While glucose metabolism can be affected by liver disease due to impaired glycogen storage and gluconeogenesis, monitoring serum ammonia is more critical in advanced liver disease for assessing hepatic encephalopathy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Loss of skin turgor: Loss of skin turgor is a sign of dehydration, not hypervolemia. Hypervolemia typically results in fluid retention, leading to other symptoms such as weight gain.
B. Weight gain: Weight gain is a common sign of hypervolemia due to the accumulation of excess fluid in the body. It is often one of the first indicators of fluid overload.
C. Hypotension: Hypotension is more commonly associated with hypovolemia (fluid deficit) rather than hypervolemia. In hypervolemia, blood pressure is more likely to increase due to the excess fluid volume.
D. Bradycardia: Bradycardia is not typically associated with hypervolemia. Hypervolemia can lead to tachycardia (increased heart rate) as the body tries to compensate for the excess fluid volume.
Correct Answer is C
Explanation
Rationale:
A. Tilt the client's head with the affected ear facing up: Tilting the head with the affected ear facing up is not recommended. The head should be tilted so the affected ear faces downward, allowing the irrigating fluid to drain out easily and reducing the risk of injury or discomfort.
B. Insert the tip of the syringe 2.5 cm (1 in) into the ear canal: The syringe tip should not be inserted deeply into the ear canal. Inserting the tip too far can cause trauma to the ear canal or eardrum. The tip should be placed at the opening of the ear canal to allow for safe irrigation.
C. Point the tip of the syringe toward the top of the ear canal: The syringe should be aimed toward the top or posterior wall of the ear canal, not directly at the eardrum. This allows the fluid to flow along the ear canal and helps prevent injury to the eardrum while effectively flushing the ear.
D. Use cool fluid for irrigation: Cool fluid can cause dizziness or discomfort for the client. It is better to use warm, body-temperature fluid during ear irrigation to ensure the client remains comfortable and to avoid any adverse effects.
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