The nurse has reviewed the laboratory results day 1 at 1800.

Exhibits

Complete the following sentence by using the lists of options.

The client is at risk for
dropdown
due to
dropdown

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

Rationale:

Hepatic encephalopathy: This is caused by the buildup of neurotoxins, particularly ammonia, due to impaired liver function. The client’s elevated ammonia level and history of chronic alcohol use and jaundice support this diagnosis. Early signs may include confusion and lethargy, progressing to coma if untreated.
Uremic encephalopathy: This condition is caused by accumulation of urea and toxins due to kidney failure. There is no evidence in the case of renal impairment, such as elevated BUN or creatinine levels, making this diagnosis unlikely in the current context.
Hypoglycemia: Low blood glucose can cause confusion or altered mental status, but this client’s symptoms and labs do not indicate hypoglycemia. There is no mention of a low glucose level, and the focus of concern is more aligned with liver failure than endocrine causes.

Abdominal pain: Although abdominal pain is a relevant symptom in liver disease, it is nonspecific and not directly responsible for hepatic encephalopathy. It reflects general liver inflammation or ascites but does not cause neurologic symptoms on its own.
Albumin 3.0 g/dL: Low albumin indicates reduced liver synthetic function and contributes to fluid shifts like ascites, but it is not neurotoxic. It does not directly cause hepatic encephalopathy or altered mental status.
Ammonia 150 mcg/dL: This is a critically elevated value, more than double the normal upper limit. High ammonia levels are the most direct biochemical cause of hepatic encephalopathy and require immediate treatment to prevent worsening neurological decline.
Total Bilirubin 2.0 mg/dL: While elevated bilirubin suggests cholestasis and impaired liver clearance, it leads to jaundice rather than mental status changes. It reflects liver dysfunction but is not the key factor in encephalopathy development.

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Free Nursing Study Resources

Correct Answer is ["A","D","F","G"]

Explanation

Rationale:

A. Administer morphine 4 mg IV bolus: Morphine is appropriate for severe chest pain unrelieved by nitrates. It decreases preload, pain, and anxiety, reducing myocardial oxygen demand. This intervention helps improve comfort and may lower sympathetic nervous system activation during an acute MI.

B. Prepare client for an exercise tolerance test: This is contraindicated during active chest pain and elevated troponin levels. Stress testing would increase cardiac workload and worsen ischemia. It is only done when a patient is stable and MI has been ruled out.

C. Administer an intermittent IV fluid bolus: Fluid boluses are not indicated unless hypotension or hypovolemia is present. Extra fluid can increase cardiac workload and worsen outcomes in MI. In a normotensive patient with chest pain, it offers no benefit and may increase risk of pulmonary congestion.

D. Administer nitroglycerin sublingual: Nitroglycerin is a first-line medication for ischemic chest pain. It improves blood flow by dilating coronary arteries and reducing cardiac preload. It can rapidly relieve angina and should be administered as soon as possible in acute chest pain.

E. Place the client in the supine position: Supine positioning may worsen breathing difficulty and is not ideal during acute chest pain. A semi-Fowler's position is better to support oxygenation. Keeping the head elevated helps reduce venous return and cardiac workload.

F. Apply oxygen at 2 L/min via nasal cannula: Oxygen is appropriate with labored respirations and signs of hypoxia. It improves oxygen delivery to the myocardium during ischemic events. Supplemental oxygen can help stabilize oxygen saturation while definitive interventions are underway.

G. Prepare client for percutaneous coronary intervention: PCI is a key treatment for myocardial infarction and should be anticipated given the client’s chest pain, elevated troponin, and high risk profile. It restores perfusion to the affected coronary artery and reduces infarct size and mortality when performed promptly.

A. Upper arm and lower leg findings B. Skin temperature C. Blood pressure D. Bowel sounds E. Hgb F. Heart rate

Correct Answer is ["A","C","E","F"]

Explanation

Rationale:

A. Upper arm and lower leg findings: The presence of ecchymoses indicates impaired coagulation, which is common in chronic liver disease due to decreased clotting factor production. In the context of active bleeding (hematemesis), this is significant and needs immediate evaluation.

B. Skin temperature: Cool and dry skin, while concerning, is a nonspecific symptom. It may support a diagnosis of hypovolemia or shock, but on its own, it does not require the same urgent intervention as abnormal vital signs or lab results.

C. Blood pressure: A BP of 92/56 mm Hg indicates hypotension and suggests the client may be experiencing hypovolemic shock from gastrointestinal bleeding. This finding requires immediate intervention to prevent end-organ damage.

D. Bowel sounds: Bowel sounds auscultated in all four quadrants suggest that gastrointestinal motility is present. This is not a priority finding and does not indicate an urgent complication.

E. Hgb: A hemoglobin level of 7 g/dL is critically low and consistent with significant blood loss. This value requires immediate follow-up, likely including blood transfusion and identification of the bleeding source.

F. Heart rate: A heart rate of 118/min reflects a compensatory response to hypotension or blood loss. Tachycardia in this setting is a key sign of circulatory compromise and must be addressed immediately.

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The nurse has reviewed the laboratory results day 1 at 1800. Exhibits Complete the following sentence by using the lists of options. The client is at risk for dropdown due to dropdown

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Naxlex Comprehensive Predictor Exams

The nurse is planning care for the client. Which of the following provider prescriptions should the nurse anticipate? Select All That Apply Exhibits

Correct Answer is ["A","D","F","G"]

Explanation

A nurse is caring for a male client in the emergency department. Exhibits The nurse is reviewing the clients electronic medical records Select the 4 findings that require immediate follow-up.

Correct Answer is ["A","C","E","F"]

Explanation

A nurse is caring for a male client in the emergency department. Exhibits The nurse is planning care for this client. For each potential prescription, specify if it is anticipated or contraindicated:

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A nurse is caring for a client who is intubated and receiving mechanical ventilation for heroin toxicity. Which of the following assessments is the nurse's priority?

An emergency room nurse is assessing a client who has asthma and difficulty breathing. Which of the following findings should indicate to the nurse that the client is experiencing status asthmaticus?

The nurse has reviewed the laboratory results day 1 at 1800.

Exhibits

Complete the following sentence by using the lists of options.

The client is at risk for
dropdown
due to
dropdown